Bieber

So, the overwhelming sense I'm getting here is that I should have just shut up and done it without protest. Which, yeah, you are all right--I didn't do myself any favors by speaking out. And maybe the only way to get anywhere in this business is to just shut up and go with the flow, especially being new to it; and maybe I am very fortunate to still have a job after doing what I did. So for the sake of my career, I will accept that I made the wrong choice there.

But the one question nobody has answered is whether or not it was right for us to have left that guy there. I get it, my job is to do what my service tells me to do and any deviation is going to lead to me ending up on more people's shit lists. And I get that if I don't pick my battles more wisely, if I don't learn to shut up and do what I'm told, I'm going to be blacklisted. But ethically, is this right? Is it really okay for us to help someone make harmful decisions? I'm not talking about letting someone refuse service, I'm talking about actually helping them make bad decisions. Yeah, the guy had a home health aid, but no one else that came and could be with him or take care of him. Should we be complicit in people's bad decisions? I got into this business to help people, and it's a pretty shitty feeling to know that in order to preserve my job and my standing in my service that I have to shut up and just "go with it" when we take someone who could have found another way home back to his apartment where we KNOW he will be in a bad situation, a way that didn't make us at least in part responsible for what happens to him after he gets there.

It's a shitty feeling to know that if that guy dies there in that apartment, I'll have helped him get there and left him there knowing he was helpless as I walked out the door.

Right or wrong, if a person is competent, they can do whatever they want. People choose to do all types of things they shouldn't- drink and drive, ingest drugs, eat unhealthy foods, refuse to be compliant with their medical care and/or medications- and even go home when you know they will have a difficult- if not impossible time caring for themselves. The OP stated there was a telephone nearby, so the person will probably realize at some point they DO need help, if it's not forthcoming via some social service agency, and they will reach out to someone.

It's not our job to ensure that someone makes the right choices. We do the best we can, we educate them, we explain in the most graphic and blunt terms possible- the possible consequences of their actions, and then let them be. Provide alternative solutions if we can, provide them with It's no different than a refusal of service or transport. We may KNOW a person needs medical attention, but sometimes, despite our best intentions, they simply refuse.

I should have also added that another action for the OP should have been to contact the employer for guidance.

I would ask my supervisors exactly what the company policy would be in this situation, and what my- and the company's liability's are in such cases.

I don't disagree that the patient has the right to do whatever they want, my point of contention is whether or not we should be helping them by providing transport for these people. We may not have the power to stop them, but is it right for us to be complicit in their harmful decisions?

I may try to find out more about my service's policy, however the way things are I'm a bit afraid of possible recourse for probing too deeply into this matter.

If you haven't heard of it, the Cochrane library maintains a similar database for many medical topics, although it is not EMS focused. I am sort of jealous of that Canadian document, though. Maybe I should have moved up there, I hear the skiing is good too....

Creating a compendium like that is a huge undertaking, I suspect you'll have more success with smaller steps, going through individual topics. Why don't you start off the discussion - pick a topic that interests you and tell us what you think of the evidence. I'd be happy to play along with a more manageable activity like that, and maybe some of smart experienced people could give some more specific input with a start like that.

Hmm, that's not a bad idea. Now to find one that hasn't been overdone, such as ETI. Standby.

I see 2 issues here. First, your refusal to "tech" on the call. That's fine, but what exactly were you trying to accomplish? Either way, you would be present on the call- whether you were driving or teching.

I suppose nothing more than trying to be firm in my principles. I know I didn't accomplish anything, but I didn't want to just cave in on my principles either.

Second, leaving an immobile patient at home with no help. You mentioned that a home health nurse would be coming by, but it sounds like this person needed 24/7 assistance- bed pan, physical therapy, etc. Clearly the person did not want to go to a nursing home for rehab, which is their right- absurd as it may seem to you.

I would notify the hospital's social service department of the situation, but I would hope they have already been made aware of it. Maybe they made plans you were not aware of.

Perhaps they did, though it didn't sound like it.

Reiterate the situation to them, tell them the person needs help, let them work out insurance issues for any aides, etc, and then I'm afraid there is probably not much more you can do. You could have refused to take the person home- which would probably resulted in the loss of your job.

Yeah, I think so too.

What did the person say when you asked how they would be able to feed themself, get to the bathroom, bathe, etc? Were they competent? Did they understand they NEEDED the help?

He said he wouldn't be able to feed himself or go to the bathroom, and yeah, he was competent and understood he needed help. Stubborn.

