medic001918

Thanks Ryan. Not sure there's much more that I can add. And I didn't jump down your throat. I made a suggestion. You can choose to make a change based on the suggestion or not. That's for you to decide. Remember that you are on an internet forum and the way you type is as good as your spoken word in person. Now you can pick how you want to portray yourself among your fellow colleagues. As far as protocols go, I have no problem discussing protocols. And like Ryan has already mentioned, I already acknowledged that protocols are different from area to area. If your protocol states that if an ALS provider is on scene they must ride the call in to the hospital, then that's fine and the way it's done. It's not how it's done here. It's not negligence. It's not abandonment. So your blanket statement about it being negligence doesn't fly. Am I the one who needs to acknoweldge differences in protocol? Or should you look within yourself and answer that question as well. My mind is open and I'm willing to discuss differences in protocols any time you want to in a civil and intelligent manner. Shane NREMT-P

I don't think negligent would be the correct charge as much as abandonment if this is your protocol. And that's fine that your protocols don't allow this to happen. But it's not negligence or abandonment for every service. This is something that happens daily in the areas that I work, and not an uncommon practice with the field of EMS. Shane NREMT-P PS - Your posts would still be much easier to read with a single period followed by a space instead of a series of periods. It makes me wonder if your spacebar is broken, but there are spaces between words so that can't be it.

Not quite true. You are only negligent if you hand off an ALS level patient to a BLS crew. If you hand off a patient that is a BLS patient to a BLS crew it is an appropriate transfer of care. However, if you end up missing something and the patient ends up having something going on that you missed, then you are negligent. And let's not forget the other key to the puzzle, you have to have a protocol for downgrading a call to BLS. There are services that can't afford to have their paramedic riding in on every stubbed toe when they have a transport crew capable of handling the call. It's not always the best use of resources in a town that has limtied resources available. Shane NREMT-P

From the sounds of the call, I can't say for sure that I would have ALS'd the call. I work in a service where I regularly can downgrade a call to my BLS partner (with one service) or where I can downgrade the call to the volunteer (my full time spot) BLS transport unit. If you're not comfortable with a call, you should say so. I know that I've gotten in the habit when I turf a call that the last thing I say is "are you guy's good with this?" This gives them the chance to speak up if they have any other questions or comments or simply want me to ride with them. As for your call, what about this call "should be ALS?" It's a 40ish year old female with abdominal pain who's recovering from the flu. Has she been taking her antibiotics as prescribed? Or did she "feel better" and quit taking them? Is there any assocated nausea and/or vomitting? any pain anywhere else? Is there any chance that she may have been pregnant? Birth control? If it's isolated RUQ abdominal pain with normal vital signs, I would probably turf the call to BLS as well. I guess I would have to know more about the patient to make a decision, but based on what I've read I am thinking BLS transport would be fine. The fact that you have three months of experience between the two of you is an issue, but not one that can't be worked around. If you approach the medics and tell them that you're new and not really comfortable with the call then chances are that they'll ride with you on the call or explain to you why it's BLS and not ALS. Don't be afraid to ask questions or voice a concern. It's the only way you're going to learn. Shane NREMT-P

-5 for bringing back a dead thread. This originial post was well over a year ago. I would hope that the original poster has already made their purchase by now. Shane NREMT-P

