medic001918

I don't know why any service would "require" their membership to have lights on their POV's, especially since they're commonly courtesy lights (like here in Connecticut) and doesn't allow anyone to operate as an emergency vehicle or to disregard any traffic laws. It seems like increased liability for zero gain to me. But if it's what makes them happy...good luck in your search.

Shane

NREMT-P

I have to agree with others in the sense that I most likely wouldn't have intubated this patient. As far as attempting to get down the stairs with this patient, if you give the narcan and it's effective in reversing the effects of the overdose you should be able to get him down the stairs safely. This is a patient that I would have worked up in the house by having my partner bag them while I established an IV and gave the Narcan. If after a few minutes you have no effect at all with the proper dosing of narcan then I would consider another option (such as intubation).

Like Doc mentioned, intubation is not a benign procedure. It's a highly invasive procedure with it's own set of complications and potential problems that come with it. Rid also mentioned the idea of treating the underlying problem rather than the effects which would be great advice. I would not have intubated him and then given him the narcan when we got to the truck. This allows the opportunity for the patient to try to self extubate causing further airway trauma for no reason. That would have put the patient at risk twice (in the first placement of the tube, and now the removal) when the device was only in place for a few minutes.

As was already mentioned, the narcan dosing could have been repeated if needed to prevent him from going out again.

It's tough to say for sure how this call would have been handled without having been there ourselves. Based on the scenario described though, intubation would have been a last option after narcan.

Good luck,

Shane

NREMT-P

Find yourself a good pathophysiology textbook and read it until the pages come loose from the binding. A & P helps, but pathophysiology focuses on the things that are broken, and how they break. This tends to allow you to better understand how to fix them.

Minus 5 for the most generic title I have seen on this site.

Learn your anatomy and physiology backwards and fowards, it will help more than anything.

Peace,

Marty

The best advice right there. If you don't know and understand A&P, you can't talk A&P. And A&P is the universal language of medicine. Too many people get hung up on trying to memorize meds, or EKG's or any other aspect of paramedicine before they understand the fundamentals. When you understand A&P, the rest comes rather easily. I wouldn't suggest reading anything but A&P. And more specifically, you can focus on the nervous system, cardiac system and respiratory system as those are the three biggest ones that we deal with and that we tie everything into.

Shane

NREMT-P

I will not use 10 codes for future referance.

I can make all the excuses up in the world to make it sound right, but you know its useless.

With that said I was having a very bad shift, it caught me off guard and I took it offensively. My apologies.

Fair enough. Apology accepted.

Shane

NREMT-P

Thank You Ruff

For those of you who are lazy and cannot read between the lines:

10-6=busy

For those who are lazy? Kind of an arrogent remark there considering that 10-6 for the FD in one city I work in means they're looking for a telephone call. So for my inability to "read between the lines" due to my being "lazy," that would mean that you want the FD to call someone. And in the other service I work for, 10-6 means that they're back in service which would mean that they could certainly come to help you out.

So your thoughts on being lazy and not able to read between the lines are 100% inappropriate and totally uncalled for. I was trying to offer something to think about for future posts to avoid confusion. It was anything but being lazy and having the inability to read between the lines. Maybe my illustration of the different meaning for the codes in two cities for the areas I work in will help to provide some explanation for why posting with codes is ineffective often times.

Shane

NREMT-P

...rescue was still 10-6 on scene...

Remember not to use codes when leaving posts. Different agencies often have different codes even in the same jurisdiction. Just something to think about. I've seen codes used a few times.

Shane

NREMT-P

When it comes to forcible entry, I base the decision more on the nature of the call. Does it sound like a life threatening call? Or does it sound more like someone just needs a ride to the hospital? I know that dispatch information is not always the most accurate, but often times it's all we have to go on. If you are called to a residence, you have an obligation to investigate the call to the best of your ability. And that includes taking a door or window down to do so if necessary. The only thing is that if you do force entry, you need PD to respond to secure the residence after you're gone. If you force entry and then leave without having an officer there to "secure" the location, you open yourself to potential problems. And the FD is always willing to break doors for us if need be. I've only seen one occasion where I wanted them to take a door and they wouldn't do it until checking every window for an entry option (including a ladder to check second floor windows). And that was for a patient who could be seen "unresponsive, but breathing" on the floor of the living with a diabetic history. For the most part though, if you ask them to do it they will do so without hesitation.

