EMS2712

I was asked to a lecture on "Lesson Plan Development and Documentation", and I am looking for ideas to incorporate with this lecture. If you have any ideas on what to incorporate, it would be greatly appreciated.

I can full understand the original poster's situation, as I have been in a similar situation when I was first going to Paramedic school. I worked part-time for a County EMS system in Ohio, who won't transition to have some true ALS Paramedic level service in the county. I have seen several EMT-Paramedics that worked their while going to school, only to be run off by the "old guard" of the department. Countywide if you are a Paramedic you have to function as an EMT-Intermediate level. The reason I have been given for not going to paramedic level include the following: We have gone without Paramedics for 25 years why do we need them now? We don't want to alienate the EMT-Intermediates who work here because of your skills. What can Paramedics do that I can't, it won't make a difference. I have learned to bite my tongue on many occasions. Has anybody else dealt with this?

Lone Star I fully agree with your view on this. I was hoping to open discussion on this. I think we have lost our ability to think. In addition, I think that we rely too much on technology on the truck. A new tool is great to have, BUT a tool is only as good as the person operating it. In Ohio, I think there are too many programs in the state, and because of that the quality of product being put out is gone down as well.

Generally, how would you describe the EMT students that are currently entering your programs? Tech-savy? Lazy? In addition, Are you happy with the students we put out, or do you think we basically teach to pass the exam and that is it?

I am in the process of setting up a mentoring program for our new instructors (CE and full EMS-I) within our department. I am looking to pull information from other instructors as to what they feel were the best resources (articles, books, CD's, DVD's) that helped them over the years in their teaching careers. I am hoping to pull this information to do some lectures and training sessions with the new instructors along the way. Any help would be appreciated. Lt. Zachary Wolfe Delaware County EMS

Here are a couple of scenarios we have done recently: School Shooting MCI: Did this training in conjunction with local law enforcement, and turned it into a joint training scenario with them. Mass Electrocution: We have done this in two situations: Pool setting, and packed bleachers at a football game. I like the football scenario as not much moulage to do for it. Hydrofloric Acid explosion in a lab. Our local MRDD program retired a smaller transport bus, and we hired the staff from the DD staff as patients, and did a special needs patient accident. It was a great learning experience for all parties involved. I hope some of those you haven't done yet. Lt. Zachary Wolfe Delaware County EMS

At the time of this incident chemical and soft restraints were unavailable. Chemical restraint is not in the county protocol, and for some reason we don't have soft restraints on the trucks. I am looking at fixing that problem. I did get end stage follow-up and talked to with the medical director. Per OSU Medical Center where the patient was transferred to, CT scans negative, Tox screen negative, cultures negative, CBC and BMP were within WNL. Patient was discharged home to care of his PMD with a psychotic episode of unknown etiology. In talking with the medic director, seratonin syndrome, would be logical, but local facility doesn't have capability to draw it, and apparently OSU didn't draw it. To answer the question the patient wasn't less combative with a particular sex. Thanks for the input on this.

Good Afternoon Ladies and Gentlemen, I apologize for not answering the questions yesterday, as I was under the house working on some pipes that burst. I will try to answer everyones questions the best that I can. Use of Narcan- I can see both sides of the argument that have been posted on this issue. In talking with the medic the reasoning for this was as follows. The patient has an altered LOC of unknown etiology at this point. Yes the airway is patent, and the patient is combative, but is the altered LOC and combativeness a side effect of a narcotic overdose, hypoxia, neurological, or some other underlying cause? With the pinpoint pupils, one could assume narcotic overdose with the altered LOC and combativeness. I am also of the mindset that if I do give Narcan, I like to slowly infuse the Narcan, as not to induce an instant withdrawal from the drug. Unfortunately, I don't know how every patient is going to present after giving Narcan, maybe he would become violent, and maybe not. I agree that is a potential risk though. Updated Blood Sugar of 152 Updated BP 172/104, P 58, R 18 T 99.1 Yes, potential for CO poisoning would be a diff. dx, but we ruled that out pre-hospital with the use of the Rad 57 handheld units showing 1ppm reading. Patient was found lying in the middle of the room with no apparent items that he would have struck his head. No signs of trauma noted on exam. No abnormal chemicals noted in kitchen. The teflon study, could possibly fit, I read that study as well, and to be honest I didn't really look to see what the pan was made of. I noticed to burned eggs still in the shell in the pan. Patient remained combative throughout transport. Upon arrival at the hospital, patient was moved to ER trauma room and report to staff Patient was initially given 5mg Haldol IM with minimal response. Patient was given 5mg IN with no change in status. IV was established, and patient continued to be restrained by PD handcuffs, under the observation of PD unit. ABG's were drawn with SLIGHTLY elevated PCO2. Due to patient continuing to be combative, patient was selectively intubated with the assistance of 25mg Etomidate, and a Propofol drip. Urine tox screen showing positive barbituates and nicotine. With patient sedated CT scan completed, with no bleeds or masses noted. Patient was subsequently paralyzed, and transferred to University Hospital. Follow up with receiving facility showing subsequent CT scans negative and tox screens showing no changes. Receiving hospitals advised the patient had blood cultures drawn and are awaiting results. What are some other thoughts. I haven't heard anything else, but I will let you know.

