crotchitymedic1986

A woman in a hot air balloon realized she was lost. She lowered her altitude and spotted a Paramedic washing his ambulance at a fire station below. She shouted to him, ‘Excuse me, can you help me? I promised a friend I would meet him an hour ago, but I don’t know where I am.’ The paramedic consulted his portable GPS and replied, ‘You’re in a hot air balloon, approximately 30 feet above a ground elevation of 2346 feet above sea level. You are at 31 degrees, 14.97 minutes north latitude and 100 degrees, 49.09 minutes west longitude.’ She rolled her eyes and said, ‘You must be a Republican .’ ‘I am,’ replied the paramedic. ‘How did you know?’ ‘Well,’ answered the balloonist, ‘ everything you told me is technically correct, but I have no idea what to do with your information, and I’m still lost. Frankly, you’ve not been much help to me.’ The paramedic smiled and responded, ‘You must be a Democrat .’ ‘I am,’ replied the balloonist. ‘How did you know?’ ‘Well,’ said the paramedic, ‘you don’t know where you are or where you are going. You’ve risen to where you are, due to a large quantity of hot air. You made a promise that you have no idea how to keep, and you expect me to solve your problem. You’re in exactly the same position you were in before we met, but, somehow, now it’s my fault.

No, i caught the sarcasm. The problem is that there was a similar report in the US (forgot the State) not long after 9/11. There are other vehicles that contractors can use, it is just too dangerous to sell these vehicles to the general public, as you can pull an emergency vehicle (with lights and sirens going) to almost any building in the US (including a school, hospital, airport). My original thought was that if you gutted the vehicle of all emergency lights and sirens, it would be OK, but then I realized that it would only take a few thousand dollars to restore the vehicle with working lights and sirens. Used ambulances have also been used to transport illegal drugs (not likely to be pulled over or inspected at road-block). http://www.caller.com/news/2008/nov/14/amb...ge/?partner=RSS

With that being said, I just realized that the poster of that thread was the actual patient. So they can clear this up quite easily. So EMS493, did you REFUSE EMS transport, or did the medics tell you that you would be OK to go by car ?

Dear Spenac and Fox, I was responding to this post on page 1 of this thread -- not fox's: -------------------------------------------------------------------------------- I don't know another way to answer your question without presenting a case study to validate my response. Patient is a 25 year old female, with a chief complaint of "I just have the flu." Patient presents alert and oriented. Skin is pale, nearly white, including nail beds and lips. She appears to feel poorly and admits to being very tired for the past three days. Vital signs BP 90/50, which is normal for patient, HR 130's at rest, RR 24. Unable to obtain a pulse ox reading. Lung sounds clear and equal bilaterally. Patient is nauseated, however no vomiting, no diarrhea. Rest of physical assessment is unremarkable. Patient was strongly urged by paramedic to be evaluated at the ER. I guess it was a gut feeling based on experience and patient appearance. Patient is goes to the ER as a walkin. Apparently she stated to the triage nurse "I don't feel well" and looked bad enough that the triage nurse nearly set her pants on fire scrambling to find a gurney and a physician. The patient had a Hct of 12 and a Hgb of 3.2. She was also in heart failure secondary to lack of oxygen rich blood. The body can only compensate for so long. The ER performed a 12-lead and it showed ischemia and T-wave changes in every lead. The EGD showed several ulcers and mallory weiss tears in the esophagus, along with a lot of blood in the stomach. I have no idea why there was no vomiting since the stomach isn't a real fan of blood. Do you need to perform a 12-lead? Probably not, especially if you are a stones throw from the ER. If you have to trek the distance, for whatever reason, a 12-lead may serve to trend any changes in coronary oxygenation and perfusion from start of patient contact until the ECG is repeated in the ER. I know every physician I work with will order an ECG on a patient with that presentation and those labs. The heart not only needs blood, it needs oxygen-rich blood, and a decrease in hemoglobin that results from a GI Bleed can send a patient into heart failure. It's not a necessity, but I'm a trending type of paramedic. I know that case study backwards and forwards because I was the patient. The most recent ECG I've had performed still shows ST changes indicative of prior ischemia. I only respond because I keep seeing the age of the patient being brought up as a determining factor in whether or not to perform a 12-lead. After my experience, it cements the fact that heart failure secondary to GI bleed knows no age. You do what you feel is right. Perhaps I'm just a little overly cautious.