Shane

NREMT-P

Before you go flexing your typing fingers and telling me to "STFU" (which is a great way to represent yourself, your service and OUR profession)...you seem to have missed a few things. So for your assistance, I've pointed them out for you and gone on to answer your questions. Hopefully you'll find this post more helpful to your cause.

When you glanced through you seem to have missed some threads that just might have covered your questions. For your pleasure and assitance, here are the links I came up with in a search for "EZ-IO" on EMTCity.com. It took me far from two days to locate. In fact, I found them in less than 10 seconds. Plus, let's not forget that in the rules for the site which can be found here http://www.emtcity.com/phpBB2/siterules.php, it states "We also ask that our members make an honest attempt to abide by these universally recognized standards of "Netiquette" when posting to EMT City forums:

Please try to do some basic research before posting. Most fundamental questions have already been discussed multiple times on this site. Take a moment to use the "Search" function on this site to find previous discussions regarding your topic before starting a new topic."

http://www.emtcity.com/phpBB2/viewtopic.ph...;highlight=ezio

http://www.emtcity.com/phpBB2/viewtopic.ph...;highlight=ezio

Those are the two with EZ-IO in the topic, there multiple other threads that have EZ-IO's mentioned. These two are directly related to the device though. Hopefully you'll find more information that you're looking for. Do some reading, and post back with other questions should you have any.

And now onto the next thing...

Maybe you'd find better answers to your questions if you took the time to explain the situation. Tell us that you had the inservice and are looking to compare agencies policies on the use. General questions such as "how easy is to use?" and "what type of situations would you use it in?" and "how effective it is?" Those are three questions that should have been covered at length in the in-service. You asked for general information, not protocol driven answers. So maybe the problem isn't us "dipping in each others buckets" but a post that could have been worded in the first place to get the answers you seek.

But since you want information, the protocol we use for it here is:

Front line in cardiac arrest or for any critical patient that needs IV access, and where IV access could not be established within 60-90 seconds.

It generally takes less than one minute to establish the IO with a low complication rate. The only contraindications are a proximal long bone fracture and/or morbid obesity. Any medication that can be given IV, can also be given IO; up and including adenosine. Generally, we only tend to use them in unresponsive patients, but it can be used in concious patients as well. If you listen to the literature on the device, it supposedly hurts less than a peripheral IV. I don't know how much I buy into that statement though.

Shane

NREMT-P

PS - You don't know who I am or what my personality is either, so what was your point? It's great that the job is fun and exciting for you. It still is for me too. But don't forget that your typed posts are the same as a spoken word in a conversation. Think your post out, write it concisely and conduct yourself with the maturity and respect towards others that our profession deserves.

We have used them with good results.

I have to deduct 5 points though for not utilizing the search function to find that a similar thread to this has already been created and discussed. Feel free to search for the answers that have already been given. Should you have more questions after the search, post again and we'd be happy to use them.

I also don't know that I'd use the words "BIG FUN!" to describe the use of the EZ-IO. As mentioned, it's another tool...not a replacement for good skills in the first place. If you don't know when you would typically use the IO access, it's probably in your patient's best interest that you refrain from using the device other than on a dummy to practice. Hopefuly your in-service training will cover more of your questions.

Shane

NREMT-P

I'm curious as to a complete set of vital signs as well. My first thoughts would be an absence seizure given the gaze and the overall presentation. But the glucometer reading makes me wonder if something else might be going on as well. Is his skin diaphoretic? Dry? I think I would probably do a repeat BGL in case I had a bad sample (it's happened to me before). Does he respond to the finger stick? If it comes up the same, maybe consider half an amp (12.5 gm) D50 or D25 depending on your protocols and what you carry. I would want to see if that causes any change in his presentation.

Since he's at school, there might not be any really well versed in his medical problems. They only have the parents sheet to go off of and who knows how recently it was updated to reflect any current condition.

What time of day is it? Would he have eaten? Can any of his classmates provide information about if he's eaten and how much? Sometimes you can pull some information there even though they're kids.

I'm inclined to agree with crazy though about the neuro involvement. However that could be secondary to a hypoglycemia as well.

