crotchitymedic1986

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.

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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.

yes a tampon test is in order--- if it tastes sour, definitely toxic shock --- and are you saying you wouldnt narcan this patient. I have been around long enough to see what works and what doesnt, and how treatment protocols change every 2 years so a new book can be printed and purchased. For instance, Calcium Chloride converted more cardiac arrest patients than mega dose epi, vasopressin, or AEDs ever has combined --- but the PHDs seem to think otherwise.

No problem explaining at all: I would not trust a thing the little ones said, but is all you have to go on. The patient is hypotensive and tachycardic. Being 14, you can pretty much rule out a cardiac event, especially since the kid isnt on meds. The OP said no signs of trauma, so we know it is probably not a trauma event, but i immobilized anyway. The patient has been to the doctor recently and got a zebra, whatever that is to a 5 year old. Most kids in the hood only go to the doctor when they are sick -- they dont get wellness exams. So, why would a 14 year old with no history be at the doctor -- for an illness or a pregnancy in my humble opinion. When children in the hood get sick, sometimes they can not afford the expensive antibiotic or the follow-up visit, so the child could have worsened and became septic, or the more critical infectious diagnosis was missed by the doctor and the doctor thought he was treating a virus or an ear infection, when the child really had menengitis or a severe pneumonia.

Narcan is part of the coma cocktail along with D50 that can/should be administered to anyone of altered LOC, when you do not know the cause (it wont hurt the patient -- I give it almost daily to altered nursing home patients who i suspect have been overmedicated to shut them up). This has nothing to do with the hood, lots of teenagers in the burbs are getting high on mommy's pain prescription.

In all probability, this is probably an OD, because it was a fairly sudden onset. The child was fine earlier and is now near death. Yes anything is possible, she could have a SA or an undiagnosed heart condition, or even a AAA --- but that would be rare in an otherwise healthy pediatric patient.

Let me sarcastically respond with this question, do response times really matter (remember this is slightly tongue in cheek) especially in a rural environment ?

1. In most rural environments, you also have a rural hospital that is likely to not be a trauma center, a stroke center, or have cardiac cath/CABG. So lets say you get there in 6 minutes, and then transport to your local rural hospital/nursing home/Tire and Lube Center, what have you accomplished ? They still have to be transported to the city hospital. But then you say, we can fly them -- Ok, you get there in 6 minutes, and 40 minutes later the helicopter is patient loaded and lifting off -- so what ?

2. What about cardiac arrest, surely you want to get there quickly and save them, dont you ? What percentage of your calls are cardiac arrests -- 1%, and of that group of patients how many walk out of the hospital -- maybe 10-20% of that 1% (remember going to closest rural hospital). So is it responsible to spend millions to save less than 1/2 of 1% of your patients ?

3. I would argue that probably 90-95% of your patients would survive a 30 minute response time. So again, if only a small percentage would benefit, is it worth all the money. It would kind of be like building a dialysis center in your rural community because you had "1" CRF patient in your town.

4. What about the golden hour --- how many multisystem, critical trauma patients survive to walk out of the hospital -- especially with the trauma center being so far away ?

Get me a hot pizza delivered in 10 minutes, as that is important. Most people who call 911 can wait 20-30 minutes (just look at any urban 911 system on friday night).

Well since she is 14 and has been to the doctor, she is either pregnant or was ill. Since she is not on any medications, most chronic ailments can probably be ruled out (Sickle Cell, Asthma, Congenital Heart Problems). Since the other kids are fine, can probably rule out CO poisoning. Regardless of cause, treatment is the same --- A-B-C- Immobilize, Intubate --- D-Stick, Narcan, 10-20 cc/kg fluid bolus (followed by Doapamine if no improvement -- not for cardiac, but because i believe she is severely septic).

Best Guesses:

1. Infectious Illness / Sepsis / Menengitis

2. Pregnancy related issues

3. Drug OD / Poisoning

4. Brain illness or injury -- Spinal Trauma or other internal trauma

Ashley, here is a street medic axiom that you should get familiar with --- "It is better to be tried by 12 (meaning a jury), than to be carried by 6 (pallbearers). Never let an out of control patient put your's or their life in jeopardy. Sounds like your company needs to take a new look at their protocols for cardiac arrest and combative patients. Even if you dont have a protocol to stop CPR, you can always call the ER, paint the picture for the physician, and get an order to stop CPR. It is a waste of resources to tie up an ambulance performing CPR on a corpse (not to mention a safety issue for driving the corpse to the ER lights and sirens).