One last thought- did this person sign out of the hospital AMA- against medical advice, or was it a formal discharge?

I'm not sure. I assume it was a formal discharge since the patient had been cleared medically.

I'm not exactly sure what you mean by "teching" the patient.

Sorry, I meant acting as the tech on the call.

As kinda a just that I have gathered you had a patient that could not fend for themselves and you did not feel right leaving them at home when you know they are going to be alone for the most part with the exception of when the aid is present in the home. Please correct me if I'm getting the wrong impression.

That's all correct.

If my impression is correct then I have a couple thoughts.1. There is an old addage you can lead a horse to water, but you cannot make him drink. I won't argue that the patient probably should not be left alone at home in his state. However if he refuses provided he can legally make decisions, then you have to respect their wishes. Situations similar to this happen all the time. The ethics debate usually ends with patients rights. To go above the patient, you would need to get something from the court. Otherwise it sucks but your at a loss.

2nd and I know this might sound like kicking a dead horse but provided they can legally make decisions they have a right to dictate their own care. Again sucks to be us sometimes.

But are we obligated to help the patient along? I mean, if someone wants to refuse care and go back home that's their right, but do we have a responsibility to ferry them home and leave them there? Is there any legal obligation for EMS providers to provide a ride home for patients leaving the ER? And should we have any hand in it knowing it will be deleterious to a patient?

This is a great site where I've found a lot of interesting research on various practices in EMS. I haven't gone through and examined all of the studies just yet, but if someone wants to highlight one in particular feel free.

http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm

(Disclaimer: some details have been changed to further preserve anonymity.)

So I worked yesterday as an EMT with a partner I had never worked with before. For those of you who don't know, I'm done with paramedic school and my practical boards, and I'm taking the written on the fifth, just as a little FYI. Anyway, our last call yesterday was a transfer of a patient from the ER of a bigger hospital who was going back home. The patient had been brought in by EMS earlier yesterday for bilateral knee pain and stated that they had fallen the day before. The patient usually got around with a walker but said that since the fall they hadn't been able to get around at all and the ER had diagnosed him with just a sprain and had put a splint on his left leg. I was up to tech since it was a code green and while my partner was in the hallway copying down the patient's information I was in the room talking to the patient, and I asked the patient if he was able to walk at all. The patient said no. Then I asked the patient if he was going to be able to get around with his walker even to get to the bathroom or the kitchen--no. The patient also stated he lived alone in an independent living apartment and had a home health aid that came in every day. At that point I went out into the hallway and told my partner that, hey, this person isn't going to be able to get around at home and take care of himself, we can't just leave him there. My partner said something about it being cute that I "cared about the guy" and then said they were going to "throw the patient in their bed and leave". At this point I was very uncomfortable with the whole thing, and my partner asked if I wanted him to tech, and I said yes.

The patient couldn't even slide over from the hospital bed into our cot, we literally had to slide him over, which we did. From there we loaded him up and I drove to his apartment and we got him into his room on the cot. The patient asked us to put him in his bed and we had to actually physically pick him up and put him in it; it wasn't like he used us for support while he stood himself up and turned to sit down--we literally had to do all the work for him. He had a stand next to his chair with a phone on it, and I asked him again if he was even going to be able to go to the bathroom, and he said no. My partner told the patient he was going to be calling us right back, and the patient acknowledged that that was true. Apparently the hospital had tried to convince him to stay and go into a nursing home but he had adamantly refused and repeatedly told us he didn't want to go to a nursing home.

When we left and got back to the station my partner chewed me out about not taking the call and basically said if I pull that shit again that "no paramedic's going to back you up for that" because I ought to be taking all of the code greens as an EMT, and there was talk of an incident report but he said he wasn't going to write one up but he did show me the part-timers' evaluation form that the lieutenants fill out for us at the end of every shift and asked me in a knowing way what I thought I should get for my evaluation that day.

I really, really don't like to leave someone at home who is incapable of getting from point A to point B, and I remember during my internship neither I nor my preceptors would ever let a patient stay at home if they couldn't get around. And I get that the hospital can't make him stay against his will, but why does that mean that WE have to help him to his own demise? The guy could have taken a taxi or found some other way home (actually, he couldn't, since he couldn't get around, which is why WE got called, but still in principle he could have). I kept thinking about what my preceptor told me once after I had particularly screwed up a call during internship and tried to refuse someone I shouldn't have, about how I would NOT leave HIS family like that, and I kept thinking that, if this patient had been my preceptor's father, what he would say to me for leaving him at home helpless.