Shane

NREMT-P

She is unable to lift her tongue to the roof of her mouth (either through communication, nerve damage or the fact that she is hypoxic) so NTG is out, we dont have CPAP nor PEEP, so thats out too. I could have tried using a BVM as a PEEP, but i went for more benign treatment since at this point she was awake and aware.

Could you have used NTG paste? It's a viable option for the patient that can't follow commands.

I agree with others that lasix probably wasn't the best course of treatment for this patient. I would have pursued a different course or treatment based on the picture you painted for us. A patient that is unresponsive secondary to hypoxia (such as in late stages of failure) would not have a sat of 98%, and would not generally be normotensive. I'm curious, was she tachy? If so, how tachy was she?

An aspiration pneumonia can present with a sudden onset. The story you present doesn't make me immediately think of CHF. It sounds like there's more to the story than what's being presented. The best treatment for this patient would be conservative, as any form of pneumonia is one that dehydration could worsen and provide additional complications for the patient.

tniuqs provided a great analysis of the call based on what you've presented. Review his information, follow up on the patient with the ED and find out what it was. And most of all, learn from this call.

Shane

NREMT-P

As an EMS veteran with 8 years on your 26, I call BS.

So... you're saying that it's all about appearances? Nice. I'll stick with reality for making my professional judgments.

If you had stopped here, you would have been been better off. You were correct at the end there. It is NOT the profession that I or our neophyte friend chose. It is not a "necessary part of the job" for an EMS paramedic. It is only a necessary part of the job for transfer jockeys. They are not the same job. In fact, the stretcher is the only common factor between the two jobs. Firemonkeys don't start their careers by working at the water treatment plant. It is not part of their job. Likewise, if somebody enters EMERGENCY Medical Services with a desire to care for EMERGENCY patients, they are absolutely justified in not wanting to be a horizontal taxi driver. And any belief by vets like you that newbies should pay their dues by doing so is simple selfish elitism without any rational foundation in reality.

Hey, if you want to run transfers for a living -- and many people do -- that is admirable and respectable. Go for it. But most paramedics I have worked with in my career -- including most of the best -- never worked a single day as a transfer jockey, yet they managed to excel as professionals in the field they chose. Your contention that transfers are something they need to embrace in their careers is a misleading lie. And your attempt to forever link EMS with horizontal taxi services is a major contributing factor to our profession never being seen as anything more than "ambulance drivers" by the general public.

Thank you so much for your efforts to hold our profession and our people back in the 1970s.

+1. Another great and well thought out post with explanations of all the points raised. I'm curious to hear the rebuttal from ambman142.

Shane

NREMT-P

Sorry, but I have to get in here.

There is a definite possibility that the individual service would not be able to survive. Just as likely, this would become a regional issue. So instead of eliminating service to the entire region, combine services. Regionalize the providers so that the call volume would increase enough to support the newly formed agencies. Just one idea that has met with some success already.

For a period, there may need to be a reduction in service. Until the bugs in the system are worked out, but in the end it would be vastly improved over the current state of affairs. Even if it means maintaining a number of volunteers on call to serve a more remote area until others can arrive. Reducing response times would be one of several benefits, eventually.

As broke as the system currently is, moving to change the way things are done should not be viewed as a bad thing. Ideas abound as to how to best alter the status quo. The problem with implementation lies with a lack of vision, or fear of change from providers that don't see the need.

AZCEP beat me to it. The way the smaller services have their financial needs met is to combine services with other small towns so that they don't have to absorb the entire cost on their own. Make it a county or regional service. The biggest problem with EMS demanding better wages is education and the fact that there are plenty of people willing to do it as a hobby and give their services away for free.

An EMT in my area makes $14-15 hour and can pretty much work as much as they want. That's not bad money considering that it's a few short weeks of time spent in a glorified first aid class. Doesn't sound like bad wages when you consider the amount of time that was needed to be invested to be able to do the job.

The majority of services in my area are volunteer as well. In fact, there's more volunteers in my area then there are paid providers. How can you demand better wages for your services when someone is willing to take your job and do the same work for free? If you're in charge of the budget, it's a no-brainer how to handle that situation. But if people stop giving their services away, the people in charge then have to fund the service appropriately. As other's have mentioned, there are plenty of other positions that they find funding for...teachers, public works, police, janitorial, etc.