1) Per the neighbors, he is acting abnormal. He normally is talkative and coherent 2) Neighbors say this isn't normal for him 3) No medications were found at the residence. Bystanders were not helpful in obtaining this information 4) Vitals P 60 R 18 BP 172/100 5)CO readings are in parts per million. Normal is 0.5-5ppm. When you hit 25-30, you have to go to a hyperbaric chamber for treatment

Mobey, I don't disagree with your thinking, however we don't have prehospital RSI as of yet. 1) On fire and EMS arrival, it was a pan of eggs that appear to have been being hardboiled with all of the water evaporated directly catching the eggs on fire. 2) Patient #1 is coughing, but states he feels better outside, and doesn't want to be evaluated by EMS 3) Patient #2 is non-verbal at this point, and taking swings at the EMS crews. Patient is fighting as crew is securing him to the cot. PD physically restrains him to cot with handcuffs x2 4) No Gas monitor available to FD 5) Patient placed on NRB at 15lpm. Sp02 of 100% prior to Oxygen admin. EtCO2 n/a, CO detector showing 1, monitor showing NSR with a VR of 68 in Lead II without ST changes. IV attempted x2 with patient pulling both of them. Protocol doesn't allow for initiating sedation. 6) Patient was recently discharged from area psych unit with bi-polar disorder 7) EMS Crew administer 2mg Narcan via IN x2 doses for a total of 4mg en route to hospital with no response. Pupils remain pinpoint 8) House was also checked by law enforcement as well as the EMS Captain for any drug equipment or pills with none being found.

On March 30, 2009 you are dispatched to a report "Out Fire" with possibly 2 smoke inhalation victims. Upon arrival FD advises fire is out, and the occupants of the structure are out side. Patient number 1 is a late 50's male patient who advised he smelled smoke from his upstairs apartment and came downstairs to find patient number 2 lying on floor lethargic. Patient number 1 advises that there is a burning pan on the stove, and evacuates patient number 2. Upon arrival of EMS patient number 1 refuses care. Patient 2 is standing upright still appears to be lethargic to surroundings. Bystanders advise patient number 2 has significant psych history. Upon making contact with patient, he becomes combative. Initial Ax A-patent, B-normal at rate of 18, C-skin ashen warm and dry with positive radial pulses at a rate of 68. Patient has pinpoint pupils at 2-3mm. Patient becomes combative as you move him to cot, and PD is on site with securing of the patient. Where do you go from here? What is your differential diagnoses? Ask any questions you ask, and I will see what I can tell you because I am not sure what to think is going on with this patient.

VentMedic, I hope you are not taking what I have stated as bashing Hospice. I may have differences with SOME of the policies that Hospice follows, but I do think they do good work as witnessed with my grandmother. I QA the report, and some of the questions I posted were those that were brought to me from the crew on the run. I will also admit that I am not an expert on Hospice care which is part of the reason I brought it up for discussion today.

I agree with what you are saying, and actually having some members of my family under hospice care, I do agree with the choice to die at home comfortably with their family in their home. I have no doubt that this wasn't done on a whim, and a lot of thought went into the decision as this has the potential to be a very emotional time. I still be believe the patient should still have some control in their care. If the patient (or family in this case) makes the decision, and it appears to be a prudent and reasonable decision, does that mean that should forfeit all rights to hospice because you disagree with the hospice decision? As I said, I wasn't on this run, and to get a full view of what was going on, I only have the report to review, and further conversations with the crew on scene. I am putting this up for discussion, and I think we have a lot of valid points on both sides.

I agree with the statement that DNR doesn't mean do not treat. In Ohio, they have made it more confusing by adding the different classifications such as DNR-CC and DNR-CC Arrest.

This is why I posted this for discussion. I wasn't directly on the run, but as it as explained to me after the run because I QA our runs. To answer the questions that I was asked. Patient was an 86 y/o male on end stage heart failure with a cardiac output of less than 25%. This was dispatched as a public assist, and subsequently our crew was asked to evaluate his condition. I was advised by my crews that he was lethargic. Family has Medical POA. In addition, the family was advised by hospice for them to maintain hospice care, they have to notify hospice if something goes wrong and they will decide whether the patient will go to the hospital. I wasn't aware of this, but upon further consultation with a couple of Dr's and Training Coordinators, in some Hospice systems you give up your rights to determine care because a lot of times the families will make decisions with emotions instead of following the patient's wishes. This also includes in whether 911 is called. I wasn't aware of this. I don't agree with this though. Please don't get me wrong, but I feel that the family(and the patient for that matter) still has a right to say in their care. Hospice does a lot of good work, but I don't think it is appropriate in this case. The crew was told that he was put on hospice because of the end stage heart condition, but they (hospice) is also giving him 25mg Morphine daily. What are your thoughts? I think this could be a good debate.