So my question to you is this: was I wrong to protest teching that call on principle? Should I have just shut up and take him home without raising my voice against it? As far as I know, we have no obligation to provide a taxi service for patients going home from the hospital, only to provide transport and treatment to patients going TO the hospital. And yeah, I know that guy was going to find a way home one way or another, but I strongly feel that we should not be involved in helping someone to harming themselves.

The first and highest edict in medicine is primum non nocere, first do no harm. But I feel like by having had a hand in putting that man in his home and leaving him there helpless, we have caused harm.

Wow!

I gotta say, I pretty much vehemently disagree with everything you've said except for numbers 4, 5, 7 and 8. In fact, if I may I'll respectfully state my points of contention hopefully without sparking anything more than a friendly debate.

This is not necessarily what I want, but it is what is needed to ensure the survival of our industry:

1. Medical Directors should be held liable for the mistakes of the company's employees. Once they have that fear in place, real training will occur.

While that is good in theory, the reality I suspect would be a watering down of all skills to only those with the least risk. "Just load 'em and drive, 'cause if you do anything wrong it's MY butt on the line." Furthermore, aren't medical directors already at least in part liable for the actions of the employees they supervise?

2. We need to go to a mandatory tiered system. The current economy will not support double medic trucks, it is a tremendous waste of resources. There is no reason to have EMT-B's, they should be banned from ambulances.

Are you saying there should only be paramedics and EMT-I's?

3. I see no reason to mandate college degrees, it just makes more money for the colleges. To those who think it brings respect, would you respect a plumber with an associates degree more than you would one that has no degree but has 10 more years experience ? Our job is a blue collar job, park your ego, and deal with what we are. Be a good EMT/Pmdc skill-wise. An AKC registered dog's shit smells the same as a mutt from the pound. Paperwork does not make you better.

I disagree with you. It's not about paperwork, it's about education and knowledge--which WILL make you a better paramedic. Furthermore, even if paper alone does not make you better, it DOES improve the image of the profession (which, while admittedly is not and should not be our primary focus, it IS something we desperately need to improve) and add more credibility to us.

4. All ambulance models should be crash-tested and brought up to car standards, airbags in the box, better restraints, more crash worthy in a rollover.

YES! 110% yes!

5. Any shift longer than 12 hours should be banned. If a longer shift is still permitted, you should not be allowed to work the shift immediately following, at any provider.

I also agree with this in general. In the sense that nobody should be working more than 12 hours without a break, however I understand that many services are pretty slow and you're not likely to go without sleep at some 24 services.

6. No one under the age of 21 should be allowed to work in our industry. I am sorry, but if you have 1-2 years experience driving a car, are you really competent to drive an emergency vehicle ? Wonder why you dont see any 16 year old 18-wheeler drivers ?

Eh... I don't know about this one.

7. You should have to pass a real "skills test" atleast once per year, where failure means you come off the truck until you prove your competency (every drug, every skill).

Yes, but can we also include a written "knowledge test" as well?

8. You should have to dress like a professional (no tshirts, no polos).

Yes, though I don't necessarily agree that polos are unprofessional, however I personally prefer button ups.

9. Each department should reflect it's community in minority make-up in employees and financial budget. We have been too "white-male" for too long, where the money goes to supplement the pensions of old white guys who make decisions that help the future old white guys. If your population is 70% hispanic, your workforce should be 70% hispanic, which means you have less white chiefs, and use that money to produce scholarships to medic school.

How about we just hire those who are qualified, able and willing to do the job?

10. Your system should be profitable, or atleast break-even financially. The tax payors should not have to waste money on your chief's EMS Kingdom, full of too many non-productive work hours (hours not running calls), expensive trucks, too many personnel for call volume, not enough cheaper BLS trucks to handle the majority non-ALS calls. To do this, private interfacility transport services should be banned, all ambulance transport that occurs in a companie's "borders" should be handled by the licensed 911 provider. If you are not good enough to be a 911 provider, you should be in the wheelchair van business.

I agree with financial responsability, however I'm leery about a for-profit service. That's not really what I feel medicine is about, and I'm nervous about getting into any kind of system where we might be required to acquire payment prior to transport or as a requisite to transport. I'm not a salesman, and I really don't want to be one. And I'm not in favor of monopolizing EMS and kicking out private services all together either.

