fireflymedic

I'll give you RSI if you want it... PD states intitally they showed up and pt was unconscious with snoring respirations slumped on wheel, gradually became combative, but pt is now settling down some claiming he's tired. Pt has no recall of the crash, so he can't tell you what happened. Last place he remembers being is 30 miles away. Speech is slurred. Pupils are dilated, but reactive. Pt is currently taking insulin and neurontin. Anything else you would like?

You get toned out at 04:30 for a single car MVA. On arrival you find a twentyish looking male fighting with PD struggling to get out of a car. You find the car in the middle of a field having gone through some fencing and down a hill. PD states they found the guy unconscious initially, but woke up a bit later and started trying to get out of the car - lower extremities are pinned requiring extrication so he's not going anywhere. Windshield has starring, positive airbag deployment. Pt unable to tell you anything, doesn't seem to comprehend what is going on. No witnesses to the accident, guy just drove up on it and called cops. You have unlimited protocols, tell me what you want to do. Assessments and all - how would you transport? You are 45 from local hospital (community) and an hour and a half from trauma center. GO.

BG of 560 is high, but no so high that the majority of people wouldn't still be functioning at some level (at least from my experience, granted we have alot of diabetics here). yeah the guy is in DKA with the fruity breath, but we should be seeing kussmaul's respirations with that, not a RR of 4. he has no gag reflex and a GCS automatic of less than 8. His airway is patent for now, but won't be for long. I'd aggressively manage this airway 'cause obviously he can't protect his own without a gag reflex. Intubation would definitely be my choice to go. Can't go wrong with spinal precautions, especially with tubin him. Less movement and there is no indications that he didn't fall off the ladder or any trauma. I think more going on here than simple DKA. Also, did you do the BG from a finger stick or a IV cath - difference in capillary and venous blood don't get accurate results with an IV cath for most machines. Aggressive airway management and fluids is good place to start with this gentleman.

Our check off takes roughly around 30-45 min. Most it takes me is an hour. I show up half hour early for shift so my truck is done prior to start of shift. This way if I get a call right at start of shift, or everyone else is out and they need a crew, we go. Works out quite nicely for our service. We can go ahead an clock in a half hour early no problem, so it's all good. If I've worked a straight through shift, and I know I've ran out of that truck all day and night, then I'll just do a quick checkoff 'cause I know exactly what's been used. Otherwise, it's everything, everytime ! My patients depend on it !

I'm curious how many here REALLY check their truck every shift. This came to light recently at our service when I was out of my regular truck for the day and was placed in a back up truck. In our service, one crew member from the truck they are assigned to checks their truck, and the other is assigned to check the back up truck. You are expected to check everything. You are expected to check the dates on everything, etc. We maintain very detailed check lists. However, my normal partner absent that day, I was placed with someone else who stated he had checked the back up truck (I ride double medic). After going through my bag, I was assured everything was fine with the fluids, IV's, tubing, etc that is kept on the truck at all times. However, when I checked the dates on the fluids (I trust no one as I've been burnt on checks before !) all but two bags were out of date for an excessive amount of time (like over a month). I realized they were just looking to see if the fluids were there and not making sure they were not out of date. I've had other instances where there was no oxygen in the main tank, no full portables, and a dead monitor. I even had one instance where there was no oil in the truck ! How many of you have had that experience and how did you feel about it? Did it make you always go behind your partner and check or do you just trust your partner? I trust my regular partner as I know he is as anal as I am about checking the truck, but otherwise I always go behind. Thoughts on this ?

I am curious whether you run as a basic truck, basic equipped ALS, or ALS truck. If an ALS or ALS equipped truck, the excessive heat is a concern on medications, one that I can think of in particular is Ativan. It is a drug which should be refrigerated or is very date sensitive (however, if refrig is a possibility, then it is preferred). I would be cautious though with the stability of any medication left inside a truck which can easily reach temps of 120 or better in the sun or heat. At our service, we pull our bags off the truck between runs to ensure the stability of medications and keep them out of the heat. yeah, it's a pain, but I'd rather have inconvenience than ineffective or sub par medications. We are station based, but frequently spend most of the day out doing runs. The only place we don't idle is at the hospital (if we do, we have to connect to the exhaust system which is a pain, so we just don't do it). In the winter, same rules apply, the bags are pulled due to cold and we keep small heaters which are plugged in along with heating pads to maintain warm fluids. As far as posting in certain areas, how well does that improve run times? Do you move to provide coverage as the trucks go out or do you stay at the same station all the time? We "stage" occasionally when we have no coverage in one area of the county, we'll place a truck there until another truck is in that area of the county which is based at that station but that is the only time. I'm just curious to hear how that works as two services near us do that, but we do not. Stay safe out there !

