captainstandup

Now Marty, you are being too harsh on the "remediated to success" folks. You may damage their inner child with this way of thinking. And ACLS, there is an organization for sale to the highest pharmaceutical bidder!

The hospital where I work started using a high flow nasal cannula for certain COPD patients and the flow rates can be considerably higher than 6 LPM. The oxygen is of course humidified and is often blended with medical air and as dust eluded to is titrated to the desired FiO2. This is further backed up with ABG;s, SPO2 and good reassessment to determine the patients clinical condition instead of relying solely on the gadgets.

I have never advocated harming someone because they are homosexual. The problem I have with the "organized homosexual movement" is in the whiny, perpetually offended give me my rights or else approach they assume. Even to the extreme of exposing children to disgusting behavior in public. One even said a few days ago that "gay is the new black" I suppose he is trying to attach their chosen lifestyle to the roughly 221 years of african slavery on this continent. (And no I don't think they deserve one dime in reparations) Anyway this is an example of just how desperate these folks are to validate their lifestyle. I submit that it is disrespectful to equate a lifestyle CHOICE to the legacy of those that suffered the horrors of slavery as well as during the civil rights movement. Please dont try to associate yourself with the incredibly honorable folks that scaramedic listed. Now with all of this said please understand I have very good friends that are homosexual and we often have spirited debate about these subjects, but at the end of the day we are still friends respectful of each other as a person. I offer you that same respect sir.

Is there a specific area or subject you are interested in ie: trauma, cardiology etc?

Forgive me if I digress a bit but a few earlier posts in thread seem to call for response. The posts to which I refer are the ones pertaining to rural meidc / urban environment or vice versa. This entire line of discussion personifies the reason we remain in the dark ages as a profession. Having a contest of who is better than who is an adult version of kids comparing the size of their private parts. This reminds me of when a nearby county added RSI, which immediately resulted in a five fold increase in intubations in just one week. The medics were strutting around comparing notes and I overheard one of them state "you better not miss a breath or I'll RSI your ass". Its this kind of thinking and uneducated bravado that causes medical directors to remain reluctant to permit expansion of our scope of practice. Medical directors and others with a stake in the "stuff" we do aren't interested in folks that are reckless and simply perform a skill because they can. These folks as well as true professionals within our own ranks must understand the science, biology, pathophysiology, cause and effect of all that we do and gravity of the decisions we make to truly become respected as professionals. RSI is a really good example for this discussion since it is likely one of the most dangerous skills we perform if done improperly. And remember in most systems if you are a paramedic then you are permitted to utilize all of the paramedic skills, regardless of your ability or lack thereof. Think of the worst employee in your service then apply this. All I'm saying here is that instead of worrying about who can accomplish what in the shortest period of time "I can name that tune in three notes" focus on whether you can deliver appropriate care to the patient and safely deliver them to definitive care. Finally I must tell you that i find it hard to believe the assertion of things that can be accomplished in five minutes. It seems as though you are saying you can perform a thorough patient assessment, make a treatment decision, begin appropriate treatment, evacuate the patient from the residence and begin transport in five minutes. If this is true you are arguably the fastest most efficient pre-hospital provider in the nation.

Exactly, it's just like an EMT or Medic thant cannot get the skills from their head to their hands, how often do we see that?

Our county dispatch has came a long way in the past three years or so. The 911 center has a totally integrated CAD that gives GPS position of the calling party whether its land line or cell. This is integrated with the county mapping system and also provides some text directions. There is also a feature that allows the dispatchers to annotate a residence if there are logistical concerns (850 pound patient, dangerous dog, any safety or operational concerns) when a call is received from or dispatched to that residence the CAD flashes with a red indicator to make the dispatcher aware of previous issues at a specific residence.. This enables them to get another unit enroute and or FD assistance. I stll hate them, they are pond scum.......................

What a great learning opportunity, thanks again. Unfortunately the Critical Care Service I work for now is hospital based and all they care about is JACO accreditation bullshit. Our training program is virtually non existent therefore we have to find creative ways of training. We have universities and Community Colleges that provide a great deal of training and education thankfully. Most of the CCEMTP's work really hard to remain current and I myself get roughly 250 hours per year but it takes effort to say the least! I must tell you this is outstanding and fun. I have already told over half of my colleagues to visit EMT City.