Excellent point, Chbare! And one I forgot to mention earlier. You're one hundred percent right, data interpretation, including relevance, relationship, and variable factors, is a major drawback to studies done in the field of emergency medicine. It's often cited, but perhaps not nearly enough, just how hard it is to get reliable, understandable, straight forward information regarding the results of studies done on emergency medical patients. To use another example, though I'm afraid it's far more simplistic than yours but still one that I like to present, you could say that in a study of mortality rates that patients who are intubated by EMS personnel have a higher mortality rate than those who are not intubated by EMS. And without the relevant details, it sounds like intubation is a bad idea (and bear in mind this is just an example, not to start a debate on prehospital intubation), however all that study would actually say is that sicker people die more often. For studies on EMS practice to be truly sound and not just number crunching, we have to look at all of the relevant variables.

Great post, Chbare, and definitely a take home point with all of the studies presented in this thread: proper interpretation of the data.

In the U.S., I'd like to see an associate's degree as the bare minimum for paramedic certification in EVERY state (mine has this requirement, but I'd like to see everyone have it as well) with more Bachelor's degree options available along with other higher degrees similar to what nursing has, first and foremost. I'd also like to see a stronger unity between EMS providers with more power in our national associations and more professionalism across the board. We are professionals and we ought to act like it, however many services are decidedly UNprofessional in their conduct and practices. I'd also like to see an increase in wages and--and this is going to be one of those that a lot of people disagree with me on--the complete abolishment of volunteer services. I have yet to see a volunteer hospital or a volunteer ER or any nurse or doctor put in the amount of volunteer hours that we in EMS seem to be willing to put in, and I think it hurts the profession when we sell ourselves so short. We provide a service and we deserve to be paid for it.

So, after reading another thread I got to thinking that it would be nice to have a place where we could all share our knowledge and form a compendium of evidence based medicine in relation to the treatments we in EMS and emergency medicine in general provide, have provided, or may provide in the future. I am aware that many if not most of the treatments we give are not supported by scientific evidence, but I realized after reading another thread on here that there are more treatments unsupported by studies than I thought.

The rules of the thread are thus: every point is disputable, however all claims must be backed and supported by references to peer-reviewed academic studies. And while the studies may tell us one thing, I also want to know what your personal and individual experiences with these treatments are; because we all know that what we read in a book and what happens in the streets are two very different things.

The goal is to find as much credible evidence for or against as many prehospital treatments as possible, and also for in-hospital treatments. Oftentimes, we look at these studies in relation to how we in EMS should be doing things, but what about the hospitals? Are they advising us against the same unfounded treatments they themselves continue to provide and are any of these treatments beneficial for ANYONE in any setting?

This sounds very much like a myxedema coma to me. The history of recent illness could have caused her thyroid hormone levels to fall, and if I'm not mistaken can't penicillin also cause thyroid hormone levels to drop as well?

I have often wondered why every ambulance seems determined to staff with only Paramedics. not to diss on the top spot, but paramedics where I work make $17 an hour, compared to my measly $12.75 as an EMT I, and 70% of the calls are NOT ALS. As I've had pointed out to me here on the forums many times, EMT B's are just trained first aid providers. Most would be more than capable of handling the 70% that doesn't require any sort of advanced interventions. That would save lots of money and plus, most EMT-P's I know are bored with the BLS stuff anyway. Lots consider it beneath their training, so now we can save a TON of money and still preserve EMS.

A paramedic isn't a paramedic because they can push drugs and intubate and manually defibrillate someone, a paramedic is a paramedic because they have the knowledge and the education. Not to diss EMT's, because until January 5th I'm still an EMT myself, but the truth is that you're right, the majority of patients don't NEED an IV and a monitor, but they DO need a paramedic's knowledge and judgement.

As far as pay-for-transport goes, I will refuse people if I don't think they need to go to the hospital or if I think there is another more appropriate place for them to be seen, such as by their family doctor (if they don't want to go to the hospital, of course), but the day I am asked to get payment before transport or payment as a requisite for transport is the day I'm done. That's not what I signed up for, that's not what I believe in, and that's not what I will ever practice. I'm not a salesman, I take care of people.

I'm a dreamer, but oh well. Just tread carefully on my dreams.

