captainstandup

Just wondering how others care for an acute asthmatic patient who also has a history of psychological problems requiring them to take MAOI's or TCA's?

I pray the scumbag inhaled deeply during the fire and hopefully suffered for three or four days then died alone and smelling like a well done camel. It would be cool if that was merely a "warm up" for his new residence in hell.

I had considered the Excelsior RN program just as a way off the ambulance. Nursing schools here are so politically charged and "anti-male" that its really difficult to gain admission regardless of my previous education and honors society status. Add this to the fact that greater nursing has a vested interest in perpetuating the "nursing shortage farce" In NC the board of nursing has been fairly successful in keeping paramedics out of the ER's in order to protect their turf. Before the nurses jump on me (like a pack of wolves) about quality of education crap or selecting the best candidates, give me a break! I can match "pedigrees" with pretty much anyone with less than a Masters Degree and have almost 16 years of caring for the sick and injured, and doing so without a net. Regardless of your education or ability, unless we kiss the "ring" of the nursing powers that be, paramedics aren't invited nor are they welcome.

I worked on a grant that would have placed an AED in each patrol car in our county but was only able to get one law enforcement official to support me. The dumbass that was sheriff at that time was an uneducated "good ole boy" that fought against the effort from the initial stages. The grant would have paid 100% of the cost which makes it even more sad.

Ok I'll agree if they are equipped and trained then they are a first response component of the EMS system. I should have been more attentive. Cops in our region are nothing more than spectators at cardiac arrest scenes. In your situation it may actually be as important for the cops to respond emergency than the ambulance since they can actually provide potentially life saving therapy

Cardiac arrests should be run in the field, and stopped in the field. Through properly applied therapeutic electrocution, first and, if we must, second line resuscitation medications and end tidal Co2 (attached to an endotracheal tube) we will have virtually 100% predictability of whether to transport to ER or morgue. Cops running emergency to these calls is questionable, EMS transporting a cardiac arrest to the hospital emergency traffic is foolish. Consider the risk to unrestrained providers attending to the patient, and for what? Exceptions to this, in my opinion, would include pediatric arrests (in interest of family and crew mental health) and cases of penetrating trauma where surgical intervention may change the outcome.

OK, father I have sinned, I despise going to them too, but hey it really really beats these godforsaken nursing home calls, unless of course the nursing home is on fire. I don't dislike the patients in the nursing homes, just the hopelessness of their situation and the neverending moneygrubbing silliness and fraud that exists within them. Perhaps it a bit of a "mortality check" that hits a little too close to home too, now that my parents are over 70.

I finally believe I understand where Dust is coming from. I agree we should never practice "cookbook medicine" Let's see what were we supposed to do after chest decompression? hmmmm . In a situation like spenac works in, 90 mile transport he I could read war and peace, why not take a look to make sure you have covered all of the bases? I certainly wouldn't be opposed to looking up a dosage for a critical care med that we rarely administer.

Could be an allergic reaction, but EMT I 2802 implied that narcan saved the patient. Oh well, I still remember vividly the "proctology exam" we received and this was for a routine audit, not a "for cause investigation"

In North Carolina the Division of Health and Human Services has a controlled substances division which periodically audits anyone that dispenses narcotics. There has to be a closed chain of custody which tracks the med from receipt by EMS, hospital etc to administration and even includes forms that document who it was given to and the manner by which the unused portion was wasted. The forms, or in hospitals an electronic form, must be kept for years. Waste requires two signatures. With this said I realize that EMT I 2802 may live in an area where injectable morphine is less controlled (perhaps its considered an over the counter med there!) however, I find it difficult to fathom that someone had access to enough of it to essentially kill them, via oral admin. By the way Dust, hows the weather in the sandbox?

Although I work for a ground critical care service, It's is inconceivable that anyone with even rudimentary understanding of patient care would expect the flight crew to simply load and leave. Its important to remember once the flight crew accepts care of the patient, they are accepting the total package. There is no way in hell I would accept responsibility for a patient based soley on a report from someone else. I have tremendous respect for fellow EMS folks but there are a few things I'm taking a look at, such as, but not limited to: Airway patency and status, based on my criteria for intervention, work of breathing, circulatory status and need for intervention, Initial neuro status and disability, breath sounds and ETT placement if intubated, appropriatness of immobilization, IV patency, Monitoring data, SpO2, EtCO2, EKG, BP and Pulse

When my Grandmother was in Hospice care they issued my mom two bottles of "liquid morphine" 50mg/ml in 10 ml vial (SL Administered) and they gave her two of them to keep my Grandmother comfortable. For the mathematically challenged, thats 1000 mg of MS. The moment my Grandmother died Hospice was called and the nurse came to the home. The first thing she did was to go directly to the medicine cabinet withdraw the remaining MS, she then had me witness her destroying every drop of MS and several other meds, narcotic and otherwise. I've haven't researched nor do I believe that EMT I 2802's patient had access to enough (or any) injectable morphine that put them into arrest. Someone will eventually have to account for the schedule II narcotics.