I find a couple of things very interesting about your post. The first of which it sounds like you're writing your post to a group of people who has never dealt with violent patients in the past. I think most, if not all of us on this board that actively work in EMS have dealt with violent patient. It doesn't matter if you like it or not, they are a part of the job and often need to be transported just as much as the patient that's sick. A police officer (at least in my area) won't transport a psych patient because if they go to jail and then are found to have a medical cause and not a psychological one (think of a combative diabetic for example or head injury after a car accident/assault/fall), then the police department has just welcomed a rather large liability. In today's litigation motivated society, the police officers would rather have someone go to the hospital to rule out any cause of the event and then charge them after they are medically cleared. Plus I'm sure you've heard of cases of the police department getting into trouble over a psych patient that they restrained dieing from positional asphyxia? No police department wants to go through the legal troubles that come with that and ambulances are how patients get to the hospital so that they have someone with medical training properly montioring them to ensure that this is not the out come. Maybe the EMS programs in Canada are different with regard to their treatment of psych patients, but the police departments here won't transport them. They will sometimes transport with you (depending on where you are and where you are going), or they will follow behind. We have the same triangular bandages that you use for restraint and when used properly actually make a very effective restraint. As a paramedic, we have the option of using 2mg Ativan and 5mg of Haldol for chemical restraint. This tends to be an effective means of sedating most patients. And we always have the option of calling medical control for repeat orders. So in your post as you mentioned to try restraining a combative patient with same means that you use, I have done so frequently. While fighting with someone in the back of your ambulance is less than ideal, if you perceive a threat or see tensions rising during transport ask your partner to stop and call for help and to assist you in restraining the patient. Utilitze your tools and think ahead. Any person has the potential to be violent. This is everyone from a child to the elderly. And you never know what might set someone off into a rage. If you think there is a solid chance the patient could become out of control, have members on scene (other EMS providers or PD) assist you in restraining the patient prior to transport. I've restrained people as a preventative measure before. While I can appreicate your story about the medic who was choked by the supposedly sleeping patient, how was the hospital to know that the patient was or wasn't truely sedated? And as quickly as that patient turned violent without warning, do you know what lies on the other side of every door you knock on while at work? You never know what you're walking into, so the potential for a call to get violent exists on every call. Working in a city that is consistently ranked in the nations top 10 for violence and where getting a police officer to your scene is not always an easy task, you learn to adapt and overcome and you become better at reading people's behaviors. I've dealt with my share of violent patients, and while they are often difficult cases to manage they are not impossible and the police department should not always be the ones transporting these patients. If you're concerned for how to physically handle a violent patient, I would suggest taking some self defense courses. You'll learn how to manipulate people to your advantage physically and you'll learn how to read their actions and have better insight as to when a patient (or anyone) is going to take a swing. There are countless control holds that take little effort to apply but that are highly effective at controling someone. Maybe after taking some classes you (or anyone else) would feel more comfortable handling a violent patient (or person in general)? Shane NREMT-P

While I understand that you are trying to do the best you can with what you have, that doesn't really mean that you should use a device for any other means that what it was intended for. Nasal cannulas have a limit on the amount of oxygen that is supposed to be flowing through it in the first place and for a reason. It's entirely inappropriate for an educated provider to take a nasal cannula and blast 10LPM through it. That flow rate is reserved for a mask style device. As an educated healthcare professional, I would anticipate you would know the proper uses of your equipment. I won't get angry, mad or otherwise with a staff memeber that is doing the best they can with what they have assuming the supplies available are being used in a correct manner. It's when they are used incorrectly (and using them in this manner knowingly makes it worse), that I take issue with it. Also as a thought, if you don't have a mask but you have an ambu bag and the patient is really not doing well why not hook up the bag (it has a face mask on it) and help the patients ventilations? You have other means of assisting this patient through their difficulty breathing rather than the inappropriate use of an oxygen delievery device. And once again, "..." between every sentence makes your posts rather difficult to read and makes them seem like one long sentence. Shane NREMT-P *EDIT* Also, I'm still not sure how the patient had SpO2 of 69% on 10LPM NC and then came up to 88% on 10LPM NC without intervention? Did I miss something?

Our protocols currently allow us to use either an albuterol neb (2.5mg) or a combivent neb (2.5mg albuterol/0.5mg atrovent). We also have epi SQ available with medical control and Solumedrol available again with medical control. There's rumors that our new protocols are going to allow us to use Mag in asthma cases. That's not set in stone yet. Shane NREMT-P

I'm confused. You said her sats were 69% on 10L and then w/o any intervention her sats were 88 on 10L? And who's giving oxygen at 10LPM via cannula anyway? Something with this call doesn't at add up. And, the occassional "..." is okay, but it shouldn't replace a standard period at the end of a sentence. Something to think about. Shane NREMT-P

When I'm off duty I don't carry anything with me that would identify me as paramedic so I definatly don't carry anything that would enable me to get involved in any way. If I'm off duty, I'm off duty and don't want to get involved other than calling 911 to activate the system for whatever area I happen to be in. Shane NREMT-P

Funny, I was thinking the same thing. Medical control might be the worst thing of your job if you don't have a good relationship with them or have a history of poor performance. Our medical control tends be progressive and allows us to do just about anything that we would like to do. In fact, there are only a few things that we have to call for in the first place. In the past two years or so I can only recall one incident where I had a medical control request denied, and that was primarily because we went to a hospital we don't go to frequently. Shane NREMT-P

I have heard of it and in fact am a member of the team. It's basically just a group of willing AMR employees who are willing and able to deploy for 14-21 days on 24 hours notice to various parts of the country that need a disaster response. I was a part of the Hurricane Katrina relife response at the Mississippi coast. It was a great experience and I would welcome the chance to be a part of another experience like the one I had in Mississippi, but I would not wish a disaster on anyone. Shane NREMT-P

