HERBIE1

Actually, medical control did terminate and even called time of death, but the doctor on scene took over care and refused to terminate. Also, the responders were initially not aware that this patient was MJ. In addition, there were no family members in the room when the crew arrived.

DId the doctor accompany the crew to the ER? That's the determining factor for us- we will follow the doctors wishes IF he/she is coming with to personally direct patient care, but again, these things are never cut and dried. Medical control is generally reluctant to override an MD on scene unless they are being ridiculous or unreasonable.

Wow. The crew did not know this guy was MJ? Why do I find that hard to believe?

Denny, if you can get that last one to work, it is pretty comprehensive and written by an awesome instructor.

Herbie-I agree, there is not enough instruction on PCR writing in class. In both my EMT and refresher class, we never talked about writing a PCR and barely talked about how to do a radio/in-face presentation. You will find that every doc has a different preference. Personally, I find the most useful parts of the PCR to be the vitals and treatments/response to treatment. It is no offense to the EMS crews, but everything else I am going to ask and examine again. However if there is a change in the exam it is helpful to know (ie asthmatic that improves with nebs and by the time I get to them they are clear, I know what their starting point was). As for radio reports, I like them short and sweet. All I really want to know over the radio is if I need to set up for a sick pt. Some of the local radio reports drive me crazy. Observe:

EMS: "Hospital X, Hospital X, This is Amublance Y, Paramedic John Smith with a priority 2 pt report. How do you copy?" Personally, I like the Xerox machine we have, but I digress.

Us: "This is X, go ahead."

EMS: "Hospital X, this is Ambulance Y. Paramedic Smith bringing in a priority 2 pt. We have a 33y/o male with chest pain that started at 6am. It feels like the same pain he had when he was diagnosed with GERD 2 months ago. He hasn't taken any of his pepcid because he doesn't have the money. His 12 lead shows a normal sinus rhythm with a rate of 88. There are no ST or T wave changes. His BP is 124/70, pulse 88, respiratory rate 14, pulse ox 98% on 2 liters nasal canula. We haven't given him anything since he says it's just like his previous GERD. He has an IV in the left AC, KVO. Do you have any additional orders or questions?" At this point I have already moved on to the next task on my list. It is not to put the EMS crew down. It is good that they are getting a full hx, etc, as they should. All of the information is important, just not necessary over the radio.

Us: "Nothing further, you're expected. Hospital X clear."

EMS: "Ambulance Y clear of the hospital channel, going back to dispatch."

There is lots of stuff there that is not needed over the radio. Like I said, keep it short and sweet. Think something like:

EMS: "Hospital X, this is Ambulance Y."

Us: "Go ahead Ambulance Y, this is Hospital X."

EMS: "We have a 33y/o male c/o chest pain. He says it feels like his previous GERD. His vitals and EKG are stable. Do you have any other questions?"

Us: "Nothing further. See you when you get here."

When you get to the hospital and are going to turn over care, the first presentation would be appropriate since you are turning over care at that point. Another thing that I find helpful more often than you would think are your response, on-scene, etc times.

Thanks for the reply doc. Pretty much the standard response from every doc I've ever asked or worked with.

The problem is, if we use the same base station, with the same person, with the same level of training on the radio, it would be easy to tailor a report to the likes and dislikes of the person. Rarely happens- we could get a brand new telemetry nurse, a 1st year resident, a seasoned ER nurse, or an attending physician. It's all about who's free to answer the radio. I agree about short and sweet- especially in a busy system. Maybe someone is waiting for me to finish my abdominal pain report and they have a STEMI- just common sense. I also don't think it's pertinent to include the fact that a patient with a STEMI had a tonsilectomy at 3 years old, and the fact that my patient takes multivitamins and is allergic to strawberries. It's just common sense to me.

We do have a protocol that allows us to give an abbreviated report for a routine, stable patient, but too often the person on the radio does not let us follow that protocol. The worst offenders? Residents or ER fellows who are taking their turn answering the radio.