Muslim extremists with a dumptruck load of ammonium nitrate and a tanker of diesel are less scary that Hillary.

Given the choice between standing by for the FD or responding to a urine soaked nursing home, I'll take the standby. Unlike the TV fanatics I work with, I always have books with me. You know those rectangular things with lots of pages and for the lower end of the spectrum pictures. Even after almost 16 years in EMS, I still try to better my knowledge base and improve the care we deliver. A fire standby is the perfect arena for this. Warm truck, relatively comfortable seat, map light and if we are lucky, we wont be pulled from the standby. There are always opportunities to learn and improve. If you are on a critical care unit, pull out the hemodynamic monitoring kit and make sure you are familiar with the cables and sets. This isn't for the mutts though, they will be out back of the rig smoking and bitching about being there.

If fire wants us to standby for dumpster fires I say we stand by. These are among the most toxic, dangerous responses they respond to. Unknown contents (and no I don't care if the mob dumped a body in there. ) Car batteries, illegal hazardous materials, compressed gas cylinders who knows. I would add that the ambulance should remain in a position that would allow them to immediately respond to an emergency call if they were the closest unit.

I suppose there is little confusion regarding patient care authority there?

I'm happy to learn Canada staffs flight crews with Paramedics. There exists, in the US anyway, what seems to be a veiled attempt to eliminate Paramedics from rotorwing services. Many now utilize RN / Respiratory Therapist crews and as I understand it, this may become the norm.

Ill agree that we should know the protocols cold with exception to pediatrics. Only a fool would attempt pediatric resuscitation without a length based tape. Even with adults its much preferred to verify dosage and admin criteria, when there is a question, instead of assuming you "know it" It's unlikely you will need to refer to the protocols for routine arrests, Mi's etc but if you have something off the wall, you always have the protocols, radios and cellphones to obtain advice through.

There was no attempt on my part to hide my disdain for SOME flight crews. You may join others in helicopter worship if you wish. The point I was trying to make is that just because an RN arrived via helicopter doesn't make him / her the final authority on proper treatment of every patient. The greatest percentage of flight calls in our region are interfacility transfer. Probably 90% of the time they are called all critical skills have been completed and all the patient requires is a ride to the hospital with ongoing support Your inference that these folks possess higher training or experience is, at least in this instance, inaccurate. I went through Paramedic School with three of them and later to Critical Care School. We have exactly the same clinical background, difference is that I actually use my skills because we, the ground transport team, aren't always grounded for maintainance or fog or lack of interest. I have had on three occasions to transfer to the flight crew and passed on it due to my personal dislike for the system as it is and the organizational culture. On the other hand, there are services west of us and to the south that are competent, kind, grateful to ground folks and always humble. In this service, even the pilots show respect to others. There exists no desire for hero worship and they actually care about the patients rather that feeding their ego's. I spent way too long hacking on helicopter folks and didn't mean to. The point I was trying to make is a nurse is a nurse is a nurse and there will be those incredibly competent providers that bring to the table an excellent ability to care for sick and injured folks, On the other hand there are the gorgeous, blue eyed big boobed, striking appearance nurses that were hired for PR and personal reasons rather than clinical ability. Take care of the patients regardless of who or how many alphabet acronyms they possess. Until you relinquish care they are merely an additional tool on scene

The best you can offer with what you are allowed to carry in your bag of tricks is all anyone can ask. This isn't an excuse to stop gaining education and perfecting your craft. If the situation is as bad as it sounds you should change jobs if possible. Even if you must drive 20 or 30 miles to a service that meets your desire to practice in a better environment of care. Although it's not always possible to do so, its sometimes best to leave services that are as backward and stuck in the past as it sounds like yours is. Hopefully over time the mutts and looser idiots in power will either quit, die out or get sued into progressing to the new millennium. Don't waste your time and intellect waiting on it to happen though. Some communities Don't deserve any better than second rate services since by default thats what their community culture wants.

Under ICS the incident commander has operational command of the scene. The safety officer has delegated authority to cease all scene operations and even order scene evacuation including abandoning the patient(s) in interest of safety. Under unified command there should be an easily understood flow and transfer of care. The RN's presence on scene doesn’t necessarily mean that care has been transferred to them by default. The paramedic in charge of care (prior to arrival of the flight team) retains care until they have reached a point where care can be appropriately transferred. With this said, only a fool would squander the additional knowledge, tools, equipment, supplies and therapies the flight crew can offer. One of the reasons this sometimes occurs is that a history of arrogance and criticism of EMS and Fire by the flight crews. This is especially true in our area where virtually without fail they are arrogant, ungrateful and exude an omnipotent persona that offends pretty much all of the "less lofty" terra firma bound providers. These folks are hated and every attempt is made to call other flight services when possible. Problem is they are virtually the only game in town. In our area the advantages of flight crews are few and include: A relatively faster ride to the hospital. The ability to bring to the scene and initiate blood infusion. The ability to initiate a central line. Beyond this we carry the same critical care medications, same therapies, and have the same critical care training as the flight crews. In this situation the CCEMTP on scene retains patient care authority until transferred to the flight crew. I mentioned relatively faster transport times because if calling for the chopper is delayed until the EMS unit reaches the scene there are many instances where ground transport is faster if the patient is treated as a "load and go" We must also remember the risk of helicopter evacuation. Unfamiliar terrain, overhead obstructions, scene debris that may become airborne and threaten the aircraft and bystanders are but a few considerations. These risks must be weighed against the actual benefit of minutes saved. In very rural area such as where spenac works helicopter evac of even mildly serious medical emergency patients may be warranted. Turf battles are inherent in highly emotional situations such as EMS. These are worsened by people of poor character who have been lucky enough to be selected for highly honored flight positions. Hopefully the old guard of the hateful, arrogant fools will “die out” or leave these services sooner rather than later. Finally, I would caution providers against the assumption that just because someone flew into your scene on a helicopter and has RN or CCEMTP on their name badge doesn’t make them uniquely qualified to deliver better care. I have witnessed egregious errors on the part of flight nurses, potentially life ending errors for the patient that was never pursued by the powers that be. We are all human, in spite of the flightsuit and arrogant attitude, they are too.