I'm going to agree. The patient should be treated for hypoglycemia. The hypoglycemia could be from burning off sugars secondary to seizure activity. The suspected seizure activity can be casued by a stroke/TIA as has already been mentioned. I also have to agree that my EMT partner and I would be having some words after this call about when it's appropriate to question patient care and how to bring it up. The duck tape idea isn't half bad. Consider myself as adding to the contribution to ship him somewhere else. Shane NREMT-P

A companies size is not a symbol of professionalism directly. That professionalism required comes from management, and more important the employees themselves. I work for AMR in Hartford, CT and we are expected to be dressed appropriately for any duty shift and we are expected to provide quality care to our patients. In a large company, it might be a little bit easier for someone who's lazy to get away with more simply because there are too many people to keep close tabs on. At least that's how it was when I was in the city. I am still employed by AMR but am dedicated to a volunteer service that has a contract with AMR to provide them with a paramedic. In making this move, I've noticed the service tends to keep tighter tabs on your patient care and interaction with others. I'm also sure that this has to do with the fact that there are only 4 full time medics dedicated to a contract town so it's easier to keep tighter control on us and the responsibility gets shared between AMR (in this case) and the service we ride with. I also work for a smaller city service that is a smaller group of providers and they hold us to a much higher standard. QI plays a major role with this service and they track just about every statistic that you can imagine. It's kind of nice to be held to a higher standard, and forces you not to fall into a pattern of laziness. Any service you ride with or work for is going to have pros and cons. And they will have great providers and sub par providers. It's the nature of not just this profession, but any profession as a whole. It's up to you find who you look up to and respect and what you pull from every interaction with another provider. This applies if you're trying to pick up a new idea that you like, or seeing someone do something that you don't like. You can learn from nearly every provider. If one experience with one crew from one service is enough to push you away from EMS as a whole, that's your own personal decision. To me if you're that easily strayed from your initial desire to be in EMS, then maybe your desires were misplaced in the first place. That is being said not to be harshly critical or negative, but you're forming an opinion of a profession based on one negative experience when you've already had what has been described as a positive one to offset it. Also as Rid had mentioned, don't think you won't see some horrible patient care as an LPN. They're not exempt from the same attitudes and behaviors that you've already described. Many LPN's that I have spoken with don't appear to have a solid grasp of the how's and why's of patient care. On more than one occasion I have taken time to explain a disease process or an intervention. Any healthcare provider who will consistently put a patient on a non rebreather at 6LPM because their protocol calls for oxygen in certain situations hardly has a firm grasp of how their equipment and interventions are supposed to work. There are good and bad in the nursing field as well (RN, LPN, etc). Good luck, Shane NREMT-P

Procanimide isn't used frequently, but we do have a few people who have used it. And our protocol does have it listed for wide complex tachycardia's. Our protocols tend to be rather generous and allow us quite a few options as opposed to just an "if this than that" scenario. Amiodarone is in the protocol as well, and a large reason why don't have it is financial since as far as I know the drug is rather expensive. Windsor has it and Bloomfield I believe has it (it's been a while since I've been up there), New Britain has it and a few others. Shane NREMT-P

Provided that my patient had a good blood pressure and is mentating well and doesn't appear to be hemodynamically comprimised, I still think I'd hold off before jumping to any kind of medication for this patient. Amiodarone would be a good medication since it works on atrial or ventricular rythems, but with a rate of approximately 125, is the rate really the issue? And does it need to be controlled? I'm sticking by my front line for this patient is oxygen and a fluid bolus before trying anything else. You could set the pads up in case you do need to defib/cardiovert, but my guess is that the patient would be stable enough to make it to the hospital. And just for something to think about Fiz, don't forget about Procanimide since it works on both the atrial and ventricular rythems. We don't carry amiodarone in the city yet even though we have it as an option in our protocol. There's only certrain services that have it that we cover for. Shane NREMT-P

That's more along the lines of what I was thinking then V-Tach. I wouldn't treat this rate or rythem with electricity or and cardiac meds. Try a bolus of Normal Saline, supportive care and a ride to the hospital with more assessment of the patient. Shane NREMT-P

The question itself is enough to stir thoughts and memories regardless of if you choose to post them or not. Shane NREMT-P

Minor correction...it's motocross. There's no "r" in it for motorcross. Just a peeve of mine having raced motocross for many years growing up. Shane NREMT-P