This is a topic that has been beaten to death. But there is a means for them to handle the problem and make the system work. While it would cause some "growing pains" again, the end result has the potential to be more than worth it for those that are trying to make a career of EMS.

Shane

NREMT-P

Her saying she was a registered nurse shouldn't have any impact on the refusal aspect. If she was alert and oriented, and had everything explained to her then it's within her rights to refuse regardless of her present or past occupation. It just might make it easier/harder (depending on personality) to convince her that she should go get checked out.

If the onset was under exertion such as walking, and the symptoms resolved with rest and only to return with exertion again (standing up is exertion for some); than I would consider that a form of orthostatic change potentially. Orthostatic vital signs are a great way to see how well the body can compensate for a change in demands. Unfortunately, I don't think they're done often enough prehospitally. If orthostatic's weren't taken on scene then there is no way to know for sure if there were changes. Was there any recent sickness such as a cold/flu? Fever? Etc? She may have been simply dehydrated if she hasn't been eating and/or drinking well. And like mentioned earlier, it could be indicative of an underlying cardiac or nervous system problem. It's tough to tell and even a 12-lead isn't the best indicator of if there's something going on or not.

ALS responded and found nothing irregular with the patient (by assessment and EKG), and the patient signed a refusal. I transported her home and she was fine, and was fine the next morning when I saw her.

I'm confused at this statement. How could the patient sign a refusal, but still require transport home? Did she end up going to the ED anyway by some other means? Just looking for some clarification.

As for the change when she stood up, it sounds like she may have had some orthostatic changes in her blood pressure and heart rate. This can indicate anything from an underlying cardiac issue to dehydration. Without knowing more about what led up to the call, it's difficult to say for sure what's going on. A patient that's 81 years old can have many undiagnosed etiologies that will effect them and cause different signs and symptoms.

It sounds like when she changes position, that her body can't keep up with the demands that it has.

Shane

NREMT-P

I'm confused. You're asking for the starting salary, but you posted what it is. What are you really looking for? Like most jobs, salary is usually dependant upon experience and qualifications. Your post just left me confused.

Shane

NREMT-P

Virginia...

Our squad is going to begin billing patients' medicare/medicaid, & private ins. w/in the next year or 2, in conjunction with our squad becoming part-paid. The plan is to not bill aggressively. Our county is small enough where everyone knows if someone comes from a family that can afford to pay out of pocket...so no, we aren't going to bill aggressively to the family on public assistance that lives in the projects...but we aren't going to take a loss and not aggressively bill the multi-millionaire down the street either. That's the plan, anyways.

Yeah, that's not a uniform approach. Hey, I'm an operations manager. that'll be left up to the folks in sharge. My billing experience is limited to paying for my kids prescriptions at RiteAid, CVS, Walgreens, or WalMart. Sue me.

Sounds like a fair system to me...penalize the people who actually work for a living. Since everyone knows my family situation, that means that they also truely know my financial situation as well; right? Agencies that bill like that amaze me. The people who use the system more than anyone else when they tend not to need it end up not having to pay and this allows them to continue the abuse. You say you're not going to "take a loss" and not bill families that can pay for the ride. What if the call from the family on assistance or in the projects doesn't warrant an ambulance transport? Should the ride still be free? Now is all you've done is turn your service into a free vehicle for the family.

If your service isn't going to bill aggressively, then don't bill aggressively across the board. Don't make it a case by case situation. That's discrimination plain and simple. Just because someone's family appears to have money, doesn't really mean that they do.

One suggestion that was proposed at a service I work for is to bill patients insurance companies, and then request some form of donation in the amount of whatever they are willing to spend in order to take care of the balance. So if insurance will cover 50% of the cost, and you have a balance of $250...you can send a donation for $50 (if that's what you can afford) and the bill will be taken care of. If you choose to pay nothing, the bill stays in collections.

EMS will never further itself while be willing to give away it's services. This is true on both a personnel, and a service issue. Volunteers give their services away for free hurting the progression of the field as a career choice. And services that don't bill aggressively end up giving away their services which hurts their profitability and more important survivability since there are many day to day operational expenses that need to be covered.

Just remember that you can't walk into a car dealership and receive a reduced price because you can't afford the car you want. The price of the car is the price of the car. Why should EMS be any different?

Shane

NREMT-P

Some people have zero attention for detail. Or no concept of time with regard to dates.