Actually what i enjoyed most about my old EMS job was precepting baby medics. You should have seen the look on their faces when i told them that they have to assess their patients without the use of a B/P cuff, cardiac monitor, pulse ox, or glucometer -- give me their diagnosis and probable treatment plan, and only then would they be allowed to play with the toys (especially the cocky ones who thought they knew a thing or two cause they passed their registry on the first go around).

all three were fighting over the crack rocks they found under mom's mattress. Three year old put a cap in her sista's ass with baby daddy's 9mm -- 5 year old shoved her down the steps to make it look like an accident (they have watched CSI before)

I agree, trauma doesnt do it for me -- no challenge there --- backboard, ccollar, one IV or two -- the only question is helicopter or not ? I like a good challenge -- the elderly patient on the grocery sack full of meds -- the dig toxic patient at the nursing home. But what I really enjoy is being able to tell the new nurse or doctor what the patient's diagnosis is, or when i tell them that patient's gonna code in about 30 minutes, and they give you the deer in the headlight look, or the look of "yeah right, what have you been smoking", and then you are proven right -- with no lab, no xray. Or when you start the IV on the patient they stuck 20 times already. Priceless ...

John Denver -- Country Road, take me home, to the place I belong ....................

I hear you -- i dont need a watch/clock to count a pulse and i can usually guess a pulse ox reading within 2% points by just assessing the patient. Which reminds me do any of you play the "guess" the patient while enroute to the call game --- we had it down to a science as to what kind of clothing they would be in, whether they would be amputee or not, time of onset of symptoms, which hospital they went to -- we could even guess how many teeth they had based on the trailer park we were responding too.

Fiznat gave you some great info, but even with that information, many abdominal pain signs and symptoms are shared by many ailments. I have seen to many critical pancreatitis or ileus patients who were not transported by EMS. The good news is that most of these ailments are not life-threatening, so as long as you have your AAA signs and symptoms down pat, and you do transport all of them, you will probably not get burned by sending them via BLS unit. It is when you choose not to transport them that they will get burned (this assumes you mean EMTI, where the BLS unit can start an IV). But even in the event of a AAA, it may be better to do a rapid BLS transport (with maybe an ALS intercept) versus waiting on the scene for an ALS transport -- there is little that ALS can fix once the AAA ruptures.

IN my humble opinion, any penetrating stab wound to the torso is a load and go, regardless of how stable the vital signs are. So if the first transport unit on the scene was EMTI, then they should have immediately transported and asked for an medic intercept if they felt they needed one. I know that we can argue all day about whether or not this was a cut or a stab wound, and it would be nice to know the size and length of the blade, but as anyone who has been doing this more than 10 years knows (and by the stories that have already been stated here) this is the kind of patient that crashes on you and makes you look like an idiot. If I am reading this right, the ALS fire transport unit deemed it OK, to wait on the scene for a BLS transport unit ? I wouldnt want to be in those medic's shoes if this patient did crash.

My immediate answer would be no, just because of the experience factor, especially in a small or rural department where critical calls are not an everyday event. I am sure the young lad is very talented, and may be very book smart, but there are some calls you only get every 5-10 years in EMS, and I doubt he has seen "everything" yet. To be in a position of command, he has to be able to handle every situation that could occur. With that being said, I see no problem with a department having a leadership training program that allows the under 21 crowd to train for that future position.

But if he has had leadership training, and is the best the department has to offer, then so be it.

If it comes to a lawsuit, everyone on the scene will be named in the suit, regardless of rank/certification. Then you will have to defend your actions/inactions through your documentation of the call and your company's policies and procedures manual. Two ways to handle this are:

1. As mentioned above, your department can create a POLICY that states, once someone of higher training arrives on the scene, and they want to provide patient care, they will have to ride to the hospital with the patient, and assume responsibility for their actions.

2. Have a written policy that states that whenever there is a conflict on the scene, medical control will be contacted for advice (medical control could be the closest ER or a specific ER for your service).

Just as you could have a podiatrist show up, who thinks he needs to crack a chest. You could have a Paramedic on the scene who doesnt have a clue or EMTs that dont have a clue. Get a supervisor or medical control involved, and document what happened and at who's direction.

Thats not a bad idea. At one of the private services I worked at, everyone had to walk in the others shoes - disptachers, medics, billing staff. It made for a better work environment and patience among all staffers. I have also seen it work when we were having a problem with one ER, we invited their manager to come ride with us, and after 6 hours of getting diverted and hearing the attitude of her staff on the radio, things changed in that ER. I think it is a great trade off if you can get nurses and medics to swap shoes for a few hours.