triemal04

It's very similar to someone in the healthcare setting calling themselves 'doctor' just because they have a doctorate level degree so that they are seen as being a physician.

Whaaaaat? Who would do such a terrible dastardly thing like that?

Bears repeating...

Sawyer thought about Mobile Life Support Services, where he also works and drives ambulances...

<snip>
Sawyer, who's also a volunteer firefighter and a part-time police officer in two Ulster County departments,...
<snip>
revoke his title on the communications committee and his title as advisor from the Youth Squad that he restarted as a 15-year-old squad member....
<snip>
The suspension Sawyer was offered came from a "culmination of different incidents" in which he violated policies and bylaws as well as other aspects of the Dec. 11 call, Gavaris says. He says he can't elaborate on those incidents.

What's the term? Whacker? Ricky Rescue? Nothing to see here folks, move along.

That's really all that was going on; this is a complete non-issue on the side of some douche acting like a moron. The real issue is the fact that this vollie department is apparently unable to meet the needs of their community. This is ignoring that the patient was also very likely extremely stable and potentially didn't even need transport. Unfortunately, most people won't understand that and will jump on the easier to see "they fired the super special hero who saved the little girl" mindset. Sad and pathetic, but hey, welcome to 'merica.

But...since the threads about what is is...let's have some fun. This guy is most likely an immature wannebe with a hero complex as is evidenced by his actions that day. He didn't attempt to get any kind of mutual aid or backup to come...he didn't attempt to contact any of his superiors to see if an exception could be made...he didn't notify anyone after the fact about what he had done...and then when he get's disciplined for breaking the rules (read being an idiot) he cries and quits. Yeah...that group is better off without him, and EMS as a whole would be better of if he and all those like him vanished.

I'm curious, would the poser here like to share which girlfriend it was that he sent messages to, while pretending to be his mother, telling her that he had committed suicide and it was all her fault? As it recall it was sometime around the holidays...

Yes shitbird, your past exploits are still easy to see here and on other EMS websites.

Allow me to make a suggestion to any lying worthless hack that likes to pretend to be a medical provider so they can gain attention: keep your mouth shut unless you actually know what you are talking about. Less embarrassment that way.

Well, beta-blockers have always remained in AHA's guidelines for the intial treatement of STEMI's for certain subsets of patients as a class 2a recommendation; I don't know that this one study is enough to up the recommendation nor do I think that 1 relatively small study should be enough.

What this hopefully will do is get people to take a second look at the COMMIT results and realize that the general conclusion reached there makes little sense, get people to start treating patient's on a more individual basis instead of as a group (not every STEMI needs, or should get beta-blockers), and provide further justification for using beta-blockers for some, not all, STEMI's.

Medscape did a decent summary write up a few weeks back.

I'm surprised it took this long after the COMMIT study for someone to take another look at this and realize that it was justified to continue to do what many doctors (ER and cardiology) were doing; ie give metoprolol to STEMI patient's that actually needed it, and withhold it from the ones that didn't need it.

What the COMMIT study showed was that if you indiscrimenently give a beta-blocker to all patient's having a MI many will end up in cardiogenic shock; it did not show that metoprolol is detrimental for all MI patient's, but that was the conclusion that the authors came to, and many readers accepted.

This will at least give people justification for treating the hypertensive, tachycardic STEMI's with no contraindications a beta-blocker.

He is. There are 4 options for why a BLS ambulance in Seattle from AMR (or any BLS ambulance) would bring a patient to the hospital that was being mechanically ventilated by EMT's; none of those are run of the mill things, and EMT's being responsible for a patient in that condition would not be the norm.

Keep in mind that within Seattle AMR plays a very limited role; they are only dispatched to BLS calls; requests from the scene will happen after someone has already assessed the patient and determined them as non-emergent. They are responsible ONLY for transport of the patient to the hospital and while on scene, even if for an extended time will have little to no responsibility or role in caring for the patient.

