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paramatt_ last won the day on November 7 2017

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  1. paramatt_

    Pain Management

    Sounds like pretty poor planning / insight from the ED to not have a plan for additional analgeisa but is also something you should have considered and addressed prior to the transfer. Anyways, if I was in your situation I would have considered calling back the doc, putting them on speaker phone so they can explain to the pt their rationale for withholding additional analgesia and allowing the pt to remain in significant pain
  2. paramatt_

    Anyone ever done this?

    To follow on Mike's post, a lot of the issues with community based care is system based. ie a for profit system isint going to benefit from such novel ideas..again, a $$ thing. Working as part of a government funded service, it's a different story and all about value for money and keeping those out of hospital who can be treated in the comunity and trying to save ambulance resources for 'real emergencies'. We are doing this both in a call diversion program (only in its infant stages) where callers can be directed to local services and a paramedic run extended care program to deal with minor wound care / burns, epistaxis, catheter problems, some home rx for migrane, gastro, etc. The major success is that everyone benefits. And yes, major baseline education differences. And spending that extra few minutes preparing some food or having a cup of tea with a pt isn't just about doing a 'good deed' IMO, but is as much about being able to assess the daily living capacity of that person. Spending that extra 10 minutes chatting with someone and looking through the fridge can raise all sorts of red flags that might otherwise go unnoticed.
  3. The easy, but maybe not so pratical advice I can give is to get out of southern California. Very archaic EMS. I don't live in the area these days but I've heard good things about Kern (and to a lesser extent Ventura, Santa Baraba, and SLO counties) if you're looking to stay in the immediate area. Maybe talk to services outside LA for your ambulance rotation. I'd recommend moving interstate if you're seriously considering a career in EMS. Good luck
  4. paramatt_

    A newbie question - stethoscope

    Didn't finish that post ^ needing replacement, it worked great. Nothing like the more expensive models, but well worth the cost. If youre thinking about paramedic school or further educating definitely worth investing on something half decent. Also, I wouldn't recommend wearing your stethoscope on public transport
  5. paramatt_

    A newbie question - stethoscope

    I had a Littman Classic SE II which is basically the lite/basic model for a good 10 years. Aside from a the occasional spare earpiece
  6. paramatt_

    Petition to Save Intubation

    Maybe petition for higher (?or minimum) education standards first? I'm going go out on a limb and say those services that have higher standards and better governance are likely going to have better outcomes no matter what you're measuring.
  7. paramatt_

    Medical conditions causing crush syndrome

    Not just the obese. I recall attending a pt, elderly, frail, and quite small that awkwardly fell and landed with most of one thigh basically under her squashed against the ground in what would have been quite an impressive accomplishment if she was doing yoga...unfortunately she wasn't and was found some 8-10 hours later with marked visible discolouration (of what could be seen) to said limb. She had multiple co-morbidities including renal failure. Anyways, we treated her as per crush injury though she ended up having a cardiac arrest after being moved. ps. can we start calling you Plain? And for the OP. there was quite a good topic some time ago on suspension trauma, if you have a chance its probably worth a look.
  8. paramatt_

    EMS Refusal of Transport

    Your department is definitely not the first to have issues like this and working in a rural area with volunteers who are giving up their own time makes things even more frustrating. The service that I work for dose not have any general refusal protocols but like most services we have had problems with frequent non-emergent patients who call wanting transport for a number of reasons, many of which just appear bored or have nothing better to do. In a few cases, there have been specific / targeted procedures put in place in dealing with these people between a supervisor, medical co-ordinatior, and the pt's GP, case worker/social worker, and I think the police in the case of one individual. If you're having issues with a specific person document document document, and perhaps if you have enough evidence that you're being manipulated or used as a taxi on a regular occurance you might be able to formalise a plan with some external help to deal with the specific person. Its also important to note many of these people do have legitimate medical problems and you don't want to dissuade them from calling an ambulance when they actually need it.
  9. paramatt_