The end result would be a Bachelor's of Paramedicine. Classes during and following the spring semester of the second year until the end of the program would be five days a week 9a-5p and during clinicals and internship each student would be precepted by and paired with an individual RN/paramedic with whom they remained throughout the rotation and would follow their preceptor's full time schedule. I'm not sure what the end total hours would be, but for the internship and clinicals it would be one year each of full time paramedic and RN work. Classes and sections should cover each topic to the full extent possible having each class every day five days a week for each semester going into and including chronic and non-emergent diseases not typically managed by EMS providers.

Year 1

Fall Semester

-Anatomy and Physiology I (with lab)

-English I

-College Algebra

-Psychology I

-Biology I (with lab)

Spring Semester

-Anatomy and Physiology II (with lab)

-English II

-Chemistry I (with lab)

-Biology II (with lab)

Summer Semester

-Medical Terminology

-Pathophysiology

-Clinical Anatomy

Year 2

Fall Semester

-Chemistry II (with lab)

-Microbiology

-Emergency Medical Technician-Basic

-Pharmacology

Spring Semester

-Immunology

-Cardiology (including CPR + ACLS)

-Endocrinology

-Pulmonology

Summer Semester

-Anesthesiology

-Pediatrics (including PALS/PEPP)

-Gastroenterology

-Nephrology

Year 3

Fall Semester

-Obstetrics and Gynecology

-Infectious Disease

-Neurology

-Traumatology (including PHTLS)

-Hazmat/Operations

Spring Semester

-Clinical Rotations (ER, ICU, OR)

Summer Semester

-Clinical Rotations (Elective Clinicals; e.g. flight medicine, rural medicine, etc.)

Year 4

Fall Semester

-Clinical Rotations (PICU, OB, Clinic/Physician's Office)

Spring Semester

-Field Internship

Summer Semester

-Field Internship

Year 5

-Fall Semester

-Field Internship

-Ambulance Operations (including CEVO)

Do I think this will ever be reality? I doubt it, much as I might wish it.

To be honest, I wouldn't be comfortable transporting a post-seizure patient BLS. I've always made them code yellow, meaning they get the monitor and an IV, and several times I've been thankful for it when they started seizing on me again.

So, the topic is cardiac arrest and transport! Here are your questions:

1.) Do you transport cardiac arrests?

2.) Do you WANT to transport cardiac arrests?

3.) What are the benefits gained?

4.) What are the risks?

5.) Should any code blues be transported or should they all be called in the field if no return of spontaneous circulation?

I'll answer the first two questions now, and the rest after some of you more experienced folks have weighed in. In the system I work in, we work asystole codes and then call to terminate resuscitation if there's no rhythm change or return of spontaneous circulation after we've done our three rounds of atropine; all other rhythms, we transport after we've gotten our frontline meds in. I would rather we did NOT transport ANY person without a pulse, however that's not the standard currently held by my service.

Just wondering specifics of how other agencies do their spinal immobilization.

Do you actually use padding? Under knees? In between knees? Blanket over the board itself? On EVERYONE?

Padding under the knees or elsewhere prn. I would put a blanket over the board if necessary (which, the way the weather is going, might be more frequently in the upcoming future.)

How do you immobilize head? Do you use head wedges? Cheese blocks. The styrofoam triangles and head pad? Rolled up blankets. Does it depend on patient?

We use the headbed, the efficacy of which I've heard is questionable, but there's not really anything that we do right now that could keep the patient from compromising their own spine if they wanted. For pediatrics, we use the LSP pediatric immobilization board--which I really like. I wish they made an adult size version.

Do you use backboards always? Or do you have the hard foam boards?

We have soft cots, haven't ever used one, though.

Spider straps? "Box Method"? Straps that click in like an X over chest? Binders? (Pre-ripped sheets that wrap around)

X over the chest.

Do you ALWAYS immobilize cervical if immobilizing lower back? Vice-versa?

I would immobilize the entire spine if I thought any one part of it needed to be immobilized.

Do you use tape over the neck? Does it go straight across or angled up (perpendicular to the forehead tape).

Nope. And I helped out as a patient for an EMT class today and they used both a strap and tape over my neck and I absolutely hated it. Felt like it was choking me, and I'm not ever going to be doing it on any of my patients.

Do you use the arm straps? What do you do for unconscious patient's extremeties. Leave one arm out for IV? All in and you unwrap later for IV access?

I strap the arms while I'm loading them, and get them out in the truck--one for an IV and one for BP.

Oh, and on another note, I absolutely refuse to be boarded ever again. =) That's how bad my experience with the EMT students today was.

Hyperkalemia should show on a 12 lead ECG if you have such capability.