Keep in mind that MikeEMT has very very limited EMS experience, and it all comes from working for AMR in Seattle; he has no exposure to any other system or department and obviously hasn't looked anywhere but into the mirror to try and learn anything.

And given his past when his bullshit get pointed out, won't be posting again for quite awhile.

We all need to remember that Mike works for a cheap , crappy transport company that only spends what is mandated by statute.

They require a pulse & a patch for hiring .

They don't provide transport crews with any equipment that might actually prove useful unless ordered to by the state.

Having to wait for an ALS truck to show up with a defibrillator is almost criminal behavior.

You do know that CPR doesn't cure fatal arrhythmia's don't you???

Cpr attempts to circulate blood in the condition of non perfusing rhythms, while defibrillation will possibly correct those fatal non perfusing arrhythmia's.

Do they always work ??? NO

Just a hit young emtb. you are challenging many folks with far more experience and knowledge than you will ever gain working for the empire. Many of us have been in this profession since your parents were playing hide the sausage in high school.

We all also need to remember that Mike is less than accurate in much of his reporting.

BLS units do carry AED's, even in Seattle, and, as it falls under the SFD CPR training, are quite proficient in their use. Now, it is entirely possible that AMR does not (but I doubt it), but then AMR does little, if anything independently in Seattle.

Overall, I don't think I would be worried about the gunman hiding. It seems like in all of the cases we hear about, the gunman is ready to die and will just keep shooting until that time comes. I see your point in a building like a school or large office building. Then I think about the situation in Aurora where it was a small building and a large area that is difficult to clear.

It is still something to consider, but yeah, I think it less likely that the shooter would truly be hiding. But...it is still a possibility, so better to have EMS kept with and behind cops regardless.

I don't know how well it would work in a theater; for the areas outside the actual theaters themselves it would be fine, but for a large open area like that, with lots of places to hide...it would be harder. At that point it really becomes a much more difficult risk vs reward situation; do you wait until the whole theater is clear, or do something similar to my previous example, which would still potentially leave EMS in the line of fire?

Triemal, I'll bet you probaly are right on the order, I may have gotten it mixed up, I don't compltely remember the order but I do remember that it was to fight the attacker which was sort of well common sense. If it's him or me then I'm going to fight. But I'm going to run my ass off to get the hell out of there first.

But I am pretty sure that they said it was 1-2-3 but again I might be wrong.

I might email the security guy and ask for his powerpoint that he used for us.

I'll ask for his permission to post, it might be of use to someone here.

Some of that also needs to be taken with a grain of salt and mixed in with common sense; obviously there might be times that it would be better to hide before fighting. I think it just something that's worth remembering and considering, if that's possible for most people in the heat of the moment.

I realize that EMS is not going into a hot zone, but with so many of these situations, the zone is moving. There is a difference between the first responding officers going in immediately in vests and with weapons and EMS going in wearing their white button down shirts and khakis.. Unless EMS is given gear and a weapon, I think you are just creating more potential victims. Part of it comes back to the fractured nature of EMS in the US. Some form of tactical training is needed and I just don't see that being possible with so many volleys. Yes, there are many that would do it (I would have given my left lung to do it back in the day) but then there are those that shouldn't be in a scene like that. I guess if you are being called into an area that has been kind of cleared it wouldn't be so bad. I guess the only way to know is to do it and see what happens.

Yes and yes. While a simple enough concept, as I said, it takes buy-in from all involved, EMS and police. If both aren't on the same page and aware of what's expected of them, and more importantly, what's NOT expected of them, this concept won't work well. I think what will happen, despite the grandiose-bullshit-let's sell more papers-let's make statements that aren't true title of the article is that it will fall, as it usually does, to individual departments to decide if this is the path they want to go down or not.

