triemal04

Likely bullshit medical claims aside, the biggest problem being faced here is that it's very likely the fault of the 2 EMT's. While real gurney malfunctions do happen, just by design and how they are used it's much, much more likely that the patient ended up on the ground due to operator error. I've had a couple times that when front wheels of the gurney hit a small obstruction (in one case a floor mat just inside the ER that was folded over on itself) and due to how the gurney was loaded and where the weight was, it started to tip forward...caught it easily both times, but if I hadn't...guess who's fault that would have been... Just another take home lesson that moving someone around on a small wheel-base while they are 4 feet in the air can have bad consequences if you aren't paying attention.

See...if you'd only been nice to that guy he wouldn't have sicced his brother on you!

Ouch, shitty situation to be in. While I think it's highly unlikely that the fall was the cause of the change in the grandmother's mentation there could technically have been cause there, so this may not have a happy ending for the EMT's and the company. Even with the state that the lady was in prior (and from a couple of comments at the end of the clip it sounds like she always had little intertaction with family), if she really was back at the house within "30 minutes" of the incident, nothing was really done for her at the ER, so proving that no additional damage was done would be hard. It's only a guess that she was transported, but I can't imagine that after falling from the gurney a company with any sense wouldn't transport her to the ER free of charge just as a CYA. I'd be curious to hear what exactly happened from the EMT's who were there, but it looks like the gurney fell over on it's side; why is up in the air, but even with all straps on, that'd still be a problem. I'll reserve judgement until all the info is out (which is unlikely), but I'm unfortunately leaning towards this being caused by operator error.

The only Autovent I've used was the 2000 so my info is a bit dated, but...it's a POS. The only thing it has going for it is that it's cheap...though I'd go so far as to say that for what you get it was to expensive. I looked into the 3000 and 4000 years ago and was less than impressed. The 3000 was 90% the same as the 2000, and from what I recall the 4000, while having some additional features, was still extremely basic, and the additional features (CPAP, O2 blending, tighter control over tidal volume, I think adjustable PEEP, and semi-adjustable I:E) didn't work very well. Needless to say the 4000 was not purchased. I can tell you from personal experience that, at least with the 2000, (which I think used the same technology as the 4000 and definetly the 3000) any spontaneous breathes caused problems. Spend the extra money, especially if this is for CCT, and even if it's for routine 911 and buy something better. From what I've been able to find the Oxylog series from Draeger is worth it, even the older models.

I don't know anything about that part of Canukistan <cough> I mean Canada, or the politics that may or may not be involved, but I've got a couple of honest questions. While Dr. Wheeler is the medical director for the BC Air Ambulance and has more experience with flight medicine than most doctors, what makes him the de facto expert? How and why was he chosen for this review? Is he a "name" as far as Canadian paramedicine (or medicine in general) goes? The reason I ask is that often when a review like this is taking place, multiple people are often involved so that multiple viewpoints can seen and to cut down on the potential for bias. It seems odd that only one person was picked, so if any of you can shed some light on that it'd be great. A STARS spokesman has said that Dr. Wheeler was flat out wrong about a couple of the cases mentioned; running out of epi was one. Was that ever resolved, or is there the possibility of it being a case of "this guy said that" and "I think what happened was"? The spokesman also mentions, and Dr. Wheeler confirms, that he had very limited time to look at all the evidence and finish his review. A spokesman saying this is one thing, but the person writing the review agreeing? That's concerning. It doesn't matter to me one way or another, just seems like there are some oddities here. Edit: he does have a good CV, so that's a partial answer, but not a full one.

I'm sorry there mikey, I was trying to give you the benefit of the doubt, but your half-assed justification and back-pedaling makes that impossible. You made a completely ignorant and innapropriate suggestion; deal with it. You suggested taking punitive action against a bad partner by backboarding ALL trauma patients. This would indicate that you know that ALL trauma patients don't require a backboard. Trying to bring up some made up numbers to make your comment disappear doesn't work. You suggested taking punitive action against a bad partner by transporting ALL hypoglycemics, suggesting that you know that ALL hypoglycemics don't need transport. Your clear lack of medical knowledge (5 minutes of death? Really? How about more hyperbole?) and an apparent inability to examine a patient is nothing more than another smokescreen for your bullshit comments. The first 4 things you suggested were fine, good advice actually. But when you start telling people to treat patients innapropriately and potentially harmfully because you don't like your partner you are nothing more than a hack who should be fired and barred from ever touching another patient.