Ah, I'm glad you brought up ohio, when i worked there, that was a sorry state of a mess to be in ! They didn't know what they wanted or what they had ! It seemed there was everything from first responders, basics, emt-advanced, intermediates both varities, medic and ccemt-p. Since KY and TN haven't made the list yet, here ya go KY first responder (though is actively being phased out) basic intermediates (though pilot programs, not actively certified by state unless part of the program) medics medic with critical care endorsement TN first responder basic (both are pretty well non existant as no longer actively certifying only renewing) EMT - IV (NS, LR, d-50, sub q epi, breathing treatments) EMT - P CCEMT P

Nothing wrong with being aggresive - you need to be decisive and sure of yourself when in difficult situations. That being said, you better know your limits ! If you aren't comfortable with it, you better have a back up or don't do it ! As far as the pedi situation, the trend is definitely drifting away from intubation. As dust and others have said, it's getting lower and lower on the list which makes me curious as to why more and more services are pushing for aggresive airway protocols (ie RSI). Yes, there is a time and place for it, but I'm seeing more and more that are simply doing things because they can. My service has very progressive protocols especially for a ground based service, probably the most aggressive in the state. However, we better be able to justify what we did and why. We are constantly reminded that the least invasive treatment that provides the most benefit to your patient is best. I don't believe it could be said any better. Just because you have the toys doesn't mean you have to play with them.

We scan occasionally just to determine whether we'll get kicked out or not since post dispatches us. God how I love the 45's, means I get to stay in bed at night ! I hear that and roll right back over. As far as responding when I'm not supposed to, nope, have no desire. I work hard enough as is responding for those who duck calls (my pet peeve !) so I don't need to respond when asked. However, if we are extremely busy and hear of a multi patient MVA that sounds serious or a code, we'll slide that way to lend a hand, but we ask first. Now, as far as dealing with another service, ALOT of call jumping went on for one place I worked. It was a pissing match between the three services in town and when the tones dropped, it was heard by all, just a different tone dropped. All three fools went screeching around town trying to get there before the others just to get the run and justify their existance. It was horrible and patient care suffered tremendously. Is the reason I left the service and last time I checked it was the same way still. No excuse for it.

AMR tried to buy us out twice and our director told them "I hate you, you're incompetent, go away !" and yes we did hear those exact words come out of his mouth ! I was impressed. There's also the issue of no fire coverage if we leave as in many areas considering most of us double for fire and wouldn't be too thrilled taking away our paying jobs. We're a private company on county contract, but also do fire coverage, so they would be left with sparse volunteer coverage and that wouldn't fly. It's a very rural area and with us they have a dependable response. They tried us being just EMS based previously and it didn't work out well, so I don't see them selling out, but like you said, who knows?

Whoa, I don't even know what to say to this. It's unbelievable, but this isn't the first time and certainly won't be the last I imagine. A friend of mine's department recently had two people trying to pull the same stunt. Can we say EMS needs more medical oversight? The first thing that happens at my dept is your cert is checked against the state for any infractions period. Is also done at every recert which is two years here. I can't believe this guy made it 17 months. AMR is trying to get a hold here, but they face some pretty good competition, so I really don't see it happening. I just wonder what legal ramifications (if any) it sounds will be made from families of patients that this guy treated. Did his falsification lead to deadly mistakes? Never mind DEA issues. The guy was handling narcs ? Makes me rethink this whole idea of "professionalism"....

check this out - is actually pretty good http://paramedictv.ems1.com/Clip.aspx?key=18604E80AC653C3F

I had a moment one day when I just lost my sense lol. I was calling in report for a transfer from ER to ER and went to tell them the pt was intubated and went, "the patient is uh, uh, forget it, we're breathing for him !" I couldn't think of the word to save my life. Walked into the ER a little red faced, but no harm done. The nurse that took report was laughing at me 'cause she was used to getting nicely put together call ins from me and I had a moment ! All well, it's okay for another day !

You all remember a few years ago when tickle me elmo became obscene elmo from some disgruntled employee? Man, I'd love to get my hands on one of those. It would be too fun....I know I'm twisted but that sounds like something I'd do.

First off, hey dust, long time no talk ! Hope you been doin okay. Now for the issue at hand, we have the duty to treat people no matter what, how little we think they deserve it, or how much they abuse the system. If you don't like that, find a new profession. McDonalds is hiring at 8 bucks an hour here, higher than the majority of EMS services for basics and all you have to do is ask do you want fries with that? That patient that calls you every saturday at three am for the "I don't feel well" little ole lady needs some service of yours. Now yes, it diverts services away from true emergencies, but that one day when you don't take her seriously is the day it will kick you in the arse. It almost has me, and I'm sure many others. Just ask the ones of us that have been in it very long. I work in a service where precious resources are stretched very thin and sometimes we have hold times for response because we and the surrounding counties can't get free due to all the dialysis transports and "b.s." runs. However, I'm not gonna be the one to loose my cert because I didn't do my job. Yeah, I don't like three am wake up calls, but I like being without a job and homeless even less !