It's also worth keeping in mind when this would really be used; we aren't talking about someone's private dwelling, this is really for an active shooter in a LARGE building. The perfect example (unfortunately) is a school, with the idea being "we have had officers clear this hallway and classrooms on each side up to the next hallway. They are currently moving down those hallways. Move down the first hall and check for/remove victims from the hall and classrooms. Obviously the is always the possibility that the shooter, like the victims, could be hiding, hence why EMS must stay with, and behind armed cops, and why, when done right, the cops are doing a better search of each enclosed space before calling EMS in.

I'm going to do a cut&paste job with my posts from another EMS website. The comments aren't directed at anyone here, so don't take offense. If it doesn't make complete sense it's because I didn't include some of the things that I was directly replying to.

The new guidelines are as follows (condensed here for brevity)

1. Try to escape

2. Hide if you can't

3. Fight your attacker - try to take him out before he takes you out because if you make it to this step - you are either going to die or the shooter is going to die.

Actually, the new guidelines that are being taught in a lot of places would go 1-3-2.

Running is still always best; if you can get out do so and don't stop until you can't run anymore.

Fight. If you have no other option confront and attack the attacker. What has been seen with many of the recent mass shootings/active shooters is that as soon as someone did something to disrupt the shooter from their "game plan" they lost it, and in several instances killed themselves.

Hide if you have can't get out and have no other option. Unfortunately, what we have also seen is that in these type of situations the shooter is going through the common places to hide...and killing those people.

I think it's more than just likely that it's ventmedic again. It's been making a resurgence on the same EMS forum's that it usually trolled with the same posting style, same persona, and same ability to read something that wasn't written, or even something that wasn't in any way close to what was written.

Miscusi, I'm pretty sure that the quoted post was tongue in cheek referencing another thread, not in relation to yours.

Easy Brother...no one is baiting you...

Actually...yeah, that's exactly what's going on.

You start nonsense no matter where you are at. I simply responded that if you are working for a service, then why even bother to pay for the fill. I'm sure if you asked your director or supervisor they would say "sure go ahead and fill the tank here" but I tend to think that you won't let your sense of ethics get in the way of a "NO" answer anyway and you'd just fill the tank at your service anyway when your supervisor wasn't looking. I mean you don't think cheating is any big deal so one can extrapolate that you wouldn't think that filling your tank for free would be any big deal either.

Not to defend him, but I do remember the original comment that was made, and while not the brightest or best policy, I understand what he meant. It is a bit of a step from cheating on an exam to theft by the way.

I mean with your extra awesome sense of marital fidelity where cheating on your wife is a OK deal that filling your oxygen tank at your service would also be an OK thing to do.

I'm sure you know that there are lot's of couples out there that don't have a problem with sex outside their marriage; I'm not just talking about swingers either (though they definitely count). Perhaps this bozo is one of those?

You are the one who has throughout your posts shown that your integrity and honesty and ethics are completely bat crap crazily skewed.

Think he's more showed that he's an idiot, but hey, everybody get's to form their own opinion.

Care to correct me?

Calm the fuck down. Either this guy's just a moron, or he's a troll. Or both. Just change your settings so that you ignore his posts (yes, that can be done) and be done with it.

Neither one would question the need for a helicopter from the field. They would assume that since the ground people are with the pt, they know what is going on. Calling the helicopter from an outlying hospital here in MI, they do start to question if it necessary.

I don't know if any of the service's I've dealt with had set standards for interfacility trips but I've heard of others that do, but at the same time didn't for field responces.

I've got my own opinions on why that contradiction exists, but I'd like to hear your take on it.

I've worked around 3 different rotary-wing services, and sadly, no requests from the field were vetted by any of them or had to meet any requirements. Basically, as long as they were available and the weather permitted...you called, they hauled. Very sad, very pathetic, and very, very dangerous.