    CHF & Low BP

    Perhaps the thought process was to increase venous return / "prime" the LV to subsequently increase stroke volume which can then be titrated with the fusemide to reduce the excess fluid. Definitely requires a careful balencing act. I've done similar with hypotensive inf STEMI pt's with a bit of failure (minus the fruse) with the aim of increasing preload. That's quite different to this pt though. To the OP: what treatment was done at the hospital and dId you stick around to see the outcome?
  10. paramatt_

    CHF & Low BP

    Just out of curiosity, how many services out there carry dobutamine? Anyways, if the pt was for active treatment, I'd be going for a low dose adrenaline infusion..likely starting quite low..maybe 2mcg/min and titrating to maintain a sufficient MAP and no more. Excess catacholamines = no bueno with a history like that. Maybe if it was extended transport I'd consider lasix balancing act, but would be very vety weary in doing so. I'd also avoid CPAP with a BP like that. I suppose a ddx like dig toxicity should be considered. Wouldn't change anything in the short term but it might mean he'd be going home
  11. paramatt_

    CHF & Low BP

    "If your heart stops would you like to be resuscitated?"
  12. paramatt_

    Books Every Paramedic Student Should Read

    Welcome & good topic. Cases in Pre-hospital and Retreival Medicine, Ellis & Hooper Written in relation to commonwealth ambulance services, however, still relavent to north American models. Depending on your background and knowledge base, some parts might be a bit over your head, but lots of good cases to help consolodate and better approach scene control / management, differential diagnoses, and treatment goals. Lots and lots of little clinical pearls scattered throughout.
  13. paramatt_

    First patient in clinicals dies

    First and foremost, that's awful...not only a job like that but that you were exposed to it as a student (I'm assuming?) Once the adrenaline wears off is usually when the emotions hits. Everyone is different and it can take some time to find a coping mechanism that works for you, however, having to deal with this sort of case on a clinical placement is just shit. I don't think there is a better adjective to describe it. I would be following up with your program coordinator to arrange support or someone to talk to, again, assuming you're a student. Just remember cases like this are the exception and its normal to feel the way you do, just make sure you get some support.
  14. paramatt_

    Transporting to an urgent care

    This should be the norm. Granted all services are different, but generally speaking, the 'you call we haul' concept is quite archaic, or at least should be for any professional ambulance service. Speaking about my own service, we give advice to pt's based on what's best for them. During normal office hours, there's limited urgent care services (i.e. non-appointment walkins) which are mainly open in the evenings and weekends but we'll regularly call a pt's own Dr to try and squeeze them in for an urgent appointment if practical..sometimes we transport, sometimes we don't. Other times pt's are happy to sit in the hospital waiting be it. I find it a bit strange that urgent care facilities wouldn't want pt's. And I don't see how it matters if a someone comes via bus/car/taxi/ambulance/whatever unless there's something I'm missing In regards to that paper, I think having a direct phone line for high risk pt's post discharge is a great idea. There are few general nurse run health advice lines that pt's regular use, however, if someone were to mention that they were recently discharged post CABG or whatever, the call would likely get transferred to the ambulance comms regardless. Some of the other processes seem to be good as well and are definitely long overdue On a side note, a while ago I read an insightful paper written by an emergency consultant which basically stated that true emergency presentations in his department were overwhelmed by the was an interesting perspective...I'll see if I can dig it up.
  15. paramatt_

    EMT co-worker keeps attempting suicide

    As Ruff said, situations like this are a very difficult to manage..unless something has occurred at work that violates a policy or safe operations, there might not be a lot that can be done until an actual event occurs. I can think of a colleague with a mental health disorder, well liked and supported by staff, but with an obvious deterioration which began to effect work. Numerous genunine documented concerns were made by colleagues to management but it wasn't until this person had some time off that management was able to ask for a doctor's approval regarding the ability to return to normal work duties and formally do anything. This is in a service that takes staff well being seriously with good provisions/support services in place. Just to re-reiterate