ERDoc

EMT-CC, or Came Close, lol

And why should we push for the paramedic standard across New York State and the rest of the nation? Read the scenario above several times until it makes sense. Which hero rescue response squad were they from?

It was *******HIPPA******** Fire Department. 8)

Yes, this was an actual call that I took a little while ago. I posted it more to vent than for a real learning experience. This is an ALS crew (EMT-CC for you New Yorkers). CPR was started by the NH staff when they witnessed him collapse, 15 minutes prior to EMS contacting medical control.

EMS: Oh, so I got asystole on the monitor. Should we stop CPR now??

Doc: No, let's avoid a wrongful death lawsuit and work this one to the ER.

EMS: The pt has been down about 15 minutes total now. They said they started CPR as soon as he went out. Yeah, he has lividity, his entire face was blue when we got here and now his hands are starting to turn blue. The only thing done is CPR. Can we terminate? Oh, you want to know what rhythm he's in? Hold on I have to put the monitor on him.

You are the doc at medical control when you receive a call for a field pronouncement. Your coversaton goes like this:

EMS: We have a 77y/o male witnessed cardiac arrest. On my arrival the pt had lividity to his face. They were doing CPR and bagging the pt. His abd is distended. He has signs of not being viable. I want to stop CPR.

Doc: So, the arrest was witnessed and CPR was started right away?

EMS: Yup. The nurse said his face turned blue as soon as he went down. He now has lividity in both hands. Can I stop?

So, what do you do?

Master of EMS Universe

Start at the top.

EMS would be removed from NHTSA, and have a Federal Division of its own.

All State EMS Directors would had have EMS experience.

Every State would have State Board of Paramedics, (similar to nursing) ran by Paramedics for Paramedics. Retirement and benefits set by state, similar to Fire Services.

All State would eliminate, certification level for Paramedic level, and require license.

EMS managers would have to have a minimum of a MBA, or equivalency of true management education.

EMS Instructors would have to have a minimum of Graduate Level to teach. Chairperson(s) having at least a Doctorate level.

All Paramedic level would be a minimum of undergrad (baccalaureate level). With option of RN/Paramedic, or Education, Management specialty for entry into graduate level. The wording "EMT" would be removed.

To be able to proclaim, the title Paramedic one would have to have at least 1 year minimum or documented experience.

All clinical hospital sites would have professor on site, like all other health careers.

EMT position would be for non medical services such as rescue, LEO, 1'st responders, etc..

Reimbursement rates would be based upon level of care, and ability to increase with proper documentation of education of staff, and TQI. and active participation of involvement in health care systems.

Benefit package and enough pay incentive that EMS personal would not have to supplement their income. Ones could actually retire form EMS

More to come..

R/r 911

Rid, what would you think of putting EMS under the oversight of ABEM (American Board of Emergency Medicine)? These are the people that set the standards for us to be board certified in EM.

Unless there is a reason not to, I always put at least a 7.5 in women and an 8.0 in men. Imagine trying to breath through a straw for a few days and you can appreciate what these pts feel. Also, in critical cases you want to be able to get as much oxygen as you can and blow off as much CO2 as you can. For peds I generally use the (16+age)/4.

The system here on Long Island is pretty bad too, though we do have ALS, but for the most part it is weekend warrior ALS. Pretty sad considering we are one of the largest volley systems in the country (both FD and EMS). Here is a link to a recent expose on the Fire and EMS service from one of the local papers. Be sure the check out the Taj Mahals that are being built to house the equipment.

http://www.newsday.com/news/specials/nyf-i...0,3691882.story

Why is it that the less productive member of society you are, the more likely you are to survive a GSW/MVA/fall or other trauma?

Why is it that the pts that come in c/o pelvic pain/abnl vag bleed are the ones that never take a shower (did you seriously not think you were going to need a pelvic exam)?

Why do people call EMS/come to the ER if they don't want to do anything you tell them to get better?

How can Some Dude and This Guy be such good masters-of-disguise? They are single handedly responsible for millions of violent assaults and have yet to be caught.

