air.stump

Jmac and Hertzvanrental

I started the TB thing to illustrate a point. The point was not who to give AB to but in recognizing the symptoms of an illness. Dust pointed out on page one that every kid with BOM and a fever would receive AB therapy because some paramedics here can not differentiate illnesses from a set of symptoms. I chose TB because it is on the rise here in the states and has been seen by most anyone in the field over the past few years. Some of our colleagues believe that the common EMSer can not come to a correct conclusion about an illness based on a set of symptoms therefore can not be trusted to administer AB correctly. I don't agree with this. This is where education and in the field, precise medical direction comes in.

IMHO, there is never an excuse for bad driving. That just sets me off.

Tiered response has been creeping into systems since high performance EMS reared it's head. This is just a way to cut down on response times. As stated by others, it is also a way to justify large fire budgets. The trend over the past twenty years or so has been declining fire responses and increasing EMS responses.

It is a waste and safety issue except when the patient turns out to be 400lbs and on the second floor.

I wouldn't take it personally. Some of those desk people have real EMS backgrounds and are probley responding to hospital requests. It would be interesting to see the stats the hospitals are referring to. If you are transporting to a level 1 center then what kind of time change are we talking here?

Sevenball wrote:

Amen brother!!!!! I've been beating that drum forever. Microwave medics can be dangerous. Aggressive medics are a double edged sword. Finding your groove is key. Above all do no harm. Be a pt. advocate, not a skills whore.

Couldn't have said it better.

Jmac, you have a point. Us stateside EMSer's have a hard time seeing the other side of an argument let alone the other side of the world. You are also absolutely right in that in other parts of the world, there are some great things happening in prehospital care. My next question would be in what protocols do you give AB beside trauma?

I think that certain trauma situations would be the first protocols to receive the go ahead for AB therapy here.

As for the education comment, I also agree. There seems to be a consensus in our profession that once you graduate and obtain your license, your education stops. IMHO that is where your education begins. Not with the bare minimal requirements to maintain your license but with courses that add to instead of refresh your your education.

Dustdevil. We agree on the basic points but disagree on the details. I think you are absolutely right on the "We don't give drugs just because we can." statement. But.......... Doczilla said, "The problem with meningitis is that if it clinically evident without doing the LP, likely the patient is in deep s#it." This goes back to my assessment position. Prehospital providers can look at a set of symptoms and make an accurate deduction. This is where the protocol, on-line med control and AB therapy could merge together. We can agree to disagree on this one. I liked the mushroom farmer comment too. Except he wasn't a farmer but a radiologist working from home online.

Logos,

Excellent point about waiting to collect the specimens before initiating treatment. If cultures show growth, the AB therapy is usually adjusted to cover the bug that grows.

Dust,

You make valid points. I understand that most EMSer's won't involve themselves in a microbiology course. They have no interest and I can understand that, some of that stuff is just boring to some. So, let me restate my position and pose a scenario to you.

AB therapy has a place in EMS and prehospital medicine. That place is to be determined by medical directors that will apply AB therapy to very narrow protocols.

Now the scenario.

You respond to a call of 30 y/o male with a cough for two months.

On the scene, you note that the house is in a lower socio-economic section of town. Also noted is that the windows are covered up and the inside of the house is dark and warm. The patient is sitting on the couch and you notice a couple of paper towels stained sulfur yellow with bloody sputum beside him. He tells you he has a cough, a fever, he has lost about twenty pounds over the last month no matter how much he eats. He is tired all the time and has night sweats. My spidey senses are telling me to put on a mask and mask the patient because I suspect TB.

Now with all that said, why couldn't a fellow EMSer come to a conclusion about treatment with symptoms of meningitis?

Another bit of information that may help us understand the confusion behind the physiology of atropine. The primary action of atropine is competitive in nature. It simply competes with AcH at the postganglionic receptor.

This makes sense when we consider another condition. Consider Organophosphate exposure. What occurs at the level of the receptor? Cholinesterase is inhibited and AcH accumulates without anything to break it down. Thus, these people typically require large and often repeated doses of atropine because we have so much AcH to compete with.

I hope this helps.

Take care,

chbare

Excellent point!

chbare,

I agree with you in that AB therapy shouldn't be thrown around haphazardly to every kid/patient with photophobia, nuccal rigidity, fever, rash,........ I am saying that with the proper protocols and medical direction, it could be an option for EMS'ers, like our colleagues in Sussex, who have longer transport times.

It is true that a lot of patients that present with symptoms of bacterial meningitis end up being viral once the gram stain and cultures are completed. There are also a decent percentage of patients, mostly kids, that have negative cultures and gram stains and still receive AB therapy. As bad as it may be, many kids less than one year of age, that show up in a ER with a temp greater than 102 and without a condition that could cause the fever, receive AB therapy.

My position is that AB therapy in the prehospital setting is a tool that could find some use on a limited basis. Which situations, which drugs, and protocols are something that the medical director should determine.

We don't administer AB therapy in the prehospital setting in Mississippi.

I have worked two services in Texas where we administered IV antibiotics, however they were only for trauma. As Zilla points out, it would be extremely uncommon for EMS to pick up a patient in the field that presented so clearly that an empirical diagnosis of meningococcaemia could be comfortably made. I don't know how such a thing could really work out in EMS. Every kid with febrile BOM would end up full of Rocephin, which would be a very bad thing. The signs are obviously clearer in adults, but still certainly not an easy empirical call, and the gravity of the situation certainly wouldn't necessitate immediate treatment versus a simple fifteen minute ride to the hospital.[/quote

I think it would work out fine in EMS. I think this because most of the reasons that kids would get LP's in the peds ER I worked in was for a fever and or other symptoms that the doc could see. Up to a certain age, a septic work up and a treatment that was geared to stop meningitis from progressing is done routinely. As the age of the patient increased, more emphases was placed on the clinical presentation of the patient. These symptoms are recognizable for most EMS providers of any level.