And how would you propose that they do that ? Ban everyone with the name mohammed as a screen name ? I think if alquida was smart enough to pull off 9/11 and the subsequent bombings, I think they would be smart enough to choose non-alquida screen names. What should be required is that emergency vehicles should only be sold to licenses emergency providers or dealers.

we black folks love our watermelon, chicken, and colt 45

Originally posted in the 10 student rules thread, now moved to here: Students please realize this of your preceptor: 1. It is important for you to be early, but realize that your practicals will not start on time because: two preceptors called out sick at the last moment, and one of them was supposed to bring the check sheets. Of the ones that did show up, 4 are on smoke break, and three are busy taking a large BM after drinking their second gallon of coffee that a.m. 2. Those who can, DO; those who cant DO, dispatch; those who cant dispatch, teach. 3. Your preceptors are divorced, and havent been laid in over 6 months (with a partner) so this is their form of sexual gratification -- screwing you -- they cant wait for you to screw up the order of KED straps so that they can fail you. 4. Do not argue with your dictator, i mean preceptor, they are always right. It doesnt matter that what you saw during your third rides in real life contradicts everything that is occuring in their scenario. Keep your mouth shut and do it as they want --- this will be the last time you ever see them in your life, unless you attend a star-trek convention. 5. You know what the difference is between a female EMS preceptor and an elephant? About 200lbs, but you can force feed the elephant to make them equal out. Whatever you say, do not make any derrogatory statements about cats. Cats are gods in their worlds, any negative statements will get you an automatic fail. Try bribing them with a lime colored moo-moo to wear at home, a gift certificate to the local buffet, or a rainbow sticker for their saturn's bumper. That should stir up some answers from the other side.

again, you are misreading what i typed --- i never said that this patient should not receive ALS, I merely pointed out that a EMTB-I should be able to recognize compensatory shock. My point was that even in a BLS system, this patient should have received EMS transport to the hospital. And for the record, a BLS unit that transported the patient during the initial 911 call and only started an IV and O2, would have been preferrable to an ALS transport hours later, after the patient deteriorated to having CHF.

We shall see ............................. Supervisors dont typically "ding" innocent medics --- if the patient refused to go, there is nothing to ding them for. I am not assuming, just reading between the lines. If I am wrong, I will be the first to admit it -- hope you will do the same.

And to the medics who actually ran the call: I am not on a high-horse judging you. We all make mistakes, it doesnt make you evil or incompetent because you made a mistake. All I or anyone else can ask is that you learn from your mistakes, and not repeat them. Thanks for sharing the call, so that others may learn from that mistake. You wont be the first or last to leave a patient at home, that should have been transported.

Boy, you guys are going a long way to justify poor patient care. Let me clarify it this way: Is there any one in this room that would not have transported this patient, based on the baseline vital signs that were presented ? There is a reason the supervisor "dinged" this crew, and it was justified ---- IF the supervisor contacted the patient, which i am sure they did, and found that they patient REFUSED transport, I doubt they would have received the "ding". If the OP wishes to come back and tell us that they tried everything humanly possible to get this patient to go to the ER via EMS, then I will accept that the patient refused AMA -- but if the OP is honest, I doubt you will ever read that quote. Maybe they didnt talk her out of going, but i doubt they tried real hard to convince her to go by EMS.

Oh, i forgot --- the BLS versus ALS point. My point was that many EMTB's and EMTI's may be under the impression that they have no liability if there is a Paramedic on the scene. This is not true, if it can be proven that any EMTB or I should have seen the severity of the call with the skills they were taught. For instance -- your patient has severe neck pain with left sided paralysis after trauma. Your paramedic chooses not to immobilize them -- the EMTI on the call is just as liable, as they were taught to immobilize this patient, and it is within their scope of practice to immobilize patients (bet you had to do a check off to prove you knew how to do it). Any EMTI should be able to recognize compensatory shock. I dont care if she were transported by a BLS or ALS ambulance, the point is that this EMTI should have realized the severity of this patient if his/her medic did not for whatever reason. But typically, a GI bleed can be handled by any EMTI that can start an IV. If your system wishes to use an ALS unit (which would have also just started the fluid bolus), so be it. But the point was that the patient was not transported by EMS, and she should have been --- BLS or ALS