You know, I don't have the 12 lead anymore, but I don't think I saw anything concerning on it. No peaked T waves, no ST changes there might have been some pathological Q waves from his previous MI's but I can't remember. It was a pretty benign 12 lead if I'm recalling correctly--nothing that led me toward hyperkalemia or a STEMI, anyway.

That's along the same lines as what I was thinking, Dave. All throughout transport I was sitting there thinking this guy had to have had an MI that took out his SA node (or at least severely damaged it). I did ask him about his carvedilol, but he denied having taken too much of it or any recent changes/noncompliance in his medications.

Because the patient maintained cerebral perfusion (no change in mental status) and a pressure >100 systolic, I decided to give supportive treatment only. I consulted with the physician at the hospital and he agreed to monitor the patient and to go ahead with 0.5 mg of atropine if he started to crap out on me, but though he continued to look like crap throughout transport he stayed stable and I didn't have to intervene with fluids or raise his rate.

The patient in this scenario ended up being hyperkalemic. I wish I'd found out more about the cause of the hyperkalemia, but I'm guessing he must have taken too much of his potassium by accident or that his electrolytes must have gotten a little screwed up while he had the flu.

All right, I'm going to weigh in on this but if my thoughts are jumbled and and I'm not thinking very clearly, it's because I've got a lot of stuff on my mind right now.

First of all, I'm all for smarter use of lights and sirens. Should we keep them? I think so. But should we run hot to every call? Heeeell no. AMI? Cardiac arrest? Difficulty breathing (tentatively)? Sure, those conditions MIGHT actually have a LITTLE clinical benefit from getting there a little bit sooner. But should we be speeding to get the patients to the hospital or running hot to the hospital with ANY patients? Honestly, no.

Can anyone think of a single medical condition that would benefit to getting to the hospital two minutes sooner? I say two minutes because I think all of the studies I've read on running lights and sirens put two minutes on the high end of possible time saved from running hot. So, is there? First of all, let's ask ourselves, what's the WORST thing that can happen to the patient? Well, the worst thing is that they go into cardiac arrest, and you know what? We can treat that just as good in the back of the ambulance as they can in the ER. What else? Are there any conditions out there that will benefit from an extra two minutes? And if the patient is going to go into cardiac arrest within two minutes if they don't get to the hospital within that time frame, is there any definitive treatment that can be initiated and take effect within two minutes that we can reasonably believe will stave off cardiac arrest? In fact, is there any treatment that can be done only by in-hospital personnel that can be initiated and take effect and reasonably prevent a patient from going into cardiac arrest within, say, ten minutes? How about fifteen? Now when we get to the twenty or thirty minute mark, it becomes a little more reasonable, but that is not the kind of time we can expect to save from running hot unless we were driving seriously dangerously.

Seriously, work it out in your heads. The clock starts ticking, this patient has twenty minutes to live, if you drive regular traffic you can get them to the hospital in in fifteen minutes, and being generous, let's say you can get them there in ten if you drive hot. What definitive treatment can be given in ten minutes? For ANY medical condition? Stroke, well they got to do a CT first to make sure it's not a bleed; AMI, no way they can cath 'em and reach the occlusion in ten minutes; trauma, won't see a surgeon have a guy open in under ten minutes starting from the ER doors; sepsis, antibiotics don't work THAT quick. The WORST thing that can happen to these patients is that they go into cardiac arrest, and we can treat that in the ambulance. However there is, to my knowledge (and if I'm wrong help me out), NO definitive treatment that can be given in the ER that we can't give in the truck that will mean the difference between life and death that can be undertaken in under ten or fifteen minutes. And the studies don't even indicate we can get THAT much time out of running hot, but they sure as hell say we can risk not only the patient's life but OUR lives as well from driving like madmen to the hospital.

Hey, everyone,

So, Wednesday is going to be my last day of internship. I took my class finals about two weeks ago (and passed, thankfully) and tomorrow I present my research paper, class presentation, and my case studies. After that, the only thing left is board prep and boards and I'll finally be done. Unfortunately, my fiancee recently went to basic for the Air National Guard and pretty much found out that the whole military thing is nothing like she was told and that it's not for her and she wants out. I wasn't ever much of a fan of her going but now I'm stuck trying to figure a way out for her. So it's been a kind of hectic and emotional end to things, though I'm hoping that things will get better and she'll get out within the next couple of weeks. If anyone has any advice on that, send me a message.