Honestly, if I were in charge, I would mandate the absolute most basic radio report. Chief complaint, vitals, pertinent interventions, destination, and ETA. With that information, the ER knows if the person is sick or not, stable or not, and what type of bed to prepare if possible (OB, critical care, ortho, ENT, trauma, etc.) What else do you really need from a prehospital report?

Susan- Kudos to you for your honesty and for starting getting yourself back together. Anyone who's been in the business for any length of time knows someone who has gone through this. I know doctors, nurses, medics, EMT's who have all struggled with various addictions. One nurse I worked with for 15 years got caught up in this and was stealing narcotics. She got clean too after finally admitting her problem before she was actually officially caught. The bosses suspected the narcotics logs were being altered, the drug count was not adding up, and they were closing in on her. She went through rehab, and the hospital hired her back with the proviso she passes periodic drug tests. She remained clean for 15 more years or so and then took a desk job after 25 years in an ER.

Point is, it may be difficult- but not necessarily impossible- to get back into the business- at least in the capacity you may want, but as a former manager responsible for hiring and firing, being honest will be an asset. Yes, some folks won't touch you because of your past, but someone will, as long as they can monitor you in some way. You may need to relocate to another area or state- depending on local laws, but it can happen. You have another chance, and not many folks can say that.

I absolutely take my hat off to you for the strength and courage you clearly have.

Note to ERDOC-

I know we've discussed this issue a lot, and I never get tired of it. To me it's one of the least emphasized(in my opinion around here) skills taught in EMT and paramedic school. These programs are trying to cram as much information as possible into their programs, but I think most short change the topic of report writing and defensive documentation.

As an ER MD, what information do you find most helpful from a PCR? What are the most and least helpful bits of information we can rely to make things easier and to be most effective? I know what I've been told by docs for years, but I'd like to hear your take in this.

Doc is right. Special circumstances- treat and get the hell out. The paparazzi stake out homes of high profile folks 24/7, so there will always be cameras, press and the associated insanity of that.

Let the ER deal with the fallout and drama. There were a couple things going on here- high profile case, and an MD on the scene. With a high profile case, you KNOW there will be additionally scrutiny on every thing you do. The story the crew got did not match up with what they saw. BIG red flag there. Couple that with the doctor trying to CYA, the crew had no choice but to transport- regardless of the probable outcome. The doctor allegedly felt a pulse- OK fine, but what was the associated rhythm? I call BS there, but whatever. We always err on the side of the patient, right? Medical control denied termination, so even if they simply transported the body with no further intervention, I see no problem with that under those circumstances. If the crew DID terminate field efforts, now THEIR actions would be coming under scrutiny- especially from the doctor on the scene trying save his own arse.

Like it or not, high profile, VIP folks DO get preferential treatment and the rules change. When a former 70 year old dignitary here collapsed and went into cardiac arrest in his doctor's office, efforts to revive him in the field and in the ER were fruitless, yet they actually put this guy on a heart lung bypass machine in the ER. For a "simple" cardiac arrest. Has anyone ever heard of that for John Q Citizen who has a massive MI?

I'd want to know any other PMH, WHY the person has a seizure disorder(prior head trauma, metabolic issues, lesions, etc), recent health issues, possible contributing factors such as a history of alcohol or drug abuse, compliance with meds, how well controlled the seizures have been up to this point, was there a recent change in medication and/or dosage, DX from prior hospitalization(was the PT subtherapeutic with their medications, ) trauma history, etc.

I have found that often with seizures, the history generally tells the story of why the person is now having problems.

Sounded like a great lecture- I listened to it while I was doing something else. I enjoy seeing/hearing other instructors and pick up pointers from everyone I see. It's funny, after I began teaching, I think I spend more time watching the mannerisms and techniques of the lecturer than I do paying attention to the content. LOL

Thanks for sharing.

Has to be due to your numbers of users. Around here, you wouldn`t just push an antidote without significant suspicion of the use of the drug.

