Bieber

Until EMS decides to actually educate providers, we have no business diagnosing in the field and telling people they don't need to be going to the hospital by ambulance. Simply put, US EMS standards are that backwards.

I don't think it's quite that straightforward. And I'm sure if you work in the field you'll agree with me on that. The fact of the matter is that we do diagnose, however you want to spin the terminology, and our diagnoses guide our treatment and even our recommendations to the patients. Do you have a problem telling a patient with a small cut on their finger that they don't need to go to the hospital? I feel that it is our job as medical professionals to be educators as well as providers, more than ever when it comes to pediatric patients and their parents. Because I don't know about you, but I have refused several parents who called for their kids and I have had no qualms doing so. Parents freak out, and that's understandable, but I think that we have to be educators and patient advocates and explain to parents (and all patients for that matter) that first off, we're not doctors, but this is what we're finding, this is what would concern us, and give them their options. They can choose to follow up with their doctor, they can choose to go into the hospital themselves, and they can choose to come with us. But, and this is especially for those pediatric patients, I am going to be upfront and tell them if the patient is stable and I have no suspicion of acute or potentially life-threatening illness or injury, that if they want to go with us we're more than happy to, but you're basically going to be paying for an expensive taxi ride unless something drastically changes. And also, if they choose to stay home, here's what they can do to try to relieve your symptoms.

I happily give pain medications out to any patient that falls into my protocols allowing me to give pain control and who I truly believe to be in pain. I try to always err on the side of caution and giving pain control, but I'm also a little hesitant to do so if my patients are able to hold a conversation with me no problem, throw a big fuss about the IV stick, or don't present in a way that is consistent with someone who is in pain. I'm also still just an intern, so it's not entirely under my control, but when I'm practicing on my own it will be and I hope to always err on the side of pain control. I'm not out to catch drug-seekers, but I'm also not completely blind is what I'm saying.

Do I think basics (or even intermediates) should be giving pain control, or even performing other paramedic level interventions? Sorry, but no. It's nothing against basics or intermediates, because I'm currently an intermediate myself, it's just a matter of the level of knowledge and experience. And I'll put it this way, I've been through basic, intermediate, and now paramedic school, and though I am new to this maybe that's a good thing in this instance, because I still see just how hard it is to be a competent paramedic and I still struggle every day at work to try and meet that expectation, and with all of my education it is still very, very difficult for me. And there's a lot of EMT's out there with way more experience than me, but even so, I've been through paramedic school and I've had to sit through months and months of lectures and labs to try and learn how, why and when to give the medications and do the procedures we do and I still pause before every intervention and question myself before I do it. So while I respect EMT's and everything that they do, I don't think that a weekend class or even a week or two of classes can make them ready or ought to allow them to do the things that, after months of training, I'm still nervous to do. And this isn't to say that an especially talented person couldn't, but rather just to give an idea of how much education it takes to competently provide paramedic level care. It's just not something you can learn in a week's time. And to be honest, I really think paramedic school out to be a four year (or at least three year) program. Where I am it's a two year degree, and I still think we need more time--especially in internship.

Beiber. No all my experiences with ALS have been good ones. But as you just stated being your ALS oriented you want monitor and IV which means BLS is out of the loop in my system. So I would just be in the back staring at the patient not really doing anything.

If I dont have ALS on board I am the provider. I will do the vitals, take lung sounds, check pupils, listen to bowel sounds, ect. I get alot of experience as most of our calls are 30 minute travel times to the ED. Plus I get to have interaction with the patient, talk BS that sort of thing.

Now with ALS on board the vitals are done by the LP12, the medic takes the lung sounds and has all the interaction. Thats what they do, its their job. They are the higher medical authority on the rig at that point.

I learn alot by watching and listening to what is said and reactions that are got. I dont mind being with ALS I just wish in my system we could do more then sit there.

Remeber that if your on a BLS rig at anytime Beiber. You may make some EMTs put off if its all about you you you in the back. Look at it this way, picture being in the back of your rig day in and day out and every once in awhile some hot shot gets back there and takes over like its all his and pushes you to the side. How would you feel.

That's a good point, UglyEMT. Thanks, I'll try to remember that if I get the chance to work on a paramedic/EMT truck.

So let me ask you another question, do you like your system the way it is? Or do you wish it were different? Instead of ALS intercepts would you prefer if your service just staffed paramedic/EMT trucks? When you guys have an ALS intercept, are the paramedics able to bring all of the equipment they need into your truck, or are there things that they have to leave behind do to space/moving issues?

The one ALS intercept I've done was for a chest pain call coming in on a BLS truck with an EMT-B and I in the back with a first responder driver. We brought our box, monitor, and narc box and rode with them into the hospital while my preceptor's partner followed in our truck. I was really impressed with the EMTs and their care, and I'm a little sad to say I haven't gotten to experience more calls like that during my internship.

That's very interesting, Richard. So, when there's just one paramedic on the truck they're only allowed to function at a BLS level even if they have all of the ALS equipment available to them on the truck? Is there any particular reason why that is?

UglyEMT, correct me if I'm wrong, but it almost sounds like you've been rubbed the wrong way by ALS on those medical calls. Is that true? How much experience do YOU get in the back of the truck as the sole provider for medical calls?

I've perhaps been spoiled by working in a system where there are always two paramedics available, and though I plan to work part-time at this same service after I get my yellow patch, I also plan on working part-time for a rural service that currently only has one paramedic and a couple of EMT-I's and a bunch of EMT's as well. There are a couple of people from my class that will be working there in an ALS capacity as well, so the service is about to have quite a few more (brand new) paramedics available to them, which may or may not be a good thing.