Because all "trauma" patients don't need a backboard. All patients, hypoglycemic initially or otherwise, don't need to be transported. You are advocating taking people to the hospital that could otherwise be left at home or if appropriate find alternate means of transport, and performing an uneeded and potentially harmful intervention (backboard)...because you don't like the person you are working with. It's not the partner that needs to be fired if that's what you think is acceptable.

You still have a year or two, so it's not like there's a big rush, but you need to be looking into where you are likely going to be living for school; if you actually want a BA in EMS and plan on staying in Washington there's only 1 school that does that so that does narrow your search. Once you have that done, start looking into who runs the local EMS; there very well may be the possibility of being hired on full-time. Despite what you might think or people may have told you, it is very possible to work part-time while in college without any major difficulties. Also check into the local hospitals and see if they utilize any sort of ER tech, and if so, what the requirements are. If you'll have a car or other transport, don't limit your search to the specific city that you'll be in; don't cover a huge area, but look around for a bit. A commute isn't a bad thing, as long as it stills is affordable. Before you resign yourself to volunteering, make sure you aren't passing up the possibility of a paid job.

Now, I'm hoping that was all said with tongue firmly planted in cheek...otherwise, are you really advocating the innapropriate treatment of patient's just because you don't like the person you are working with and want to make them leave? Think hard on this one.

Sick, very sick. While at this point you can't really avoid intubation, you need to do it properly, and not rush. That BP isn't sustainable; start a large fluid bolus, and preferably finish it before giving any meds. Have epi drawn up in a "push dose" concentration; 10-20mcg/ml and be ready to use that to get over any changes in the BP, or even to quickly and temporarily increase the BP just prior to giving a paralytic or sedative. Depending on why you think that BP is low (the results of your overall exam) it's worth considering starting a pressor infusion now. As to what meds you will/won't give; there wasn't any mention that I saw of how awake the patient is. Any sedative you give needs to be given in very reduced dose (yes, even the vaunted ketamine) and still has a high potential for causing a further drop in pressure. If the patient is awake you can't avoid it, but just bear in mind that this person won't actually require much for sedation (cut by at least half if not more), and, in this situation if there is a bit of recall...that may just be what has to happen. Sux versus roc...in all honesty I'm less concerned with the possibility of hyperk than I am with what else is wrong. Is it possible? Absolutely. Likely? Well...that's debatable. I'd be comfortable in using sux but there is nothing wrong with the more conservative route of going directly to a long acting paralytic either. If this is someone that you judge to be an easy intubation and will be able to mask-ventilate it's less concerning. And in all honesty, if you can mask ventilate them it would be ok to use a mainanence dose of roc (0.6mg/kg) instead of the starting dose (1.2mg/kg) if the prolonged paralysis really was concerning to you. No matter how you choose to intubate, it's going to be a problem, both during the act, and after. The bigger concern here shouldn't be on what paralytic, if any, that is used, but on how you are going to sustain this patient, and correct what is causing his hypotension. The same the freak has for everything; his ass, google and wikipedia. Honestly, I don't understand why admin still allows him to post.

Like I said in the other thread...not worth wasting time on. Some people are, some aren't. Some can change and become worthwhile, and others can't. The ball would be in his court.

Compartment syndrome leading to rhabdo and acute renal failure. Edit: Damn Canucks! Always getting there first! If he has been doing repeated, prolonged sessions of sitting on his couch it ups the odds of something like that developing, especially if there was something solid that he was sitting on. It doesn't completely fit, but it comes pretty close, especially with the repeated comments of "pain out of proportion;" that's one of the things that get's taught as a reminder to remeber compartment syndrome; pain out of proportion to the injury or exam.

Come on people, don't you get it? He's going out with a "small unit." It's obviously a high-speed low-drag Marine special operations team that is super secret and completely disavowed by the government; that's why a "civillian" is being used for medical support, as "civillian" is clearly spec-ops speak for "heavy duty world class operator." Orrrr...maybe I just have an overactive imagination... If it's official training they need to follow their established policy for this, which will likely entail a higher level of care and resources than you'll have available. If it's not official training or is off the books training/fun, then without knowing specifics about the environment you'll be in it's really hard to give any specifcs.