Looking to the future, what were your first experiences as a brand new paramedic just out of school? How did you change from when you were an intern and what was different for you being the second one on the truck?

Is this an inferior wall MI or just right sided? What does V4R say? Anyway, assuming I have at my discretion and authority to treat with those medications as I wish, this is my treatment:

*Nitro x3 or until systolic <100 (actually, I think wants it gets in the 110-120's I might go ahead and reassess from there) or pain 0 with a fluid bolus running concurrently and another on hand for severe hypotension, with fentanyl substituting that if no relief after x3 nitro and holding both if the patient's pressures start going down. Basically, if I can keep my preload good and still dilate those coronary arteries, that's my goal.

*Gonna hold on the Lopressor. Yeah, it's not a bradycardic right sided AMI, but the rate's about where I want it to be anyway (and maybe it'll come down with some pain relief, too) and I don't want to stunt the SA node any more if it's part of the infarcted tissue.

*Heparin 60 U/kg up to 4,000 units bolus then 12 U/kg/hr up to 1,000 units per hour.

*Plavix 300 mg PO.

So, I'm going to be graduating from paramedic school with my AAS in December and I'm looking toward the future. I absolutely love working as a paramedic, but I originally got into EMS to get a taste of medicine after I decided I wanted to go to medical school and I'm ready to get headed back down that path next spring. I don't expect to be able to work a full time schedule (it's set in such a way that I can't have the same days off every week), but I'd like to work as many hours as I can. However the university I went to prior to getting into EMS has very few online classes and the schedules are horribly non-conducive for working people and basically made for the 18 year old student who plans to live at the dorms, and to take the classes I want (and need) to take this coming semester I would have class Monday through Friday with only the weekends off. Being the brand spanking new paramedic that I will be, the absolute most thing that I need to continue to improve my abilities is to get experience and I'd like to get as much of it as I can.

So, here's my question for you people who have or currently are working EMS while going to school: how did you do it? Did you sacrifice time at work for school, or did you take online classes or did you just suffer a horrible schedule trying to juggle both? Also, if for anyone else here from Kansas, does anyone know about Fort Hays University's online classes?

Bierber I hope I did not offend you. I appreciate your comments and your ability. I was talking in general and was not meaning anything twords anyone in particular.

I agree that we all make descisions base don our own knowledge and thats exactly what we all should be doing. I guess my rant was more for the folks that think they are or can be the end all be all of emergency medicine.

Agan sorry if my little rant before offended anyone. I did not mean to come off that way, I just wanted to shake the box a little and have folks think about things a little.

Not at all, UglyEMT. I can understand where you're coming from, and I know your heart is in the right place. Don't ever worry about offending me, I've got thick skin and I don't take things personally. This is exactly why EMS entered the world of the internet, so we could have these kinds of discussions and learn from each other.

Awesome post Bieber! Well thought out, honest, introspective, with great explanations for your logic...Really, really good post.

Thanks, Dwayne. I'm humbled by the praise of someone like yourself.

I've read this type of statement a few times during this thread. What kind of protocols do you mean? Other than, "A provider should give serious thought before delivering narcs to a hemodynamically unstable pt" or the like, I can't think of a pain protocol that I've worked under. I had medics at my last service claim that we were not to give narcs for abd pain, but I did, and do, and afterwards tried to find their reference, but couldn't do so. Now, understand, I have never memorized my protocols word for word but always have a good 'flavor' of what each might entail and I can't really think of a protocol that a pain patient my fall within other than those listed as indications for the drug? If they are in pain and I can mitigate that without retarding their condition then I do so...

The protocols I work under allow pain management for patients complaining of chest pain, abdominal pain, and isolated trauma with a blood pressure >90 mmHg and no mental status or respiratory impairments. Unfortunately, I work in a very much "cookbook" and "mother may I" type of service. But we just got a new medical director, so I'm hopeful for change and more independence to use our heads.

I am so with you here. As in Crotchity's example, (and humor taken in the spirit intended as I wouldn't have been able to pass that up either) I would almost certainly not have given that pt narcotics as his physiological markers were calling bullshit on his verbal claims.

Exactly. And I'm not claiming to be an expert or anything, but it seems like there is a very vast difference in the way people complaining of pain who DO have visible signs of it (in their presentation and vitals) act versus how those who don't have those physiologic changes act. I'm not saying it's a fullproof tell, but it's just one of those extra things that makes me go "Hmm..."

Yeah man, I wish I could give you several ++++s plus a gold star for this statement.