I have this one or mine may be an updated version of this one as it has two CD's instead of the audio cassette. In any event I would suggest searching for the most up to date version of this text. Heart Sounds and Murmurs: A Practical Guide Barbara Erickson (Author) Paperback: 129 pages Publisher: Mosby-Year Book; 3 Pap/Cas/ edition (January 15, 1997) Language: English ISBN-10: 0815131461 ISBN-13: 978-0815131465 Product Dimensions: 9.5 x 7.4 x 1.3 inches Shipping Weight: 1.3 pounds

You made about nine really good points dust. I'm getting that OB book down right now. I think the part of this I have failed to understand is the discussion pertains to quite lengthy transports. I have always taught students the key to adequate patient care is good protocols and the key to excellent patient care is the ability to process a myriad of information, relate it back to the patients current situation, properly apply the protocols, and have the intellect to be prepared for a change in condition. Our service isn't in "down town LA" but we are about 30 minutes from a level II Trauma center with NICU and PICU 24 hours per day. I thinks this clouds my reasoning when presented with a scenario like this. I like to think of myself as the patron saint of thinking out of the box "no pun intended"around our service and am often told "paramedics just take people to the hospital". These folks will be around here until they are so broken down they cant work anymore or will be forced out as EMS actually becomes a profession requiring education and folks that can adapt to an ever changing environment of care. I'll be back on this one when I am better prepared to open my mouth...............

Field management is simple, treat the symptoms, guard the airway,IV, O2 (but that will change in the near future with all the free radical data coming to light) be prepared to treat seizures, analgesia for extreme pain and zofran or promethazine IV if you are nauseated. You need a CT now to rule out lesion and CVA. Although you said no to neck stiffness I wouldn't rule out encephalitis.

Wow we have standing orders for virtually everything and rarely call medical control but I would call them on this one. Other than treating his respiratory issues there seems to be little we could do on the ambulance. Possible exceptions include NTG drip as mentioned earlier and since we carry heparin we might consider a heparin drip but not without an order given this fellow isn't in A-fib. What he needs is an ACE inhibitor and as sick as he sounds he needs a swan-ganz for hemodynamic monitoring. He also needs to have an echo. It's quite likely he may need a balloon pump placed until valve repair or replacement can happen.

Thanks for an awesome scenario! I sit here a bit red faced for failing to properly assess the patient which includes HEART SOUNDS! How embarrassing, ok back to paramedic kindergarten for me........................

Is it possible he is reacting to something he was using to wash dishes? Exposure to certain toxins will cause "non-cardiac" pulmonary edema. Of special nastiness are chlorine, ammonia or nitrogen dioxide. I know, this is grasping at straws but this is an unusual presentation. What about considering an albuterol HHN tx earlier in the case. Another concern would be a massive lung infection but ordinarily this would have been know by the patient and would have been of gradual onset.

Damn, now I have to research syphillis infections and the associated pathophysiology. Thats what I really enjoy about these threads, they really make you think. With that said I doubt its related to syphillis hmmm back to you in a few.

Based on the presentation and progression of this case I feel he is suffering from CHF. Although most of the folks we see with CHF have either a much higher or much lower blood pressure. You said frothy sputum, is it pink or clear? Anyway we need to get a V-4 R before we start slamming him with nitro in the event he is having an MI with primarily RV involvement. We also need a second IV in case this fellow needs to go to the interventional cath lab, but we want to limit fluid admin to KVO for now. Also I didn't notice if anyone asked if this guy was taking viagra, levitra or cialis as this is more common in diabetics. It would also be nice to know if he has dependant edema or a distended abdomen suggesting hepatic engorgement with fluid. In absence of RV involvement this guy needs nitro q5 as long as his pressure will stand it or in our case a NTG drip. He also need 120 mg of lasix. Since he is getting really tired and lethargic I think we are likely beyond the point of being able to use CPAP therefore we are going to be forced to RSI him. akroeze is spot on in that this person needs high flow diesel fuel. It would be really nice to have a chest x-ray and labs but obviously these aren't available in the field.

Now spenac, you know we are out there to "save lives" gag, cough, sputter, grimace. I cant even keep a straight face on this one. We are there to provide a service and in turn get paid to do a good job. Hey if you think the rural EMS or dispatch, volunteer folks are amusing you should spend some quality time around an arrogant flight crew.

You wouldn't want to hire them and I didn't hire them. It was a shame for one young man fresh out of school with a brand new BS in Emergency Medical care and a shiny new paramedic card. This kid came to the interview with some kind of earring type device above his right eye, had a tongue piercing that distorted his ability to speak clearly and finally had what appeared to be a chain tatoo that came up his neck just above the collar. This kid scored higher on the pre-employment exam than anyone before him. He scored marginal on the interview but in the meeting afterward where we tally the scores and make the hiring decision everyone on the committee expressed concern regarding how this guy would be perceived by patients. It may be acceptable to hire someone like this in a metropolitan environment but in a mostly rural community it would not be well received.

Perhaps we have reached the saturation point. Not everyone can be an emergency "responder". I have serious doubts about the usefulness of the whole community based silliness anyway. When I was in emergency management the feds and state governments were really pushing us to advocate for CERT's. I wasn't sure what the underlying motive on this was either.