Okay, I started this topic, so I'm gonna stretch out my neck on this one. It's gotten completely outta control. I have seizures, I take medication for them, technically this is a mind altering drug right? I'm not allowed to work 24's with no sleep though I do work extended shifts, I have at least four hour breaks where I'm off the truck in them. Every six months I provide my employer with a statement that I'm fit to work - now how would that not work for others? I haven't heard anybody suggest that theory yet. Also, I think it should be more open to take mental time off if needed. I know many services including ours are short staffed, but it's an option for 4 weeks. I love where I work, they take care of us and work with what we NEED both physically and mentally.

Mystery shoppers in the ER and EMS? Is that what you call my BS patients? When I worked in a trauma center, things weren't neccessarily better than in the smaller hospitals, larger volume, bigger problems, along with the little ones, and the county jails to deal with. None of which were fun. They treated us well for the hell they gave us, but I wouldn't dare do it again (my boss left). Plus had to babysit student docs, medic and nursing students to boot and always the patients and put up with all of their mouths to go with 'em. I think mystery patients are a waste of energy and money on everyone's part. There was one hospital near here that used to put the 'average' wait times for certain things ie lab tests, ct scans, x rays, whatever. They kept to those pretty well. They also went out of business...enough said?

Check responsiveness - a x o x 3 clock : 20 sec

most services around here it's between 21 and 25 though most are 21, no major driving infractions, no more than one accident in last 5 years, less than 3 points on your license in last 5 years, and no suspensions or history or DUI (ever for our service). This is general info for my area.

Hey, I've been busy lately and not been on much but what happened to the ALS and BLS forums? They do away with them?

We're dispatched by state PD as are most counties surrounding us, so we follow their codes. However, if a crew goes without transmission for over 15 min to update dispatch, they call to check, if no answer after 3 attempts, then they send us a trooper. After the first of this year though, we got GPS and we had frequent problems with them not being able to reach us in some remote parts of the county. Better equipment and the GPS as well as increasing number of dispatchers has helped reduce false alarms.

As someone who primarily serves in a rural setting, but have been in just about every type of EMS setting short of flight (which hopefully one day I will) with 8 years of experience (not NEARLY enough, but enough I feel to comment on this) I can say when I started with my 120 hour basic, complete with 150 hours of ride time, and 10 hours in ER (more requirement than most have) finishing at the top of my class I walked out knowing just enough to kill someone. I spent nearly three years on the truck before I was expected to respond 911 and by that time did I feel comfortable and adequate to manage a severely injured patient for 45 min until they reached the hospital? Absolutely not, nor do I think any other basic is prepared adequately for this situation. I know the response already - well call for ALS or a helicopter. In my area, you can't get another truck and frequently helicopters can't fly due to weather or land due to the terrain. Would I want a basic fresh out of class managing my family or me in that situation? No way. I do believe the education standards should be raised. NREMT is moving the right direction with the push for a minimum of 2 year degrees for medics by 2012. Will this affect education? I hope so. It might make things a little tougher for people to get their medic as every joe and sam fire department or ems service but it might cause us to raise the requirements and gain some of the professionalism that Dust is talking about. It did for the nursing profession, I don't see how it could hurt us. Think about the job and what you really want to get from it. Do you want respect and to treat patients with the best amount of care? Or do you want to do what's easy for you? Expand your horizons and push for the best of patient care. If more is asked of me, I will give it. I am in this not for the money 'cause Lord knows I don't make enough, I got in it 'cause I love what I do and the challenge good patient care brings. If that means taking my education to higher levels, then I'm all for it.

You know one troubling thing that hits my mind is so many here saying I was with a FD at 13, 15, etc. One is NOT responsible enough even to be a volunteer at that age. When faced with issues that are life or death, I believe you shouldn't be involved until at least 18. At that point then, enter as a probationary until 21. The service I work for won't hire anyone under 25. That being said, I entered EMS the day I turned 18, however for a year I was only allowed to ride as a third to get experience. Then I got to graduate to a transfer truck for another year and finally progressed to a BLS 2nd out truck. I was 21 before I was able to run first out 911. Do I think it helped me gain the maturity and stability I needed to gain before being put in an emergency situation? Definitely. Wish more companies would do that, unfortunately with the overabundance of fresh outs and people quitting at a rate to be rivaled, I don't see things changing soon.

I worked within an ER at a major level one trauma center for a year to take a break from street EMS. For me, the pay was about equal so I couldn't complain, I had a better schedule, and had the opportunity to see and do more within my skill level daily than I ever did on the streets (even though I work within a busy service). They split the medics up into trauma, fast track, medical, cardiac, or peds. I was in the trauma area and loved every minute of it. Docs would frequently show us things encouraging us to learn explaining everything from CT scans, to how and why such an injury affected a patient in the way it did. I did some time in the medical side and got the same response from the docs there. I ended up leaving only because the schedule I worked didn't allow to continue with school and getting a shift change was extremely difficult, so I returned to regular EMS. However, I learned alot and if given the opportunity again, I'd take it. We started IV's, intubated, pushed drugs, and operated more independently than many of the nurses. Great learning experience, especially if you get in a trauma center or busy top notch medical hospital.