Why is it that people have no clue that there is no cure for the common cold?

Why is it that people feel the word 'Emergency' in EMS and ER is optional?

Just a few points to ponder.

I think a lot of folks out there don't realize that Combitubes and LMAs are buck devices that are used until a definitive airway can be established. A definitive airway is a properly placed and secured ETT or a true surgical airway (Trach or cric, NOT a needle cric). It is only appropriate that if a basic has put a combitube in that the medic should attempt to get a definitive airway established. That EMT partner that was offended by it needs to realize that it is about proper pt care and not his precious little ego. I'm not sure about the role of LMAs in the prehospital setting, they seem to unstable to me. Like others have said, master proper BLS skills and there would not be a need for adjuncts, thus decreasing the risk to the pt (isn't this what it's all about?).

Why do Pt's always start experiencing chest pain after you have given your report to the triage nurse at the hospital saying that they are not having any chest pain? Or more critical pt's, who's symptoms miraculously resolve as soon as you pass through the ER doors.

Don't feel bad, it happens inside the hospital also. A pt will c/o toe pain when the med student goes in, then abd pain when the resident goes in and finally chest pain when the attending goes in. When the admitting resident comes to see the pt, the pt will wonder why he is being admitted for toe pain.

Pt has no good veins, IV attemps x3 enroute failed. Why bgl? We didn't take one. No indications for it as far as I can see. ECG 12 lead shows 1st degree HB, otherwise nomal. Prob. not sepsis- no recent hx of any signs/symptoms of infection. BP in legs- L 90 sys, R 130 sys (or vise versa, I don't remember). Micturation syncope?....lasting approx 5 hours? I dunno, you're the doc. Any more ideas?

Mictruition syncope can last quite a while from what one of our cardiolosists have said, but I didn't realize that it had been 5 hours so you are right not likely. Do not rule out sepsis in this case. Elderly people are not up on the latest textbooks, so they don't know how to present with typical symptoms. Though I think it is low on the ddx (especially with those BPs in the legs), don't take it off just yet. Let's get cultures. I think we need to continue trying to get IV access, when you get to the ER we'll drop a central line in.

Let's face it, the ddx on this case is huge, and we need to do a little workup, especially before we run to the OR. The first things we need to do as soon as the pt comes through the doors is a bedside US to look for free fluid in the abd and to look for an aneurysm and we need an EKG (she wouldn't be the first to present with atypical MI symptoms, it's pretty common in the elderly). Other things we would need to worry about (most of which people have already mentioned) are divertics, possibly with perforation (will need an upright chest xray), UTI (let's get a UA), appy or dissection (will need a CT), micturition syncope, as well as other less threatening things.

I had not mentioned that I had him on NRB @ 15 LPM, and they were getting worst, that is the only reason because when he started having the runs of VT, I got a little worried, I would like to know as a ER doc would you have choose Lidocaine or Amiodarone in this case. I would just like this oppioion form a ER Doc so that I might have a feeling of the difference or the same ideal. Since you are Doc and ER at that in a big city you must have used both thousands of times and problaly have seen differences. Thank you for you time I know that you are busy.

I don't know about the big city part or the "thousands of times," but I think what you are describing would do fine with Lido. I must admit that I have never used Amio outside of a cardiac arrest. For situations like the one you presented I would always use Lido (can't say I have any evidence for it, just the way I learned).

This case just shouts BAD!!!! First off, we have a 90-something year old with belly pain and bad vital signs. Divertic is a possibility, but I wouldn't want to hang my hat on it yet. It would be nice if our ambulance has an US machine, we could do a FAST exam to look for evidence of blood in the belly (really bad given the coumadin).

Again, all I think of with this scenario is BAD!!!

The lido may or may not have been needed (I wasn't there, so I can't judge). The EMS director needs a little re-education (or as recently been discussed in other threads, some education period). I hear the vollies where I work always getting mad because we repeat things that they do when the pt arrives in the ER (retaking the history, doing our own EKG or our own finger stick). I think this is a perfect example of why. You should always do your own assessment, regardless of how much you trust the person that is giving you the info. If you document what they tell you and then it ends up in court, you will hang.