Why it works like that is a bit complicated, but really it comes down to the fact that a large part of EMS in the US is delivered by for-profit companies, and I feel very comfortable in saying that the vast majority of flight services are for-profit as well. Helicopters (and airplanes) are expensive to buy, maintain, and provide pilots for; with the amount of overhead, if they aren't flying regularly, they aren't making any profits...bad for the owners. But worse for the employees when they will staff them with only 1 pilot, use smaller, cheaper helicopters, take off in questionable conditions, fly with no questions asked, and fly to anything instead of reserving themselves for calls where they are actually needed.

In the areas that I've worked, flight services were not regulated the way that ground EMS was; no contracts with specific hospitals/nursing homes/whatever were needed, no approval from the state or local ASA were needed, there was no requirement to prove that a "need" existed for that area...all that was needed was for a company to shell out the money to start a base. Unfortunately, that lead to there being multiple helicopters from different companies covering the same area...so to make a profit (that word again)...you called...they hauled.

Until flight services are regulated at the same level as ground EMS this problem will continue.

Until flight services will only respond when specific patient criteria is met this problem will continue.

Until flight services do not need to worry about making a profit this problem will continue.

I don't think the mechanism is that unknown; it generally seems to work best in lipophilic drugs so I'd think that was the main reason, though there are other possibilities. I don't know of any real human studies either, but there have been a fair amount of case reports of it being used in various toxic overdoses (not just beta-blockers) with good results, and in many hospitals it is being used with some regularity. In all the ones I can remember it was always used in conjuction with standard therapies though, (which would seem to be appropriate) so how effective it would be alone is very debatable. Just my personal opinion, but if it and other therapies continue to show promise at some point a study will be done; I don't think it would be unethical either. Just make the control group standard treatments, and the experimental group those same treatments plus lipids, or whatever.

Oops. Missed the part about levo. I wasn't sure what you meant about "supporting her own respiratory drive," glad you didn't mean CPAP. So it should have said:

At this point you have placed a 20g PIV in the AC, given 0.8mg of narcan IVP, 2500ml of normal saline, and are assisting the patient's respirations with a BVM.

You have a levophed drip running at 8mcg/min.
Your vitals are now:

GCS-6 (1/1/4)

p-132 with PAC's, BP-80/36, rr-5 spontaneous/shallow, 12 assisted, SpO2-still unknown, ETCO2-42mmHg with a normal waveform.

The patient only will withdraw to deep painful stimuli and is otherwise unresponsive.

You assess the patient's airway as a Mallampati 2.

You place a foley with return of 80cc of dark concentrated urine.

After giving versed and succynocholine you successfully place a 7.0 ET tube and OG tube. No return of stomach contents with suctioning of the OG tube.

Being quick thinking you place a probe to check a core temperature; 38.4C.

What are the doses of the meds you will use for continued sedation (and paralysis if you so choose), and dose for steroids?

After a couple of minutes you recheck the BP and it's now 70/30. Now what?

Interesting stuff, nicely done. Since it's part of the same subject, I'd suggest looking into both lipid emulsion therapy and high-dose insulin for beta-blocker OD's; both are extremely promising, and may eventually show themselves to be more beneficial/preferred to large doses of glucagon. For some people I think they allready have.

A final note, I'd be very interested in seeing exactly where the "33% remain asymptomatic" came from. My only potential area of concern is that they are lumping all OD's together (as I suppose is appropriate) and the people who took small amounts yet were still technically overdose's account for a large number of the asymptomatic patient's. Without seeing the numbers it is something to think about; if the patient was otherwise healthy then it would stand to reason that it wasn't their prescription, so they may only have taken a few pills but thus been called "an overdose." I'm willing to bet that the same person who takes a couple of hundred milligrams and is technically overdosed will fair differently than if they took a couple of grams. I could be wrong, but it is an area of concern for me.

I will admit that I did treat a teenager who popped some of daddie's metoprolol (dont' remember how much) after his girlfriend broke up with him...granted it was early on, but other than a moderately low heartrate he was asymptomatic...