Ok...didn't expect that. Is he on blood thinners at home beyond aspirin? Any chance he could have accidently ingested some? Gotten extra aspirin? What were his initial clotting times? Any history of liver issues or alcoholism? Signs of bruising or bleeding on physical exam? Given his anemia, prolonged hypotension and some degree of renal insufficiency or failure the elevated troponin isn't that unexpected, or worrisome; yes, an echo is in order in the future and if it continues to elevate post resuscitation or if other cardiac symptoms develop then it needs to be addressed more, but for now...leave it alone. Continue with the fluids, very unlikely that 1 bolus will be enough at this point; fluid responsiveness should still be checked after the first but plan on several. Levophed still may come into play later though. What's the patient's recent history before admission; how long has he really been sick for? With the known recent onset (and complete lack of ability to clot) technically the afib could be converted...but that can wait until (much) later; it's not the cause of his issues and there are much more pressing concerns that need to be addressed. Any chance of getting the ETCO2 with a waveform? Not much change in treatement at this point; lots of fluid, maybe levophed later on, albuterol and atrovent, magnesium after his BP is a bit better, and without marked improvement in his respiratory status, intubate before leaving. This is not someone to fuck around on intubation with; he's already tired, anxious, hypoxic, and has a host of other problems. If his mentation, respiratory status and overall work of breathing don't return to normal, leaving without a secure airway in an obese man with a 60 minute transport time is plan dumb. It doesn't need to be done immedietly; take the time, get fluids on board, give what meds you can, but it does need to be done before leaving. Trying for something like Bi-PAP/CPAP with sedation is not appropriate in this guy, and leaving the most controlled setting with the most resources available for the opposite is a bad deal waiting to happen. A transfusion is also in order, but I think that can wait until you get to the next hospital, unless the present location has blood that they can hang and send with you, in which case I'd say go for it.

What has been the trend of his BP? When did he go into afib? What has his urine output been over the last 24 hours? Fluid intake (oral and IV) for the last 24 hours? Current 12-lead ecg, initial, and a previous if there is one. BUN? BNP? Was there ever a chest x-ray? Current lung sounds? JVD? Peripheral edema? PND? Clinical signs of dehydration? What treatements have been given since admission? If the wheezing is due to bronchoconstiction start treating him with albuterol and atrovent; with his Mag being that low a Mag drip wouldn't be a bad idea, but that's going to wait until his BP is better. Need to know more about the afib; if this is new onset afib with a known start time the low BP might (that's a large 'might') be due to the loss of his atrial kick, in which case cardioversion would be appropriate. But, that's a large drop, and there probably isn't a known onset, so this will wait, but may come into play later. Start a fluid bolus; even if he is in renal failure (that's not certain yet) he'll be getting dialyzed, and at this point volume is needed. Once the first bolus is in and the airway secured check for fluid responsiveness; if he is then give more fluid. If he's not due to a sepsis induced cardiomyopathy or some other reason, start him on levophed...probably slowly give another bolus at that point as well. Unless there is a marked improvement with the albuterol he must be intubated before leaving. Talk with the attending and if one is available, anesthesiologist. If they can do an awake intubation with light sedation and a topical anesthetic then great, if not, plan for a difficult intubation, have a video laryngoscope handy (if there is one), use a high-flow nasal cannula to help with the desatting, and start with just a lower dose of ketamine (0.5mg/kg-1mg/kg) without paralytics. If you have to paralyze you're doubly screwed as rocuronium is all that should be used. Have your backup airway ready and a scalpel...though that would be a nightmare. Keep him sedated with versed (or ketamine I suppose) and fentanyl. Pneumonia/flu sepsis COPD exacerbation acute renal failure new onset afib Biggest questions right now how long has he been in afib, and how he does with the above treatements. edit: shit, missed the blood sugar. What's the ABG? That's not entirely true; patient's can go through the ER if for some reason their condition changes during the transfer, and there are hospitals that, depending on the type of patient, will evaluate them in the ER and potentially keep them there for treatement before sending them to a specific unit. I don't know specifically about a direct transfer from a standard medicial floor to an ER without a known destination in the new hospital, but I don't see how this would be innapropriate; not all hospitals and doctors are created equally, and what one thinks is a severe, critical patient may not be to another. To have them checked in the ER to see what type of care is needed makes sense. But, if this is an EMTALA or JCAHO violation it wouldn't surprise me.