Is flumazenil also in your SOPs for altered mental/conscious status?

Yeah-in urban areas, folks will abuse damn near anything they can get their hands on- legal or illegal. Let's put it this way, in the ghettos, most providers carry a pocket full of Narcan vials and/or preloads because OD's are so common. A few years back we had an outbreak of heroin batches laced with Fentanyl. BAD. It would take gallons of Narcan just to get them breathing again. I wish we had Mazicon here- we've been asking for it for years, but our system is not exactly progressive, not to mention in large systems, any new drug or piece of equipment is a major expense, so they really need to justify it before we can carry it.

(edit to inset a forgotten thought)

I can't say why, beyond my pay grade, but all the medics I have worked with pushed the Narcan once they heard Four was on-board and it seemed (at least to me) to have the same effect. A few minutes after the push response came up, then the agitation, then the vomiting.

I never realized Narcan or its dirivatives were strickly opiode reversers. I have seen it used so much from drunks to crack ods I thought it was the cure all sober in 5 minute med.

Time to read up.

Probably simply SOP's. Most anyone with a depressed mental status for unknown reasons gets Narcan in our system. And yes, it IS strictly an opiate antagonist, but it's side effects are minimal and it could actually work.

Believe it or not, people actually lie to us when we ask if someone has been indulging in illicit drugs... LOL ///sarcasm off

No Underwear - Makes Sense to Me

A man came to visit his grandparents, and he noticed his grandfather sitting on the porch in the rocking chair wearing only a shirt, with nothing on from the waist down.

'Grandpa, what are you doing? Your weenie is out in the wind for everyone to see!' he exclaimed.

The old man looked off in the distance without answering.

'Grandpa, what are you doing sitting out here with nothing on below the waist?' he asked again.

The old man slowly looked at him and said,

'Well....last week I sat out here with no shirt on and I got a stiff neck. This is your grandma's idea.'

LOL

Stolen...

Don't beat yourself too bad Herbie. A lot of times, even if you don't find out what is going on there is nothing to do but wait it out. Toxicology is fun but the treatment is often just supportive.

Kinda like the Exctasy and Special K overdoses in recent years. These people would suddenly become apneic, run extremely high fevers, and all the hospitals could do was supportive- ventilator, let the drug metabolize, and hope there wasn't brain damage. I recall seeing local ER's on the weekends with at least 3-4 patients on vents. Scary stuff.

Absinth is illegal in the US, though there is a movement to change this. From the description, it sounds like the response to the Narcan was coincidence. If she is drunk, sometimes just the stimulation from what you are doing is enough to get them awake again.

One of our initial thoughts was this was a potential suicide gesture, but we found no evidence of that. As for the stimulation- she had zero response to the airway or the IV stick. After reading up about absinthe, this stuff is wild. There is even an entire society devoted to getting it legalized here. I realize the levels of the "psychoactive" drug vary greatly among the various preparations of the drink, so I imagine it would need to be strictly regulated.

I honestly think these drinks may actually contain wormwood since it's a common herb used for all types of holistic treatments and I don't think it's regulated. Since there are no ingredients listed on either the original can or the modified version, there is no way to know what they actually contain. Based on this patient's presentation, it HAS to be more than just ETOH.

Doc- I should find out the ETOH level tomorrow when I follow up on this patient. I am very curious to find out if there is more to this story, exactly why she was taking the Flagyl, and if we missed anything. Could she have chronic diarrhea and other GI issues which could make her dehydrated? Distinct possibility, but who knows?

Did the patient present nausea or vomiting. I would expect some sort of gastric discomfort from the Flagyl and ETOH mix. Has she been puking a lot and was she possibly dehydrated? It seems that this drink is bad for the body, I would wonder what effect the metronidazole might have had in her overall condition.

Nausea-no vomiting or diarrhea per the boyfriend. Nausea w/ us. I have no idea why she was taking the Flagyl, but I honestly doubted it was relevant to her immediate problems.