Good luck in your ride time. My approach to students is that will give them whatever time it is that they want from me. If they want me to spend all day going over drugs, scenarios, etc...I'll do it. But if they appear disinterested in being there and taking advantage of the learning environment that has been presented to them, I'm not going to push too hard and go out of my way to help someone that doesn't want it. If you want to learn, I'll do anything to help you to do so. If you're there just to do your "ride time," I have other things that I can do with my time. I've already gone through school and the precepting process to obtain medical control. You're just beginning. Take advantage of your opportunities as they arise. Don't come to ride time with the intent of getting something else done that you need to do. It's a bad idea to wait until the day a paper is due for class and to be writing it while you're at ride time. Planning is essential as a paramedic and if you're doing this then you didn't plan properly. Hoping to get a paper done while you're riding with a service is a huge roll of the dice at best. We could be busy doing calls. We could be going over drugs or other areas that you want to work on. Ride time is for riding. This includes doing calls and taking advantage of your resources. Also remember that there is a fine line between being cocky and being confident. You want to be confident. If you show up to ride time prepared and you feel like you are ready to be there, you will find that preceptors let you do more than someone that is not being decisive and is too afraid to be interactive with the patient. If I ask you why you want to do something, it's not because what you want to do is wrong. It's to make sure that you have the knowledge behind the intervention. I won't let you do something that is wrong. If you're going to be giving medication or performing any intervention, as your preceptor I have the obligation to make sure that your thought process behind it is correct. Ask questions if you're not sure. Don't make up answers. Be confident and the sky is the limit. I'll just hang back and 100% let you be the medic. I'll just be there for oversight or if you need an extra set of hands. Be prepared. Wear a watch with a second hand for taking pulses and other vital signs. Bring a stethoschope. One of the worst things a student can do is to show up unprepared expecting to use my personal gear. The same student showed up at my service three times without a stethoscope. It finally got to the point that any call that he needed a stethoschope for other than a blood pressure he was pushed back to observing. The first time I might give you. The second and third time is unacceptable. I make it a point to show up at work on time and prepared. You can show up for ride time prepared. Be on time. Showing up late is a bad way to start the day. You don't have to bring us donuts or anything else to start the day off well (althought it can be a nice gesture). Be active. If you see us cleaning around the station or detailing an ambulance, come help us out. Treat your time at the services you ride with as a job interview. Make a positive impression and you just might get a position there someday out of it. Most of all...have fun at ride them. You'll most likely get to work with a variety of great providers that are more interested in helping you and seeing you succeed than they are about watching you fail. Ask questions. Get answers. Be motivated. Be active. Be confident. Shane NREMT-P

+1. This patients previous history of a-fib would have nothing to do with my decision to apply the cardiac monitor to this patient. This patient is getting worked based on presentation and mechanism of injury. There is a high potential for internal injury in this patient that needs to be addressed. An irregular pulse alone is not often times a reason to apply the monitor. You have to look at the complete picture and see what's going on to make informed decisions. Shane NREMT-P

As unfortunate as the accident was, it does happen and will continue to happen for as long as we drive on roads. It just as easily could have been a family or any other group in the car for that matter. The concept of wearing seatbelts at all times is not a new platform by any means. Many states currently have seatbelt laws that require them to be worn, but like any other law you can't enforce it to 100% effeciency. There will be people who don't want to wear them and will not wear them. It's just the nature of being human. They have the freedom to make their own decisions. And Connecticut is also among the states that has a law restricting who can be in the car after you first obtain your licesne. I don't know the details of this law, but I know it is one that has evolved over the past 10 years or so. Good for you for wanting to take a stand on an issue and encouraging people to wear seatbelts though. Shane NREMT-P

It sounds like if your'e getting paid twice for working the holiday (your regular hours, plus standard holiday pay), you are getting paid extra for working the holiday? If you were to take the day off, you would be paid straight rate for the holiday. If it weren't a holiday and you had the day off, you don't get paid at all. If it is a holiday and you work, you get paid twice for those hours. Sounds fair enough to me. Holiday pay at one service that I work at is 2.5 x my hourly rate. And the other service is hourly rate + $30/hour. Shane NREMT-P

Cut him some slack after this statement? This is saying that he knows the difference and can write "just fine," but essentially when he is typing he chooses not to. If he truely didn't know the difference, I might agree to cut him some slack. Because he's not willing to put in the effort to make his typed word on par with his claimed written word, then there is no slack to be cut. I guess it comes down to motivation. If he can't take some criticism now that will benefit him for the rest of his working career, than who's to say that he'll take criticism in the working world. +1 for Rid on this one. I agree 100%. Shane NREMT-P

Thanks for the correction. While not being perfect, it seems that the post does flow better and is much easier to understand than that of the original poster. That was more or less the point I was going for. Corrections made to my original post. Shane NREMT-P