paramatt_

Just a bit of insight / opinion from one of those non-US degree requiring countries..

I just spent that last 25minutes trying to articulate the merits of having a degree in EMS, however, both my rationale and frustration cannot be summarised in a single online post so I'll just agree with what Mike already said.

One quick point to consider...when you look at some of the better known services in the US (medic one, wake co, Boston, etc), what are these services doing that have people are standing in line for jobs and what type of people are willing to put in the effort vs an easy employment mom and pop provider or even a well paid fire/medic job?

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

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. 

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 

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 

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 

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.

16 hours ago, Just Plain Ruff said:

I would definately put the obese patient down as a candidate, especially an extremity that gets caught under their weight after they fall and are unable to get up on their own.  

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.

Ok ill get things started

How's she positioned - sitting/laying/slumped/ etc?

Skin colour?

Consc state - just AVPU 

Pupils?

Also can we confirm that BP...manual if the first was NIBP and the pulse ox pleth 

A bit late, but just a couple things to add..

Id also be heading to the nearest facility with neuro. Btw; have we had a good look at his head..ie any recent trauma/falls/head strike? Probably not going to change our management but the reviewing facility would want to know potential med vs trauma aetiology.

Il. As air vs ground, unless he's going to get RSI'd, he poses too much of a risk of dropping his bundle mid flight. Would definitely want an extra pair of hands in the back during the 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.

10 hours ago, Off Label said:

Counter intuitive, giving volume in that situation. Then take it off with Lasix. Perhaps just a stop gap measure to get the coronary perfusion pressure up.

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?

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 

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

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. 

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.

1 hour ago, Arctickat said:

"Transport to the nearest APPROPRIATE medical facility".

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 room..so be it.

25 minutes ago, Just Plain Ruff said:

how many services "CAN" transport to a urgent care center?  I don't know of any services in my area that are able to transport to urgent care facilities and I believe its high time that we begin to be able to.  

I also think that Urgent Care facilities are pushing back against this though. 

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 non-acute..it was an interesting perspective...I'll see if I can dig it up.

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

2 hours ago, Just Plain Ruff said:

Again, this is a minefield.  

 

Good question, however, a bit more background would be helpful. There have been users in the past who have asked similar questions with topics deteriorating into train wrecks of their personal problems. Maybe provide a bit more clarity on your background and rationale for posting and I'm sure you'll get some informative replies

For the record, I work in for a service where fire and EMS are separate entities..including different budgets, management structures, and call-taking/dispatch, though we do share some stations and work similar rosters. Similar to the NPR story our work load is far greater than fire...maybe 7-8:1, maybe higher, such a night shifts where its not uncommon to do 10+ jobs while the ffers at the same station are tucked up in bed and haven't done anything. We might grumble about it from time to time (perhaps a bit jealous?), however, I haven't heard anyone mention it being unfair or a waste of money...we singed up for paramedine, they signed up for fighting fires, though I do have a proposition to argue for the need for better utilization of resources...which might also assist to solve some of the problems in Chicago any elsewhere.

Lets say there's a city called Factitiousville that's looking to balance its budget. Fire and EMS services are provided by the city as are all the other normal departments one would find as part of a local government. There may be an over abundance of fire fighters and an under-staff EMS component or  even a well structured EMS system where the ffers have a lot of idle time. So why not merge fire and public works to help cut costs? Before any ff/medics run me off the forum, isin't this kind of a no-brainier? The tools and equipment are already there, the ability to carry out basic maintenance projects, do some tree felling, ensure the parks stay watered, hang banners and do all the other basic tasks that a public works person could do a firefighter could also do. If there's a fire-related call out then off you go.

For the record I am serious about that. It is unfair and frustrating to hear fire unions that keep tradition at the top of  their arguments for being involved in EMS. There are other ways to serve one's community and it doesn't always need be with lights and sirens.

To make coming up with ideas easier, it would probably be a good idea to give a basic overview of what type of service you work for. Things like pt demographics, urban, rural, or whatever, any major trends in call-out types, other services available such as hospitals and community services, etc. You will probably find a number of gaps that your service can potentially fill or assist in in someway or another whether clinical or surrounding education or health promotion programs.

I'm working outside the US, but have a bit of knowledge of transfer/retrieval services. It's quite common to have lower acuity pt's that require similar transports both domestically and internationally. The first thing I'd be fuguring out what services / care is required during transport as some of the others suggested as there will obviously be additional costs depending  on staffing requirements. The referring dr should be able to give guidance on that.

A quick Google of 'United Sates domestic medical transfers' brought up a good list of companies that specialise in such work...once you know what he needs during transport you should be able to contact them directly for quotes. A good provider should be able to arrange all the transfers and liaison work between the the sending and receiving facilities 

Same...backboards for extrication only. Occasionally we might leave someone on if packaged up and its a very short transport time, maybe 5-10minutes max.

1 hour ago, Ruffmeister Paramedic said:

IN the end, we were able to get the tube but not after some very very tense minutes.  She never lost oxygenation but we paralized her and then had a very difficult time intubating her.  Took about 10 minutes to fully secure the tube but all her numbers and color was what you would expect from oxygenating her well.  This patient made the CRNA earn his on call pay.  But I was sure we were going to code her.  But someone was watching over her that night.  She had no negative issues based on our intubation attempts except for some scratches on her soft palette.  She should be about 15 years old now.  

That's probably one of the most horrible situations you can be in, especially with a pead. I suppose if her oxygenation deteriorated you would have been looking at a surgical airway.. It sounds like you guys did a great job nevertheless, and with a favorable outcome.

Good chance for a side question..it is reasonably common to have poor airway control on seizing patient's, especially those with trismus, even if its just short term...anyone have any good airway management techniques in such situations? I'm a fan of high-flow nasal cannula with lateral positioning if possible.

Thanks for the replies. I definitely agree with you Ruff that cost and potential lack of use has merits what medications are stocked. However, working for a government funded service that generally transports to government funded hospitals one would think there might be better continuity of care..which unfortunately isn't the case. Can be frustrating to see pt's with prolonged seizures or those high risk for multiple seizures get phenytoin loaded upon arrival to emerg which is probably something we could safely do (all our trucks have syringe drivers)..not meaning to digress...more interested in hearing about other services do things.

DD, thanks for that resd. Very interesting information and definitely picked up some new terminology. Just briefly, although I appreciate the treatment approach and timing structure including giving an opportunity for meds to take effect, I don't know how generaliable it would outside be the hospital/icu setting. Just thinking about TBI or suspected intracranial hemorrhage pt's which I've seen go straight to GA after poor or limited effect from benzos with a goal of not only seizure control but getting prompt imaging and definitive treatment started.

Looking forward to some more discussion