Just Plain Ruff

JWiley, I'm impressed, some would have slinked off away from this thread and never returned. The fact that you are calling your medical director and looking through your protocols, well hell, you just don't see that anymore from many people. Good on you. Please let me and others(Wendy included) know what your medical director says to you. I'd be interested to hear his response.

The Heffernans (sorry for spelling if wrong) bless their family. One kiddo died in an ambulance and another is terminal and has a year to live. And this family focuses on this project,That's pretty impressive.

Damn, it took you 25 years to get here, was it worth the trip?

That's pretty cool

But those same ER docs won't cover your ass when you get sued, only your Medical director will do that and ONLY If you followed protocol. What if you had a viable patient and you gave that drug or a drug that the "ER Docs have told me they would rather I tried to use it instead of not trying it" and it caused significant harm to that patient. Do you believe that those ER docs are going to stick up for you? They more than likely will NOT and it will be you and your medical director's butt's on the line and then your service will be paying a big judgement because you did what you did. Be really careful on this one, you are on a slippery slope and you gave a drug that was not on your approved medication list in your protocols for cardiac arrest and you went beyond your purveyance as a provider and you got lucky this time. Be really careful for the next time you might get an ER doc who might just lodge a complaint against you for going outside your licensure and then you are up a creek because you have no standing and your medical director really won't be in any position to help you. Just be careful and judicious, you don't want to get a reputation of being a rogue medic,

There are a smattering of Tactical medics and a couple more flight medics. You will have a much harder time becoming a tactical medic without the law enforcement background but it can be done, not saying very difficult, just saying, hard. Flight medic is really just getting your medic, getting street experience and then getting in at a flight service at the right time when they have an opening. I have found that the flight services in my area(and several other ground services) operate under what I call "who you know" and if you don't know the right people there's no way in hell you are going to get a job with any of those services. But the jobs are out there but you also have to understand that flight medicine is quickly becoming the Alaska Fisherman of EMS in danger factor. Keep your dreams alive my lady, don't let them die. You can do it but it is going to take some hard work on your end.

I think we need to get a good idea of what medicines that she is on and what she might have taken. If we don't know, I'm probably leaning towards no speedball but with a presentation like this, you always have to have that thought at the forefront of your mind.

I'm speaking from managing her post narcan in the ED which is where I would end up taking over her care since my last two jobs were on hospital based EMS which once done with the transport to the ER I'm the one who gets to continue as her primary caregiver along with a nurse so Yes that is a concern but as a street medic only, probably not a big concern for me as that street medic. And yes, had I have given her the 2nd dose of narcan and the other depressants really shown their stripes, then I'd probably be back at the starting point of having to manage that airway that I just removed a OPA from. Wow, going full circle he he . So I suspect that with the 2nd dose of narcan we can semi rule out much more benefit of narcan so let's transport her to the closest ed but let's consider the EKG first and see if she qualifies for a Cardiac center. Did you say that each hospital had good bad or excellent cardiac care facilitlies? ah re-read your first post, I'm going take her to the closest facility as it sounds like they have cardiac care as well as the facilities to handle this patient. I'm also going to transport by ground because the helicopters I'm used to wont' transport overdoses due to security unless they paralyze and intubate them for the crews safety and the patients safety. We have a 15 minute flight to where I'm at and then at least a 15 minute flight crew scene time in order to get the patient paralyzed and tubed and all their ducks in a row so I can be 30 minutes into the trip by the time that the helicopter even gets to me, at a minimum. This lady now after all our interventions isn't really completely massively critical necessitating a helicopter so I'm driving her.

Did I miss something in this thread? where is the patient with cataplexy? I didn't see anyone who fit the description below. But let's also not confuse cataplexy in humans with epilepsy in cats ok Definition of cataplexy - cat·a·plex·y ˈkatəˌpleksē/ noun 1. a medical condition in which strong emotion or laughter causes a person to suffer sudden physical collapse though remaining conscious.

Ok, so the first round of narcan is given, let's do a 2nd. Is she fighting the OPA? I would suspect if she is able to open her eyes and focus on you that the OPA is soon to come out. If we give enough narcan, it might just come out and be thrown at ya. But I digress, let's give a 2nd round of narcan but then do we run the risk of counteracting the narcotics and then seeing the effects of the other drugs that the unresponsiveness was masking?

Dont' secondary line packaging expire?(holy grammar hell batman). If they do expire then if you service just throws them away,why not commandeer one or two for yourself.

oh ok, then I'm not gonna give any d-50. But Narcan for the win but of course, like most of these scenarios, there's something more sinister going on here so I suspect narcan will be inert on her.

I believe that blood sugar is quite low. but I also don't know the conversions because you damn foreigners use a differetn system than us Yanks. But I'm going to scream the old mantra - less than 8 intubate but seriously, this lady is really really sick. I'm going to start ventillating her and eventually intubate her because she sure isn't doing a good job on her own is she ergo - Agonal respirations Second, IV started and gonna give her some narcan and if I got the conversion right, she's going to get some D-50 has anyone checked her pill bottles to see if they are at the levels that they should be. Something about the husband leaving for a couple of days and coming back to "THIS" just doesn't sit right with my spidey senses. Did they have a fight and did he leave for a couple of days thus setting off aprecipitating event for a suicide or could it be that his being gone allowed her to stop taking her medications/or vice versa took too many, because he's the only responsible one at the home and he makes sure she takes her meds. Either way, I'm not messing around after the narcan and d-50 and IV, she's getting a ride to the ER, Initially the closest one but if our further exam rules out CVA or something more dastardly, then diversion is in order.