Mateo wrote: Again, the patient may have decided to drive herself to the hospital after the ambulance crew came and evaluated her. I would assume anyone who thinks someone needs to be seen at the emergency room would not talk them out of transport, but rather try and talk them into being transported by ambulance. Sometimes though, you just cannot change someone's mind. We just don't know the whole story. I respond: Mateo, I realize you are new, but unfortunately lazy medics leave patients behind all the time. It is easy to see, although the OP will deny it, that this patient was talked out of going to the hospital via EMS. My point was not that a 12Lead shouldnt be used, my point is that they should have realized that this patient was very sick with just the basic vital signs that they had. The patient was in compensatory shock. IF orthostatic vital signs had been taken, the medics may have discovered much worse vital signs (my guess is that this patients standing B/p was probably around 70palp). The OP wrote the question as if, "we did everything we could, do you think a 12 Lead would have showed us how critical the patient was ?" You didnt need a 12 Lead to see that. You are right, in that some patients do refuse care, but I dont think it would have taken much talking on my part to talk this patient into going to the hospital via EMS. Note the OP did not say that the patient refused EMS transport after several minutes of us begging her to go, and getting a supervisor involved. In conclusion: Technology is a wonderful thing; do 12Leads on everyone if you wish, use your glucometer, pulse ox, and KED whenever you get the chance --- but dont leave shocky patients at home.

EMS49393 wrote: Patient is a 25 year old female, with a chief complaint of "I just have the flu." Patient presents alert and oriented. Skin is pale, nearly white, including nail beds and lips. She appears to feel poorly and admits to being very tired for the past three days. Vital signs BP 90/50, which is normal for patient, HR 130's at rest, RR 24. Unable to obtain a pulse ox reading. Lung sounds clear and equal bilaterally. Patient is nauseated, however no vomiting, no diarrhea. Rest of physical assessment is unremarkable. Patient was strongly urged by paramedic to be evaluated at the ER. I guess it was a gut feeling based on experience and patient appearance. Patient is goes to the ER as a walkin. Apparently she stated to the triage nurse "I don't feel well" and looked bad enough that the triage nurse nearly set her pants on fire scrambling to find a gurney and a physician. The patient had a Hct of 12 and a Hgb of 3.2. She was also in heart failure secondary to lack of oxygen rich blood. The body can only compensate for so long. The ER performed a 12-lead and it showed ischemia and T-wave changes in every lead. The EGD showed several ulcers and mallory weiss tears in the esophagus, along with a lot of blood in the stomach. I have no idea why there was no vomiting since the stomach isn't a real fan of blood. My point: [b]The EMT talks about a "gut feeling" --- shouldnt have needed a gut feeling for this patient -- they should have transported. The medic had a gut feeling that told them this patiend was OK to go in the car, and MISSED THE EMTB-101 signs that this patient was in SHOCK. At the time of the 911 call, this call was a simple BLS call, but it became an ALS call because they left her to go to the ER sometime later, on her own, which allowed her to deteriorate to the point that it became an ALS call.

First let me say that I do not know all the facts of this case, but it could be a dangerous precidence for all of us (and yes, some of this is tongue in cheek): 1. If in fact she took the patient to a hospital different than that requested, would you want a medic fired who flew a "trauma mechanism" patient to a trauma center who latered turned out to have no significant injury (patient sues because they encountered unnecessary medical bills) ? We educate or overrule our patients decisions lots of times. 2. Is everyone in this room saying they have never made a transport decision or suggested a transport decision that did not benefit them personally. Have you ever suggested that: a. A patient not go to their facility of choice that is 5 hospitals away, when a closer facility could handle their non-emergent need. b. A patient not go to the urban teaching hospital on a friday night, because you know they will have to wait 16 hours for treatment, and you will have to wait an hour to find a bed. c. the pateint go to the closest hospital so you could get back to the station to eat or sleep. d. refused to take a drug seeker to the hospital that is an hour away (because that hospital hands out drugs like candy). e. that the patient who called you at 30 minutes before shift change should go to the closest facility versus the one that is an hour away (putting you off work and late to your part time job by 2 hours). f. agreed to take a patient to a more distant hospital, sacrificing coverage in your county because that hospital feeds you for free, or is close to that great 1/2 price restaurant. I am not trying to justify this EMTs actions, as they are deplorable, just realize that legal precidence can have some unforseen consequences. And before you jump on your soapbox, read the above again, and make sure you have never, not even once, been guilty of one of the things I have posted.