Well...according to emedicine, in otherwise healthy people OD's of certain beta-blockers MIGHT be asymptomatic, though I'm sure that will depend on the total amount taken. Regardless, it's nothing I'd hang my hat on; while the patient may not present as unstable initially, with a known ingestion being prepared and ready to treat seems much more appropriate.

It definetly can cause hypoglycemia, and not just in kids. But from what I can remember it's a pretty uncommon, though regardless, for many reasons unrelated to that a cbg should still be the first thing checked.

I couldn't tell you off the top of my head (can now after looking it up) why beta-blocker OD's can cause hypoglycemia. I think that the glucagon fixing the hypoglycemia and also fixing the cardiovascular issue's happen does happen for technically the same reason. Glucagon up's the production of cAMP in the heart and in high doses will have a positive inotropic effect while in the liver the cAMP increases the conversion of glycogen to glucose.

Essentially it's about cAMP. That what you were getting at?

Edit: This is just a sidenote and only based on my own experiences, but all the beta-blocker OD's that I've seen, while profoundly hypotensive usually didn't have that slow of a heartrate...probably not less than mid to upper 40's. Something to think about.

Short stay: 24 hours post charcoal admin, and needs to have had a couple of bowel movements.

Long stay: until he stops crapping black.

This is where a toxicologist comes in because off the top of my head I have no clue.

1g/kg is pretty standard for a kid, I'd start there.

Honestly, at this point I don't think I'd aggressively start treating this kid, especially since the rest of my treatements are reactive, and right now there is nothing to react to. If he's not showing any symptoms then this is a case that charcoal might actually be what really helps. And for all we know he only took 1 pill.

He get's to stay with me and will continue to be monitored, but other than that...

I'd actually be curious if something that could stop a reaction from happening (lipid emulsion therapy) would be started at this point in a hospital. I'm guessing no, but that's a guess. Pretty sure the other treatments I listed would be held off on and high-dose insulin would also not be started.

I'd still like to contact the grandma's pharmacy if possible. This will give at least the worst case scenario for how much the kid could have taken, and if it's an extended release pill or not.

With a 5 year old...I think I'd go ahead and give charcoal now. Between the grandmother and you talking to the kid (and the flavor sweeteners that some AC's come with) you should be able to talk him into drinking it. The issue with sedating for an NG tube would be that even a drug that leaves the respiratory drive intact (like ketamine or etomidate) will still have his LOC depressed; ups the risk of aspiration. I think if it came down to that I'd use a small dose of etomidate to place the NG tube, then after he was awake start to administer the charcoal.

I'd also take a minute to talk with the kid away from the grandma. Ask him if he took anything that day or was playing with grannies pills.

Cross your fingers that this isn't the real deal, because if it is, you can sustain him, but not fix him.

At this point you have placed a 20g PIV in the AC, given 0.8mg of narcan IVP, 2500ml of normal saline, have stopped bagging the patient and placed her on CPAP at 5cmH20.

You have a dopamine drip running at 5mcg/kg/min.
Your vitals are now:

GCS-6 (1/1/4)

p-152 with PAC's, BP-74/32, rr-5 spontaneous/shallow, SpO2-still unknown, ETCO2-48mmHg with a normal waveform.

The patient only will withdraw to deep painful stimuli and is otherwise unresponsive.

You have a nifty istat (that you only have the cheap cartridge for) and a portable lactate meter so...

Sodium-140

Potassium-5.2

Chloride-124

Glucose-301

BUN-30

Hematocrit-48

Hemoglobin-12

Lactate-7.2

Further bloodwork is unavailable.

No x-rays, CT, blood cultures (or the ability to draw them) or a urinalysis are available on your medic unit. You do have the ability to place a foley if you so choose.

You assess the patient's airway as a Mallampati 2.

You are now 30 minutes away from the level 3 trauma/community hospital.

What next?

You're doing ok so far, I'll let it go a bit longer before I finish with a couple comments. I will say that this is a call that every paramedic should be capable of handling and, other than the extended transport time, there isn't anything that extraordinary going on here.