So...you're saying that volunteer EMS groups in New York are mafia fronts? Probably none of them care...all this was, was a local story that was gaurenteed to make headlines and sell papers; I doubt anybody at any of the original news agencies that reported on this really cares what actually happened. The really sad part is that a lot of people that have commented on this and identified themselves as EMS providers take the side of the bozo.

I bet it would be, as would the conversation that took placed before the ambulances left the station, and the conversation where the bozo was told he was being disciplined. So...does this mean I should expect a bunch of people with weird accents to show up outside my house with pitchforks and torches?

It very likely didn't; what I meant was that there are questions about this group and the service they provide, or rather how well they provide the service, that are more important. But...if the paramedic was part of that group, was he listening to other dispatches and aware of the fact that his transport was going to a non-emergent call? If not, why? If he was, why did he not have them redirect? (this ignores the fact that he very well have determined that there was no real emergency and that the patient didn't need transport right away)

While I sympathize with anyone who loses their job due to company shenanigans, this should be an abject reminder to anyone considering a job change to perform thier due dilegence, especially when looking to open a new service or base. Let me be clear: especially when opening a new service or base in fact. Oregon is saturated with flight programs; Life Flight, Reach, Air Life, Mercy Flights, Cal-Ore... Ontario, where Air Methods was based is in fact home to one of the Life Flight bases. Interestingly enough, up till very recently Air Methods provided the air frames, and I believe the pilots and ground crew for Life Flight. What happens seems to have been that Life Flight went to a new group and Air Methods didn't want to lose the revenue, so they opened their own competing base. Ignoring that Life Flight is very well established in Oregon and is the defacto provider for that part of the state. It's no fun to lose your job, but before picking up and moving to a new state, let alone changing employers a bit of research is in order.

But was the paramedic part of the vollunteer service (as a secret paid person they neglect to mention as so often happens...) or was he part of a professional ALS service that relies on other local agencies for transport? There are still questions that remain to be answered, or at least should be answered to get a real understanding of what's going on.

Technically the "D" modifier that went after the "EMT" was for EMT's that had been trained to use a standard defibrillator and recognize shockable and non-shockable rhythms...at least in some states. Yet another bit of EMS history that shows how fractured EMS has been, and continues to be... On a side note, anyone else having major problems with pop-ups and getting automatically redirected to other websites from this specific site? Kind of makes it unuseable...

This. Nothing but this. There is no clinically relevant reason for the additional courses or the quest to be called "doctor" in a clinical setting other than trying to be seen as no different, and just as good as a MD/DO. With less than half the relevant medical education, or even education in general, to say nothing of the difference in clinical hours. If the people at the top of the nursing community would just focus on nursing for a change instead of everything else, perhaps they might make even more meaningful changes.

Missed 5, 84%. While some of the later questions are open to interpretation and there seems to be some political bias going on, it's highly disturbing that the average score is less than 50%. Actually, I take that back, it's not disturbing, it's just another sad example of how truly fucked up this country has become, and will continue to become.

I'm not going to, tempting as it is. This whole situation, while started because of a bozo and stupid American's, does bring up some questions about this particular vollie group, their practices and SOP's, how well run they are, and how well they really serve the community. If the average person had a quarter of a clue they would be more concerned about that and not some punk 20 year old wannabe hero. As a side note, the comments in the various newspapers and EMS related news sites from people alleging to be EMT's and Paramedics are extemely scary...

It may be a system where BLS units only automatically go to BLS calls and wait to be requested for ALS transport...of course if that was the case the part about there being such a loooong and terrible wait doesn't make sense. I think that just helps to show that this bozo is an idiot, and that, unfortunately, that area is being done a big disservice by the whole group of vollies; apparently they aren't capable of prioritizing calls and making decisions on the fly.