To make a short story long, this actually reminds me of a recent case. At the university hospital that I work at we have a code BAT (brain attack team) for when a stroke pt comes in that may be eligible for thrombolytics. When the code BAT is called it activates the stroke team (Neurology, CT, MRI, ICUs). We had a pt come in that was a code BAT. So she gets into the room and we start working on her. About 5 minutes after the neuro team is in the room our triage nurse announces that another code BAT is coming back. The neuro resident offers to go do the initial assessment. After I finish my part with the first pt, I walk into the other room and the neuro resident walks out saying that she is done. I ask her what she meant and she says the lady has a finger stick of 10. Yup, this particular nurse is a little over aggressive, but has the best intentions.

I have to admit that I have never encountered this in the field. Or in the hospital either, for that matter.

(Not too many kids running around with implanted defibrillators, I suppose. )

But can others who have seen it tell me if Nate's experience is typical? Are the patients almost always reasonably comfortable? Or are there going to be some who might need a little Valium?

This is one of those situations where it depends on your pt. Those with a low pain tolerance will be screaming like they have a 2 foot kidney stone, while others will just describe it as annoying. Personally, I'm a big fan of aerial spraying of valium, percocet, diaudid and zocor.

This is kinda off of the topic, but what does the J stand for?

So what would an ALS provider do?

Malfunction: Nothing more than an basic really right? I mean other than a precautionary line and EKG

Needed: Would you push drugs in this situation?

No drugs, but in case the unit started to go south and the pt became unstable it might be good to have ALS. I would put on a monitor and definately get a line going.

Unless you have monitoring capabilities I would not use a magnet. The pt needs to be put on a montior, but depending on your proximity to the hospital it might not be worth waiting for ALS. If the AICD is firing because the pt needs it, it is doing its job and doing it correctly if he is still conscious. You may want to have the AED out just in case, but let the AICD do it's job. If it's malfunctioning, there is not much any level of prehosital provider is going to do about it.

Here is a link to a great article on cocaine toxicology from emedicine:

http://www.emedicine.com/emerg/topic102.htm

I stand corrected as to one of my previous posts. Labetalol has a 1:7 ratio of activity on alpha:beta receptors, so it is not the best choice. Looks like we all learn something from these scenarios.

It sounds as if everyone is in agreement on ntg (although you would need to watch out for reflex tachycardia). ASA is not a bad idea, won't hurt in most cases. Someone mentioned beta-blockade for BP. This would be BAD. Cocaine is an alpha agonist. If you block just the beta receptors you have unopposed alpha activity, which causes vasoconstriction, worsening the already bad MI, increasing the BP and possibly leading to stroke. This is the one MI where you NEVER give beta-blockers. You can start with something like labetalol which has both alpha and beta, or you can go with other options. This guy is having a cocaine induced MI, which is not all that uncommon.

There is no tenderness/pain is not reproducable. The pt was chatting with some friends about the theory of relativity and its relationship to the season finale of Grey's Anatomy. This is his first time speedballing. So it sounds like everyone wants to see a 12-lead, so here it is.

No LOC. VS 210/106 118 22 Pt takes no legal drugs, but says he has taken a few speedballs and has been drinking some Crazy Horse. No herbal suplements. The pain is crushing and he is diaphoretic and nauseous. No sob. LS CTA b/l.

Elevated B/P and back pain with Hx of HTN and S/P MVC raises flags regarding complications from an aneurysm (hence the questions), however, I cannot rule out a possible vascular obstruction at this point in time. I opt for hasty transport and initiating 2 lines at TKO with continued freq V/S monitoring, O2 therapy, and continuous cardiac telemetry. Progressive EMS??

Take care,

chbare.

How progressive do you want to be?

You are called to a private residence where there appears to be a party going on. Your pt is a 32y/o male with no PMH who is complaining of sudden onset of left side chest pain that started while he was talking to some friends at the party. (VS-eh, should we let this one walk? )