In terms of liability to a pre-hospital provider or service the only thing that trumps refusals is of course issues related to driving. With that said I have never taught students to become focused on liability as their sense of right and wrong in caring for another person. Start your day with the desire to use a combination of education, training, experience and clinical judgment to guide your actions. Our SOG's require the following to allow a person to refuse: 1)Conscious alert and oriented 2)No evidence of impairing substance 3)No injuries of a severity that could be classified as distracting ie: pain that could distract or alter a persons ability to comprehend the risks of refusal 4) Person is of legal age to refuse (18y/o) If we encounter situation where the childs life or quality of life could be at risk, we involve law enforcement and child protective services. A signed refusal is only as good as the civil jurys sentiment toward a plaintiff with a claim against you, or even worse the family of a dead patient. A lot of folks treat the refusal as if were the holy grail that covers them in event of bad things, unfortunately this is a fools bet. Its also important to note that this refusal occurred during a time when the EMT or Medics were due to get off shift. It would easily be perceived as though a crew didn't want to work over whether this is the case or not. Another thing that jury's look at is an EMT or Medic's "refusal rate" or how many refusals a particular provider does over time. Don't be mislead into thinking that HIPAA would protect you from them being able to look at other patient records as all they need is a court order. The key to all this is to clearly follow your protocols / SOG's to the letter. Painstakingly document a THOROUGH patient assessment, establish the patients LOC in a manner other than "A/)X4". Instead state something like "Patient is fully conscious alert and oriented to date time person, place and is without evidence of impairing substance or distracting injury." Also note in the documentation that the risks of refusal were clearly explained to the patient and he/she states they understand and accept those risks. If possible under your SOG's call in on a recorded line or over the radio to include Medical Control in the documentation process and finally have someone other than your partner to sign the refusal form as a witness. There are no guarantees in EMS but I can assure you if things go wrong with a refusal situation they (the agency, admin and perhaps the Md's) will throw you under the bus instantly!

I really need to figure out the etiquette of EMT City. By the way I have e-mailed everyone I know about this site. I am embarrassed that I didn't know of its existence until just a couple weeks ago.

Don't lower yourself spenac, you have demonstrated an unusual acumen for spirited discussion and it's been fun joining in. Why would you resort to unspenac behavior? I was trying to articulate the knowledge base of our personnel when I said they were among the best trained in America. Of the 40 plus employees we have one Phd, seven master's degrees, six bachelor's in EMS and nine associate's degrees. 73% are NREMTP eight are CCEMTP. There are six state certified paramedic instructors. These folks enjoy very broad protocols and aren't required to contact medical control for anything except to notify them of ETA and in circumstances where specialty care may be required. These guys and girls have worked really hard to accomplish the level of expertise they possess. Childish silliness is beneath you. Oh and by the way akroeze what the hell would a Registered Practical Nurse from Canada know about training in America anyway?

One of my best friends is a lesbian and in a committed relationship. She doesn't spend one damn minute of her life protesting, whining, pissing and moaning about how disadvantaged she is, you know why? Because she is a professional self assured individual that doesn't need to draw attention to herself or the "gay cause". Her relationships are, like everyone's should be, private. She is decent hardworking and honorable unlike the 99% of the gay men in the town where we work who are constantly marching or in the media crying because someone has infringed on their "rights"

I never say never and we do have a legitimate discussion. I am waiting on you to tell me what crucial information can be gained from a digital inspection of the patients vagina that will change your care of this patient in the field? I have, in over 16 years, never said the words "we don't need to know that" nor will I EVER. There is simply no instance where I have led colleagues or students to belive there are limits as to what they "need to know" I'll start the discussion by guessing the answers. As I have already said perhaps you are trying to determine how soon delivery will occur based on dilation. 2) You are trying to determine if the membranes remain intact or not 3) Perhaps you are trying to gain early warning of an abnormal presentation, presenting part or prolapsed cord requiring emergency surgical intervention. What information are you going to gain that offsets the risk of digital examination and justifies delayed scene time? Like I said this is a discussion about a medical topic, no need for veiled cynicism or to impugn the knowledge of each other. I am really interested in learning from your perspective on this subject.

Perhaps I did misunderstand Rid. In any event I never say never but I admit you could have derived that from my post. I must ask though, what useful information can you gain from checking for dilation in the field that will affect or change your care of the patient? I mean information that is totally different from that gained from visual inspection. I have crunched this for several minutes and the only thing I come up with is a better estimate of where the patient is in the delivery process (time to delivery). Does this determine whether you stay on-scene or drive with reckless abandon? I noted in my earlier post that we would make appropriate preparations for delivery. I am trying to learn something here so skip all the personal attacks and help me understand the benefit that outweighs the risks of doing this in the field.