Unlike 19 or 20 year olds she probably wouldn't be blasting through intersections, at 90mph against the red, either. A great friend of mine had a saying "drive only as fast as you are willing to wreck" The speed at which I am willing to wreck has steadily decreased over the last few years. It is quite unlikely an 85 year old EMT could safely extricate and evacuate a person trapped 300 feet over an embankment, but it is possible she could be effective in aiding in their treatment onboard and enroute to the hospital. I agree with Dust, age really isn't the determining factor, but I must add that both the agency and the individual must remain cognizant of the environment of care. We simply cannot allow our focus on touchy feel good political correctness to cloud our judgment and present unnecessary risks to patients or to the individual EMT / Paramedic. There exists a delicate balance between the recklessness, inexperience and strength of younger providers and the wisdom and physical limitations of older providers. As long as we can provide a reasonable blend our patients will benefit from both.

I had a crew that was responded to an unknown medical call. Upon arrival they carry all of this crap into the residence only to find an incredibly belligerent individual who was later found to be intoxicated with alcohol, vicodin and ativan. This guy had already spent 9 years in prison for felony assault. Upon entering the room the individual, who was ambulatory, make a sort of flanking maneuver and isolated the crew from the door and in doing so retrieved a rifle. While the individual was retrieving the weapon the crew escaped through a different door made it to the ambulance and left the scene while calling for help. The crew abandoned a brand new Lifepak 12 A relatively new Ferno Stretcher Thomas Jumpbag with pulse ox, meds, etc Oxygen bottle and regulator Suction unit Drug pack with full compliment of resuscitation meds One even left his portable radio Law Enforcement was called and after about three hours the looser was captured. The crew was distraught over the situation, but were most concerned about having abandoned $31,000 in equipment and causing their rig to be out of service for three hours. Instead of being criticized by their supervisor or myself, we issued commendations for excellent actions to each employee during our next staff meeting. We supported our staff 100% and they were taught repeatedly to remain safe by whatever means possible including use of deadly force against an attacker. (by whatever means possible) mediccjh's post inspired me to muse exactly why we carry all of this mes in first anyway? Practically speaking what equipment will you immediatly need. you need is a stethoscope, airway management stuff, cardiac monitor / defib, a few dressings and bandages, and perhaps one IV setup. First line cardiac meds could be kept in the monitor pouch along with airway stuff. Too much stuff hampers your ability to work safely and efficiently. What are some other items we should take in initially?

I've given this thread a lot more thought today. Perhaps input from other stakeholders is OK, but too often this becomes a political platform for the most uneducated and biggest trouble makers in emergency services. In volunteer organizations there is little that can be done to require leaders to have higher certification levels. I personally feel it to be counterintuitive to permit anyone to lead an EMS organization that isn't currently credentialed as a Paramedic. My reasoning is; how can a leader that has no understanding of even paramedic level pharmacology, A&P, Medical Emergencies, etc be effective in advocating for necessary equipment or supplies? How can they negotiate reasonable salaries, when they have no little understanding of what it takes to do the job? Most important would be their inability to have meaningful input or influence on scope of practice / environment of care issues. Four years in university business school and an EMT card is not enough! Leadership must have the education and BACKGROUND in Paramedic level care in order to be effective leaders and patient care advocates.

In all of your statistics you didn't mention how many of those volunteer agencies provide Paramedic level services. Also when I mentioned primary provider, I was speaking about the agency responsible to the "authority having jurisdiction" not just those who, as I said in my earlier post, dabble in emergency medical care when they dont have a fire to put out. I'm not slamming volunteers, I'm just saying that those trained to the highest level of pre-hospital care must be the decision makers. Fire departments in NC normally operate at the First Responder or EMT Basic level with some offering EMT-I but all of these are in actuality a function of "delegated practice" through the EMS System Plan. As an EMS Director I and the Medical Director essentially complete authority over who provided ALS services in our county. We also implemented a franchise ordinance to help weed out the parasitic private ambulance companies from attempting to move in.