Welcome, Nathan. Browse away, pick a topic that interests you, and jump right in. Not sure what other forums you have visited, but in this one, you need to have your wits about you. All opinions are welcome, but you better be able to justify your stance. There are some top notch folks here from all over the glove and every day is a learning experience.

Enjoy.

The thing that was so frustrating was that like many folks who mix their pharmaceuticals and based on their vitals and exam, you never know exactly what they have ingested. Obviously a straight opiate will constrict pupils, but a stimulant will dilate them. Our patient had midrange- although sluggish pupils. Opiates- and alcohol- depress respirations, but the stimulants do the opposite.

From what I read about this stuff- and other similar formulas I guess- is that the stimulants mask the depressant effects of the alcohol, so even though you may have consumed more than enough alcohol to get drunk, until the stimulants wear off, you don't feel it. Thus, you drink more than you normally would, and as soon as the stimulants are gone, the ETOH hits you like a ton of bricks- the "knock out".

I'm an old fart, so this stuff never existed when I was doing the party scene and out clubbing. I've never had a Red Bull and Vodlka or anything similar, nor do I care to. I don't do energy drinks-good, strong coffee is my stimulant of choice.

When I do get a chance to indulge, I enjoy my premium and hand crafted beers, and an occasional top shelf vodka or gin drink.

Hi Herbie. I have ALOT of experience with this product and some of its variants. Everything you described sounds spot on to our experience. For some reason this crap puts folks on their ass and it gets scary for realitives and bystandards.

I am assuming Naloxone is the same pharma as Narcan. I have seen the turn around after a push of Narcan and the hostility as well. I would love to hear the toxic screen, not because I suspect drug use but would love to see what "other" ingrediants are in Four Loko that are not listed.

Yes- Naloxone is Narcan.

Like I said, allegedly those ingredients are no longer in this drink, but the old stuff is apparently readily available.

I wonder about the wormwood claim. After reading about it, this seems like a pretty serious chemical. Major stimulant, and the reason absinthe is banned in many places is a component in the herb called thujone. Apparently wormwood is found in many things- with low concentrations of the thujone.

Interesting read here:

http://www.webmd.com/vitamins-supplements/ingredientmono-729-WORMWOOD.aspx?activeIngredientId=729&activeIngredientName=WORMWOOD

You are all Re-TARDs. If you are a male waitress, you may not be able to be hired at Hooters, but in any town that has a hooters, there will be several other restaurants you can work at. In most towns, there is only one Fire Department or at best a county fire department and 2-3 city departments.

Take your hoods off, douse the crosses you set fire too, and realize that as whites, you can not speak to something you have never experienced --- discrimination.

I really want to be a black man.

I want to know what it feels like to have a ready made excuse/alibi every time I don't get what I want or think that I deserve, or to explain every bad thing that happens to me.

Must be nice- and comforting.

Check out the old thread on this issue. It sounds like it's been resolved, but probably not to our satisfaction however.

Tried, but I am having browser issues tonight. Will attempt later.

Just had my first experience with a patient on this alcohol/caffeine drink. I heard bits and pieces about it, about OD's and deaths associated with it, but never- to my knowledge- dealt with someone under the influence of it. To be honest, I had to do some homework on it. For those unfamiliar, let my explain what this stuff is.

Generally sold in 24oz cans, in multiple fruity flavors

the "Four" comes from the original 4 ingredients:

12% alcohol(a fortified malt liquor) by volume- roughly 3 times the ETOH content of a typical beer.

caffeine- the equivalent to 4-6 cups of coffee

guarana(a stimulant similar to, but far more potent than caffeine)

Taurine- an amino acid type chemical- also a stimulant

There have also been accusations the drink contains wormwood, which is the intoxicant found in absinthe

So- 3 stimulants, plus one depressant.