Haha, thanks.

Me too brother..

Oh great, you mean it's never going to go away? Haha.

Agreed completely. One of the reasons that many basics have a hard time understanding this is that their clinical/physiological knowledge is to shallow to be able to understand the explanations. It's difficult to explain when you can't explain that a fracture, is not a fracture, is not a fracture. It's the same mentality that says that " I don't need to know how the heart works to put on a splint!" But, well, it really helps to know how circulation works if you're going to apply a splint to a complicated fracture while trying to allow the greatest possible long term outcome. I think you've made your point perfectly, I'm just piggy backing it so that I can steal some of your glory..

I do wonder about folks saying that Nitrous should be allowed for basics based on the fact that is a relatively safe drug and self administered. I've never used it, but I can accept that it's relatively safe, the problem I have is that it may mask sysmptoms, mental/physiological that should be caught throughout an ongoing assessment. Many medics I know can't manage that on unaltered patients, I'm not sure I'm comfortable with that at the basic level. But again, I'm speaking from ignorance as I've not used it in my practice. I am curious to see what others think...

Never got to play with it, I'm afraid. Well, except at the dentist's office. My service used to use it a long time ago, but they got rid of it when people were showing up at the hospitals with empty tanks after only transporting one patient for the day so far... Haha. So I can't attest to its effects or safety, really.

The more I read this thread the more worried I get I dont know about everyones training or schooling what-have-you but I know that when I was in school I was told we DO NOT diagnose patiens, we are providers, not doctors.

My dictionary defines diagnosis as "The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data." Like I said, you can call it whatever you like, and I'm not saying that we can accurately diagnose every disease in the field (because we obviously can't), but what we do fits the definition of a diagnosis.

Ok that stubbed toe doesnt need m transport. I get that. BUT I am not refusing a pediatric patient, EVER. I have seen peds go from fine to pucker factor faster then you can read this. Most cardiac peds are from respitory problems. Choking is a big thing, they love putting stuff in heir mouth. Ever seen an exray after a relieved choking episode? Not pretty.

As far as adult patients. If they called its THEIR emergency. Unless its tottaly benign, IE stubbed toe paper cut ect, I will be transporting. I am not loosing my liscence because I felt their wasnt a problem. I do not diagnose, I treat. Once I am trained and educated for a number of years in med school plus internship then certified as a Doctor and add PhD after my name I will be an EMT, Emergency Medical Technian, be it basic intermidiate or paramedic. I am not a doctor thus I treat not diagnose.

I respect you and your method of doing things, and if your way of doing things is to not refuse any pediatric patient or most adult patients, then I respect that too. Like I said previously, people have their own ways of doing things and honestly I completely agree that the safest thing is to NOT refuse any patients. However, I do refuse patients, adult and pediatric alike, and I am likely to continue to do so; that's how I've been instructed, and that's my comfort zone.

I think some are getting that big head and think they can diagnose. I hope ou dont, I dont want to hear of any of us in the City lossing their liscense. I see it in the field alot, folks making desicions based on "diagnosis" versus training and SOP.

Sorry for the rant and I hope I didnt offend anyone but I had to voice my opinion.

Not at all. You're entitled to your opinion. And you can think I've got a big head and I'm full of it, and that's all right with me too. And you can call what you do whatever you like, but what I do falls under the definition of diagnosis and that's what I'm going to call it. Can I diagnose everything? No, not at all. Not with my limited resources, and I'm not arrogant enough to think that even if I did have all of the resources that I currently (or will ever, for that matter) have the knowledge to diagnose everything. That's just unrealistic. I make decisions based on my diagnoses and I live with them, for good or for bad. I will always err on the side of transport, but I will also refuse patients that I consider to be in no immediate danger and have no suspicion of going south and who don't want to go to the hospital. And one day that may come back to bite me on the ass. I hope not, and that's why I do my best to expand my knowledge, to better my ability, and to try and make the right decisions. I fully understand the risks I'm taking, and I'm not afraid to come right out and admit it to you guys. And yeah, I'm green as hell, but I'm also following the guidance and leadership of my preceptor, who I consider to be an excellent paramedic, and maybe I'm arrogant to think that because he does it I can too, but I'm at that point in my internship where I'm the one making the decisions, and he hasn't stopped me from refusing anyone yet, so I can only take that to mean that he trusts my judgement enough to trust me to make the right call for my patients. As I grow in EMS and learn more, maybe my opinions will change; but they are what they are right now.