http://www.funnyandjokes.com/plot-to-kidna...ma-exposed.html

With what looks like imminent passage of the Mother of All Bailouts (following on the heels of a year's worth of government-funded rescues of private homeowners, lenders, insurers and automakers), Washington has turned Aesop's famous fable about prudence and hard work on its head. The time is ripe for a revised 2008 edition of "The Ant and the Grasshopper:" In a meadow on a hot summer's day, a Grasshopper was chirping and carousing his time away. He watched scornfully as an Ant nearby struggled to store up large kernels of food and build a secure nest. The Ant pulled overtime shifts to pay off his loans and accumulate retirement funds for the future. "Give it a rest," the Grasshopper said. "Why bother saving and slaving and toiling and moiling? Let's party!" The Ant demurred: "I am planning ahead for winter, and you should do the same." The Grasshopper blew off the Ant, squandered his supplies the rest of the season and abandoned his home while on vacation (paid for by tapping every last cent of his home equity gain) instead of holding down a job. When winter came, the Grasshopper's pantry was empty, and his shelter ruined from neglect. The Ant, weary from planting, harvesting, and stocking up for months, was dining comfortably in his nest. Cold, hungry, jobless, facing foreclosure and up to his two pairs of eyeballs in debt, the Grasshopper limped to the Association of Community Winged Insects for Rescue Now and demanded recourse. The office was swamped with thousands just like him. ACWIRN immediately put the Grasshopper to work registering dead ants as new voters. Funded with tax dollars from the rest of the meadow's residents, ACWIRN organized mass protests at the Bank of Antamerica, ambushed its top officials at their private homes, harassed their children and demanded that the meadow's politicians halt all foreclosures ("We must keep Grasshoppers in their houses!") and outlaw discriminatory lending practices against starving, homeless Grasshoppers ("Well-stocked shelters are basic insect rights!") The banking industry capitulated; the Orthoptera Lobby secured hundreds of millions of dollars in housing earmarks, grants and counseling subsidies to support the Grasshoppers with the shadiest credit and employment histories. Antie Mae, the meadow's government-backed home lending giant, fueled the push for increased insect homeownership in the name of biodiversity. Its executives cooked the books and headed for the hills. Katie Cricket and the Mainstream Meadow Media joined the grievance-for-profit circus, profiling Grasshopper sob stories and drumming up ratings as bewildered Ants wondered who was looking out for them. The banks drowned in toxic debt. More Grasshoppers fell behind on their mortgage payments. Bailout mania and panic gripped the meadow. Our little Ant, minding his own business, heard a knock on his door one late winter night a year later. It was his old, sneering Grasshopper neighbor. With ACWIRN's presidential candidate, Barack Cicada, now in office, the Grasshopper had been hired by the meadow as a tax collector. "I'm here to take your provisions," the Grasshopper cackled. But it was the Ant who had the last laugh. "I've learned my lesson," he told his shiftless friend. "Why bother saving and slaving and toiling and moiling? I've spent all my savings. I'm walking away from my mortgage. Thrift is for suckers," the Ant said as he headed out the door, leaving the Grasshopper empty-handed. ---

But you miss a key point regarding 12Lead and Stemi -- 12 Lead changes may not show up for up to 36 hours after an MI, so why not transport all chest pain patients (symptomatic and of reasonable age) to Cath facitlites, ditch the cost of 12Lead and put that money in medic's pockets.

I agree with the focus on the patient -- make sure you have warm IV fluids, and that you keep one backboard inside the patient compartment, instead of all on the outside so the patient doesnt have to lay on a slab of ice. You can feel and correct your coldness, your patient may not.

How about this one --- Sir, we need to immobilize your neck, so please come lay down on this board we placed on our stretcher. Cmon guys, if you are going to walk them to the stretcher, dont immobilize them.