Shane

NREMT-P

Fiznat actually works for the same company I do, and last I had heard is that the problems were cleared up. He is just waiting for his turn to precept as a new paramedic. And you're right, he is a smart kid and I have no doubt that he'll be a fine paramedic. His blog is definatly worth the read.

Shane

NREMT-P

vcfd35s,

I say give it a shot with the judge, What do you have to lose? and as for 3 speeding tickets; I wouldn't be to quick to judge anyone on traffic tickets, although I have never had one, I have seen how merciless cops can be when they're ticket happy.

I can't remember who said it, but it was something about at the age of 20 not having enough time to work hard for what you want. Well I disagree. Its wrong to pretend you know someone's situation and compare to your own situation.

Good luck man, hope it works out for you.

You may have seen how merciless cops can be when they're ticket happy. But do you think that was the case on three seperate occasions? Personally, the ticket's aren't a big deal. Over the years, I've gotten a few myself. But when they're grouped together in a narrow time frame, that indicates the potential for a larger scale problem. So well an officer may be "ticket happy," you have to do something wrong in the first place for the officer to initiate the stop. I wouldn't be so quick to blame the officer for doing their job. Any time they let someone go with anything less than a warning, they are being nice. There's no mandate that they have to cut you the slack. It's a courtesy that they extend to someone. Just something to think about before you paint the cops as being the bad ones. Sure, there are bad cops. But from my experience (both on and off the job), it seems as though they're a small minority in the group. Now, if you said that all three tickets were issued by the same officer, you might have a case. I highly doubt that's the case though. And if you really don't want a ticket...don't violate a posted law in the first place. The only one to blame when you get caught is yourself.

Now all of that being said, it doesn't mean that I always do 65 in a 65...but if you get caught on multiple occasions, the common denominator just might be the person driving the car as opposed to the "ticket happy" cop.

Shane

NREMT-P

I am not asking the judge to erase the tickets off my record. I am simply asking for permission to attend traffic school on two of those tickets so the points can be dropped. I was already informed that if permission was granted the tickets will still be on my record and still reported to my insurance but with a DMV point count of zero. I am fine with that, and am not looking for forgiveness for my tickets.

But will just having the points off your record be sufficient to gain employment? Many employers can't hire people with poor driving history's due to insurance. So if the ticket still reports to insurance, I don't know if all this trouble will help you or not.

Shane

NREMT-P

I have seen cushing's triad in the field. Time of onset for cushings is more related to the severity of the CVA and how quickly everything develops. The faster the bleed, the sooner the onset. In a subdural bleed, where the symptoms takes hours and sometimes days to develop you wouldn't see it quickly. In a subarachnoid bleed which is arterial in nature, you'd be more likely to see the symptoms develop rapidly.

As for your GSW patient, I would think that the posturing you saw and the changes were due to the physical trauma to the brain more so from an increase in ICP.

I'm pressed for time since I'm about to go to work for my tour tonight. But hopefully that helps a little. I'm sure someone else will elaborate some more.

Shane

NREMT-P

Pills from Grandma's house? And a symtomatic bradycardia? My guess might be a beta blocker overdose. I would try to have a family member call Grandma and see what pills she's on. Otherwise, call medical control and see if you can get an order for some IV Glucagon.

While all of this is going on, we'll be doing the basics such as supporting the patient's airway, oxygen administration, etc.

Shane

NREMT-P

Regardless, optimal documentation lists exactly what parameters you are utilising, not just "x3" or "x4" because obviously, parameters differ from provider to provider.

Excellent advice from Dust. I always document x/3 or x/4 depending on if there's an event that can be tied to the call. An example is a fall, that's where the "event" is cruicial. For a medical such as chest pain, if the patient has called themselves then I'll use x/3. But you should ALWAYS document the parameters you were using.

And to Mobey, you have oral glucose in your protocol for an unconcious, hypoglycemic patient? And you think you can only do good with oral glucose? I'm just curious, but isn't one of the direct contraindications for oral glucose having the inability to control their own airway? If a patient can't control it and you give it to them, there is a significant risk of aspiation that could directly be tied to your treatment. Something else to think about is that oral glucose is rather thick, and not the easiest substance in the world to suction. Your best bet would be managing this patient by some other means than giving them cause to aspirate and complicating their condition.

Shane

NREMT-P