This is an interesting post. The one thing you all are forgetting here is history. What has happened in the past between these two guys that pushed the violence level up to the use of deadly force?

When I lived in the city, the neighbor's kids would jump my fence to retrieve their ball on a regular basis. Not once did I feel the need to lock and load on their parents. I say that and ask the question again, what has happened in the past to lead up to this?"

I worked in a rural system that toyed with this (RRU's) for a bit. We used them for the same reason, to cut down on response times. We found out that these trucks only work if they are backed up by transport units. They worked the best on the busiest nights. They would also get tied up on the busiest nights waiting for the transport units to clear. Anyway, we scrapped the idea because they had a narrow band of use.

This is one of those double edged sword things. On one side, you have a paramedic that is trained to protect herself from harm and help others who are harmed. On the other side, you have a company that is threatening the paramedics if they step into harms way but, by policy, places them at harms door step on each and every call.

I would want to know what the unions position is on the practice of RRU's. I would also bend the ear of my union rep and voice my concerns. I usually am not for unions but in this case, this seems like the place for them to work for their pay. Also, what is the company and paramedics legal exposure on this call?

As of yet, I have not been in the paramedics' position. I don't envy her position. My sympathy goes out to her and the family of the assault victim.

Here's a small obscure list to think about.

Cochise - Audioslave

Saturday Night Special - Lynyrd Skynyrd

Need & The Spoon - Lynyrd Skynyrd

That Smell - Lynyrd Skynyrd

Bad Moon Rising - Creedence

O'Death - Ralph Stanley

Use Me - Bill Withers

No Rain - Blind Melon

Feelin' Bad Blues - Ry Cooder

Burin' Hell - John Lee Hooker

Steady - Jerry "Boogie" McCain

Baba O'Riley - The Who

Just Dropped In - Kenny Rogers

Communications: Respond to a patient at XXXX in respiratory distress.

Me: Copy, unit XX enroute.

Communications: Unit XX, be advised that we are attempting to get an interpeter.

Me: Copy. What language does the patient speak?

Commuications: Unit XX, be advised the patient speaks scottish.

Me: (Snicker, Snicker) Copy. Your can cancel the interpeter, I have a working knowledge of that language.

Communications: Show you enroute.

I am happy to say that I have had little to no issues with the ER staff of any hospital I have transported a patient to.

Maybe this is because I usually don't take anything that is said to me about my patient care by the ER staff too seriously. I know who my boss is and if I screw up badly enough, I know I will get a visit from him.

Maybe it is because when I do screw up, I don't let the ER staff discover the mistake, I tell on myself. This takes the wind right out of their sails, real fast.

Maybe it is because I have worked in peds and adult ER's and understand the "verbal sniping" that goes on between the crews and the staff. It is only the "stress" check valve popping off. Think of it the way a nurse or doc sees it: I just finished working up X amounts of patients, I got to go to the restroom, and you are bringing me one more.

I just don't ever buy into the hype. I remember that the "emergency" that I was called for is the patients, not mine, not the ER staffs'.

Stumps Laws of EMS

1. Don't buy into the hype.

2. It's not my emergency it's yours.

3. Never, ever tell a pilot how to fly.

4. Police have the guns, firemen have hoses and tools and that is where the problem arises.

5. It's OK to panic for five seconds when the sentence starts out, "Hey ya'll, watch this..."

See number 4.

EMS in the places I work at are more or less safety observers.

On my military job, most of the calls are heat related.

On the civilian job, it is chest pain.

Hell yeah!!!!!

Hey Man, did you do the flight course at Benning? If so, when? Buddy of mine used to teach that.

EDIT: I meant Rucker, not Benning, lol.

After three years of asking, I am finally going to Rucker this August. I got the F designation for my current orders. I was there for the dunker last summer and enjoyed that. I am getting all twitterpaited waiting for August.

Hey i have been and Army Medic for the past 8 years and im in the process of becoming a flight medic and info anyone would like to pass on to me

Flight medic school is at Ft Rucker, "Mother Rucker", in sunny,hot, southern Alabama. The school is four weeks long and has a correspondence course requirement before you get there (it is testable material, hint, hint). The course content is aeromedical physiology and all those cool card courses rolled into one (ACLS, PEPP, etc..). If aplogize if I am over-simplifying but that is about it. I do believe that you will find it informative at the least.

68W2F and STILL in the Huey.

HM3 8404 in a past life.

All the bells, whistles, and alphabet cards.

Good to be here with ya'll.

When I got out of the Navy in 1986, I would have thought such an idea was the greatest thing since sliced bread. I had just spent four years as a corpsman assigned to a USMC unit. THEN, I went to paramedic school and found out how wrong I was. The difference between the average, non-Spec Ops military medic and a civilian paramedic is almost night and day.

NOW fast forward a few years and I went into the Army and was shocked even again as to the differences between Navy medics and Army medics. Both are fruits but one is an apple and the other is a grapefruit. Also to be noted, both are products of their environment. They are only going to be as sharp as their duty assignments were.

It would be a mistake to skip any instruction and or education requirements above the NREMT-B level. We should be looking at ways to strengthen our profession instead of watering it down. Military trained medics have a place at our table once they have completed the same education and examination requirements as civilian paramedics.