On a run last night, our squad was dispatched to the residence of male heart patient, who was unable to get up. Upon arrival found patient lying on floor. Family advised that they were assisting patient back to bed, and he became weak, and was lowered to the floor. Patient is under Hospice care due to severe 25% cardiac output. Patient is lethargic, with vitals as follows. P 168, BP 104/68, R 20. A-patent, B-spontaneous and non-labored, C-normal, warm and dry. Monitor shows a narrow tachycardia, with no visible "P" waves. Patient's family refuses patient to be transported d/t the fact if the patient is transported they would lose their Hospice care. Family advised that they have been instructed that they must call Hospice to determine if they should call 911, and if they do and have him transported, they will lose Hospice care. What are your thoughts on this?

The Alert software is a CAD/information management software package for all public safety personnel. We are switching all fire, EMS, and law enforcement agencies in the county to it. The dispatchers will be using it for information management as well as GPS and CAD. EMS will be using it for their PCR forms through the wireless interface in the truck through the MDT's in the vehicles. We will also be using it eventually for Daily Logistic Reports, as well as Run Statistics, and Time Sheets. We can actually do silent dispatching with it in that we actually don't have to talk on the radio at all. We also can interact with the other agencies and/or units responding with us. I know this is just one of the software programs out their for this.

We recently updated CAD system, and will be putting the MDT's in our trucks. Has anybody switched to or currently using the Alert software?

I use LP 12's at my full-time job, Zoll M-Series at my part-time job, and Zoll E-Series at my volunteer department, and the more I use the Zoll M Series the more I like it. We use the Zoll Report software as well, and I like the continuity of using the Zoll equipment

I work full-time for a county EMS service in Central Ohio, and we have "Bunker" style turnout gear issued to all of our full-time personnel, and we carry extra at the stations for the part-time personnel. Some of the fire chiefs that we run with in the Southern part of our district talked to our chief, and expressed concern over is getting into a vehicle involved in an auto extrication without proper gear. We have to wear it on any auto accident, or technical rescue. We got the Fire-Dex gear and Bullard helmets. It isn't a law in Ohio though.

I don't know if you found the answer you were looking for about the AMLS Course. The course is sanctioned by the National Association of EMT's. With the EMS alphabet courses, you have ACLS that covers Cardiac and Some Stroke issues. Then you have either ITLS/PHTLS which deals with the trauma. AMLS looks at all of the other medical issues in between. It focuses more on assessment, and making a differential diagnosis for what is going on with the patient. I have taught a couple of the AMLS courses and loved it. I think it is a good refresher course for the seasoned medics, but an excellent course for just starting out..

Thanks for the response Northern. We have recently established the monthly CQI program within the division, and also participate with CQI programs at an additional 3 hospitals in the area. For us to have each station host wouldn't really be feasible for us as we can't take all of our crews out of their respective districts. In addition most of our facilities don't have the space to have 34 personnel in a conference setting(34 is our standard complement on duty at any time.) I may be mistaken, and if I am please correct me, but our definitions of stations may be different. I mean no disrespect if it comes across that way, but I want to make sure we are talking about the same things. We are going to the monthly CQI meetings, monthly In-Service/CE Lectures, and are implementing quarterly division staff meetings. We roughly have 105 full-time personnel, and an additional 20-25 part-time personnel (we have a new recruit class going through the hiring process right now).

Dustdevil to answer questions.... I am have been a Paramedic for about 6 years now, and I was an EMT-Basic for 2 years before that. I went college for fire and EMS, and completed my first year. The entire second year of the program was Paramedic School, and I didn't feel that the three month summer vacation was NEAR enough time to work as a Basic and become proficient. I took some time off and work for another year and half as an EMT-Basic before I went back to Medic School (9 month curriculum). I am going back to Nursing School as well as finishing my bachelor's degree in Health Science Administration. I have completed the Critical Care Paramedic curriculum, and an Ohio EMS-Instructor. I have held that certification for about a year and a half now. I was an Ohio Special Topics Instructor for 2 years prior to that. I have most of the alphabet cards as well. The big thing I would like for when I do the lectures while I am on duty is hands-on. We do our monthly CE lectures, and average about 30-40 personnel attending those. When we do the CE lectures on station, we usually have at most 8 guys (depending if the fire department first responders decide to join us). If they don't join us, it is myself and the medic crew I am teaching(three guys). In our system we are an EMS only system. We run a three man crew with minimum staffing 2 medics, and an EMT-I. At this point we only have 4 EMT-I's full-time in the department. We have phased out hiring the EMT-I, and are going Paramedic only. Most of our crews are all medic crews anyway.

That was the impression I got with after taking the course. I LOVED the critical thinking aspects of the course. I don't think it will go the way of the ACLS Course as, I don't know think it will catch on like ACLS. One of the rural departments I work for is implementing it this year into our training curriculum, and my full-time department is going to put it in the rotation for next year. I thought is was an excellent course though.

I recently completed the AMLS course that is offered through the National Association of EMT's, and also completed my instructor certification in that course. Is there anybody else that has the course implemented into their training curriculum? What are your thoughts on it?