Apparently after the deaths and OD's the FDA forced the company to reformulate the product late last year, and allegedly the removed everything except the alcohol. So- it's now essentially a fruit drink with booze. But-this article claims the original version of the product is still being sold illegally in many stores- at least in the Virginia area as late as July:

http://www.nbc12.com/story/13784441/banned-four-loko-still-being-sold?redirected=true

Our patient: 36 year old female, approximately 150lbs, found unresponsive by boyfriend when he came home from work. He tried the usual ghetto tricks to wake her up- dumping her in a bathtub, dumping ice down her pants- no luck. So- he pulled her out, dried her off, dressed her(nice of him) and placed her sitting up on the couch where we found her. Minimal response to pain- appeared to be very intoxicated, flacid. BF found 2 empty cans of Four Loko- no other alcohol or other drugs present on scene. PMH of HTN- Lisinopril and Flagyl were the meds, NKDA. Also a PMH of IVDA- heroin- last used allegedly 3 months ago. Boyfriend strenuously denied she could be using again, and there was no evidence of fresh needle marks, no drug paraphernalia found by police or crew, no trauma. ALS established.

BP- 140/90, IV established- Blood sugar 137, Sinus Tach at 108, RR 14 but shallow- occasionally snoring respirations. Pupils midrange, equal, reactive but sluggish. Pulse ox 98% initially on room air- 100% with nonrebreather mask. Skin pale, warm, dry. Lungs clear/equal. Nasopharyngeal airway- tolerated well respiratory rate and effort improved. Administered 2mg Naloxone IVP.

Response- repeat vitals after medication- essentially unchanged. After approximately 5-7 minutes, Pt pulled nasal airway, began to be verbal, very slurred and difficult to understand, admitted to the 4 Loko, but denied drug use. Became increasingly more restless and uncooperative, and upon arrival at ER was placed in restraints by staff. Talking now, still highly intoxicated, but denying drug use, stating all she had was the 2 cans of Loko, and was actually singing the praises of the stuff, and actually wished she had more of it. LOL

Hospital was not familiar with similar cases and was doing homework on this as well. I will follow up on this case ASAP and get the results of a toxicology screen, more information, etc.

So- our thoughts- likely heroin use combined with ETOH intoxication. Too coincidental that she became more responsive after the Naloxone. BUT- being unfamiliar with this product, not knowing whether this was the new or old formula, and wondering about the combined physiological effects of these compounds, we simply did not know for certain.

What say you guys? Any familiarity with this stuff?

What is the status on the lawsuit? Has it been settled? Gone to trial? Dismissed?

And you should know better than anyone, firefighters dont take jobs for money, they take them for benefits.

This is the most ridiculous-and inaccurate statement- I think you have ever made here- and that's saying a lot.

How do you explain the existence of so many volunteer FF's and then reconcile that with your statement above?

Back to the original post-

STUPID beyond belief. BIG TIME suspensions due for these clowns, and if the union had an ounce of decency, they would NOT file grievances about this. Make these jackasses show their video in a rehab center where teens are in wheelchairs, recovering from GSW's. See if they find the humor in this.

Honestly- yet another example of FF's having way too much time on their hands.

Why is this guy even married? Between work, time spent planning his escapades and actually engaging in them, how can he possibly have time for a wife?

Amazing.

Do you guys really believe that only 2 women have applied in 40 years ? Come on, really ? Really ? Really ? White people are amazing in the lengths they will go to cover up their discrimination.

Or the converse of that- although I will put a qualifier in there: (SOME) Black people will go to great lengths to find discrimination in EVERYTHING.

Got any facts there was discrimination? Have any data of all the women who were discriminated against? Any first hand accounts? Sworn statements? Newspaper articles? EEOC lawsuits? Class action suits? Court decisions or awards for damages? Rumors? Gossip, maybe?

No?

\\\Dismissed.

To respond directly to the thread title: WOW- they may have been the only 2 people who applied in 40 years!

This article means nothing, unless they include how many qualified female applicants they processed, and how many total positions were filled during that time.

Then again, I guess it's much more fun and inflammatory to imply that some type of bias existed here, but no bias means nobody gets a lotto payout.

Good luck to this FF in her career and I hope she stays safe!