I got one better than that, I worked at a service where our station was direction across the street (not a busy street mind you) from the hospital. We would run code to that hospital for a patient transfer. The total drive time was about 25 seconds. And guess what, if you didn't run code to the hospital for the transfer you got suspended. What a freaking stupid policy.

Yep Mike, I've also learned the hard way about having a family or friend ride wiht the patient and then interfering with patient care. I got a couple of bruised ribs from it.

I heard of those snakes as well. I believe it was the banded krait or something like that. Here's a link to a nice education piece on this particular snake. http://www.snakecharmerbook.com/excerpt.html It's got a sad ending.

My God, I've known dwayne for at least 5 years and he really isn't as old as he seems, by PNG standards at least.

Snakes, I hate snakes, said Indy "That's just my pet snake Reggie" said Jock

Think liability and lawsuit and that is probably where this is coming from. If you don't have a signed release and something happens to that rider, then the sky is the limit on how much they can sue you for. At least with a release signed, the county or the service can say "hey you signed a release and you were given the risks of riding. You accepted the risks and gave up your rights to sue us" and that will sometimes keep a lawsuit away. Follow the money on this one boys. If you don't have a release, you probably want to talk to your services lawyers about getting one. I speak from significant experience on this one.

Great response EMS, I was speaking strictly from a resident point of view, you live it. Maybe we can get together and compare notes or have a beer summit. How far are you from Hanover? I'd be interested to see if there's the possibility of a ride-along out your way? Plus my family is always looking for things to do in Maryland so what do you have out there for us to come see in your neck of the woods?

This is probably something that falls into the "We've always run hot to these types of calls so why change now" type of mentality at these types of services. This also probably goes back to the old management style of thinking that if the public sees you running hot to almost every call then they have to think they are getting their money's worth. If I was dispatched to the scene running hot then I probably would have but this is a prime example of a call that should have had more information obtained. The dispatcher should have asked more questions in my opinion (sorry Brent and other dispatchers) But seriously, dispatchers are not given enough credit or TIME to get a good enough information from the caller in order to dispatch appropriately. I love where I used to work. the 911 call taker got the information, dispatched us and then we had the luxury of getting a call back number and were able to call the caller back and get more information. From that call we could either downgrade our response or upgrade and add resources. For non-breathers, we didn't usually call back but for other calls (many) we did and it worked out well. I for one would not have responded emergency to this one but unfortunately, you really didn't know what you had until you got there, right?

I live in Maryland and it's pretty impressive the amount of resources that I have within 5 miles of my apartment. I have 6 ambulances, 11 fire trucks and countless police agencies. Even the NSA is within 5-6miles and they also have a pretty well armed police force. There are at least 4 medical helicopters that can get to my apartment complex within 5-10 minutes of each other and those are just the state police helicopters, I have heard rumors of private helicopters as well. It's nice to have that tax that everyone who drives pays. I have no issue paying that fee. I also know that the Shock Trauma center provides excellent care. I also spent many months in Colorado and did some pretty remote driving through backroads to Breckenridge and other places via Colorado Springs and never really worried about my health and being injured but it was a fear as to how long the ambulance would take to get to me. But if you choose to live in a rural area, I mean really rural area, then you have to expect a decrease in the level of services that you would normally expect to get in a more populated area such as Colorado springs or denver. Same as in rural maryland, I expect that if I go into the boonies of maryland then my ambulance coming to get me will take a lot longer than the ambulance which would respond to my apartment in Hanover MD. IT's the nature of the beast. You cannot get away from it. The article did a good job of explaining the decrease in the level of care you are going to get and that rightfully you should expect. I'm not saying you should expect mediocre levels of service but you get what you pay for most of the time and if you don't pay for a full time paramedic staffed ambulance service, then you get less than you deserve. Sorry but that's not a dig at EMT providers.

And Cottonmouths are the nastiest, they can actually aggresively attack you if I remember hearing that right somewhere. I'm hearing of more and more exotic snakebites these days, cobras, vipers and their ilk, you get one of those bites and you better get them to the right hospital. One other thing, there is a group of nationwide conferences on reptiles where reptile owners and dealers will bring their snakes and other poisonous animals to a convention center and sell them. If you have one of those conventions in your area and you will be the EMS agency responding, best to get your ducks in a row on where to send the unlucky contestant who gets bitten. One bite from a mamba or exotic viper and the bitten one is more than likely gonna die. Have a plan in place. There is a reptile convention in Baltimore soon. I plan on going with my son.

Yes, I worked mainly in rural areas and our response time was usually average of 10-12 minutes and more like 15-30 minutes if they were out in the far reaches. 95% of those arrests we went on had NO cpr started and we just arrived after 15 minutes of driving in order to call the coroner. Some had V-fib or a rhythm and codes were started but the majority of the time they were asystolic. The ones who survive are the ones who fit into the witnessed arrest, cpr started and EMS a short drive away. Other than those folks, most are slated for the funeral home. I want to die in my bed, no cpr and my wife just calling our doctor saying I passed in my sleep. That's how I want to go just like Grandpa did while driving one day, not like the other 4 people in his car screaming.

I have had no issues with providing Nitrous to any patient. You have them hold the mask and when they get too somnolent they drop their hand and the nitrous can be replaced by an oxygen mask. Most patients report moderate to significant relief from pain. I can have them begin to get "buzzed" for lack of a better word, and initial pain relief and then I can provide IV and IV pain relief. It's a nice one two punch. I for one won't do a dental procedure without Nitrous. Especially when they are going to pull a tooth.