I think you are asking the wrong question, the 12-Lead is the last thing you should be worried about. The real question is why you didnt transport a SYMPTOMATIC Hypovolemic patient. You had a low blood pressure, poor color, poor perfusion, and tachycardia. That should have been enough to let you know this patient should be transported. If your partner and yourself can not pick up on these basic assessment skills, you shouldnt bother with any higher technologic equipment. I am not questioning your intelligence, but my guess is if you had been on a basic truck you would have transported this patient. Dont let your lazy paramedic partners cost you your license -- yes i said your license -- this was a basic call. In the future, transport these patients that you do not feel easy about -- if your partner doesnt like it, volunteer to tech the call -- if he/she still doesnt like it, get a supervisor involved. I would have suspended you, not dinged you -- this is gross negligence.

"NEVER explain yourself--your friends do not need it and your enemies will not believe you anyway." - -- Elbert Hubbard

Good points, but i think it is only fair to turn the tables and give the students a chance to speak to power, so is my short list of preceptor / teacher suggestions --- please add yours. (which is tongue in cheek, so dont get too pissed off): Students please realize this of your preceptor: 1. It is important for you to be early, but realize that your practicals will not start on time because: two preceptors called out sick at the last moment, and one of them was supposed to bring the check sheets. Of the ones that did show up, 4 are on smoke break, and three are busy taking a large BM after drinking their second gallon of coffee that a.m. 2. Those who can, DO; those who cant DO, dispatch; those who cant dispatch, teach. 3. Your preceptors are divorced, and havent been laid in over 6 months (with a partner) so this is their form of sexual gratification -- screwing you -- they cant wait for you to screw up the order of KED straps so that they can fail you. 4. Do not argue with your dictator, i mean preceptor, they are always right. It doesnt matter that what you saw during your third rides in real life contradicts everything that is occuring in their scenario. Keep your mouth shut and do it as they want --- this will be the last time you ever see them in your life, unless you attend a star-trek convention. 5. You know what the difference is between a female EMS preceptor and an elephant? About 200lbs, but you can force feed the elephant to make them equal out. Whatever you say, do not make any derrogatory statements about cats. Cats are gods in their worlds, any negative statements will get you an automatic fail. Try bribing them with a lime colored moo-moo to wear at home, a gift certificate to the local buffet, or a rainbow sticker for their saturn's bumper. That should stir up some answers from the other side.

I would look specifically to your area of coverage, and find the need. Maybe you have a higher infant death rate, maybe more CRF patients, maybe a lack of AED's and citizen CPR training. The problem with these programs is that they tend to be the first to get the budget axe when times get tough, so I think it is important to create meaningful / measureable change. To site one example of this thinking: Maybe you have a stretch of hwy or a specific intersection or country road where the majority of your traffic fatalities occur. The past statistics are easy to obtain from you 911 center or your own call records. Maybe something as simple as a new redlight, a stop sign, or a sign that educates the public to the number of deaths that have occured one mile up the road, will significantly decrease deaths, which you can measure and say, "we saved 22 lives in 2009". Or maybe it is a busy intersection where lots of accidents occur (but not fatalities); you can work with your city or county to change that intersection, and again say "we decreased auto accidents by 40% at this intersection by just changing the sequence of the red light (instead of sequence of red- to left turn green arrow, to green light, to yellow, to red -- you change it to red, green, yellow, red, left turn green arrow). If not a redlight, maybe it needs a four way stop, or better signage. I would look at greatest needs in my community, weigh the cost of improvement (remembering that you may get buy in from national organizations to help you if you have a good plan (Cancer, diabetes, stroke, cardiac societies --- universities, drug companies, etc), weigh complication of how many internal and external partners i need to make it happen, and how measurable the goal is. Start small, build your way up.

If you read back a little further you will see that pregnancy was the first thing that i asked about. And its not that I am against new treatments, i have just been around long enough to see things come, then become taboo, then come back again -- or worse the continuous cycle of jumping to the next greatest drug or treatment only to find out that the outcomes don't change. And before you discount coma coctail as old school and ignorant --- if you have a diabetic patient that is symptomatic of textbook hypoglycemia, all the signs and symptoms, but your glucometer says "90". are you going to withhold D50 or glucagon or instaglucose ? No, you treat the patient --- and by giving narcan i am treating one of the most likely problems for this patient who is critical, in the absence of any more facts that might change my mind -- I can only go by what i have been told so far. This could change.