In my limited experience, I've found dual-paramedic trucks to be very fortunate and something I kind of like the idea of, especially with me about to be a brand-spanking new paramedic myself. On the other hand, I'm intrigued by paramedic/EMT trucks because of the inherent challenge in being the only ALS provider available. I don't know how your services are or how you guys run your calls, but I very rarely make a patient code green (code I by most of the country's standards?). The way my protocols read, I'm free to make them a yellow if I think they require paramedic evaluation, and I can pretty easily justify making any patient a yellow (code II?) and in fact do make most of them a yellow unless I can be certain of what's going on with them today and don't have any suspicion of their conditioning worsening. At the service where I'm doing my internship, I've gotten on average between five and ten calls per day, and out of them I've probably only made a dozen or so code green. In my system, all yellows get a monitor and IV, and it's rare that I don't at least have a look at their heart (which automatically makes them a yellow if I put them on the monitor).

Unfortunately, I never worked as an EMT before going to paramedic school (which has come back to make my internship much more difficult than it could have been), and I'm a big fan of working as an EMT before going to paramedic school because seeing the people in my class who did have that experience versus myself, I can see where they've got a leg up on me. At the same time, it also means I'm very ALS oriented in the sense that I'm all about seeing what their heart's doing and having IV access, though I tend to be conservative in my treatments themselves. So for me, it's easy to justify myself and say "I want to put them on the monitor and I want to have IV access, though I don't plan on giving them any meds or fluids unless something changes", but on the other hand, I have gotten almost no exposure to working with an EMT and the dynamics inherent in that kind of system.

Hi everyone.

So, I'm curious. Throughout my internship, which is coming to an end soon, I've worked with my preceptor and his partner who are both paramedics in a large service that runs dual paramedic trucks. They do hire EMTs part time if you're in paramedic school (I work part time for them as well, sort of) and are about to hire several EMTs full time. But so far, my only interaction with a BLS crew has been during an ALS intercept for a BLS only truck coming in from the next county over.

I've never worked with an EMT before in an ALS capacity, and pretty much all of my exposure has been in a dual paramedic setting, so I'm curious as to what kind of staffing your services maintain, and your own experiences working on paramedic/EMT and dual paramedic trucks. What are the benefits/cons to each model? Do you have a preference?

Chest auscultation?

Has he been compliant with medications?

I’m very cautious of the PHX AMI at such young ages!

Let’s have some 02 (10L via mask)

I’d like to get a line in and run some fluids for the postral hypotention.

He has symptomatic bradycardia (poor output from the symptoms of excertion) so I wouldnt rule out giving some atropine (considering his weight I’d like to give 1mg)

I’m not quiet sure what non diagnostic ECG means but I’m guessing there is not heart blocks.

At the hospital will probably Dig load him.

If were not responding to the atropine then consider pacing if the patient remains symptomatic and adequate perfusion is diminishing.

Is there any other information you’d like to share?

Lung sounds clear and equal bilaterally. He states he's been compliant with all of his medications.

Sorry, I thought non-diagnostic was a more universal term, apparently not! No ST elevation/depression, T-wave inversion or other signs indicative of ischemia or infarct. No heart blocks noted but there are some signs of left ventricular hypertrophy.

You got your line, after a 250cc bolus he's up to 120/80 with some improvement in color but no definitive change in rate. He continues to have periodic episodes of regular sinus rhythm rate of 70 that last a few seconds. Decrease in weakness, increase in SpO2 to 98 on 10 LPM via NRB.

Atropine brings his rate up to 100, which completely relieves his weakness and gets his color back to normal, next blood pressure is 130/90. Repeat 12-lead is still non-diagnostic with no signs of ischemia/infarct or block. 4-lead is now a junctional tachycardia.

Thoughts on a diagnosis?

You now have an Intensive Care Consultant and Intensive Care Paramedic who arrived on the chopper. The chopper has a ventilator. CVC is in. Nil imaging or pathology available. We question a spinal injury from MOI but defiantly has extremely strong and equal bilateral limb movement (takes 3 of your to hold down his arm to get the second IVC in). Reflexes were intact before RSI.

As I said, there's a positive spin to this story. What do you want to do with the ICP?

Why don't we try 1 g/kg of mannitol and see what that does? It'll reduce the ICP and increase the CPP, and if we have that art line and can get a MAP and if we can still keep an eye on the ICP (I assume they local ER doc put an ICP monitor in, though technically the patient doesn't meet the criteria for ICP monitoring, but since we got one earlier I'm assuming one's in place) we can get a CPP as well and have a better idea of where we stand. Ideally I'd like to get that ICP down to <20 mmHg and keep that CPP >60 mmHg, and maintain the patient's BP <160 systolic, which it's skirting the line right now so I'll leave it be.

A 400 pound guy with no medications? Something doesn't seem right there...

When you ask him more specifically what "cruddy" feels like, what does he say his symptoms are? Vitals, especially a BGL. If he isn't already on diabetes medication, my suspicion would be that it is just not diagnosed yet. Hyperglycemia could lead to the dry skin and "cruddy" feeling, and symptoms are slower to present.

Next question... can he walk? No need to carry someone who is just feeling a little ill, if all their vitals are good, and no reason to think cardiac/ respiratory/ anything that would get exacerbated w/ exertion.

Patient's complaining of general malaise and some weakness/dizziness. No respiratory distress, no chest pain/discomfort. No nausea/vomiting, diarrhea/melena or abdominal pain. Patient denies any recent medication changes/additions/discontinuations and states he's taken his medications today. Patient also states he has been getting over the flu recently, no meds taken for it.

PMH: AMI (heart attack at 21 and at 33), IDDM, HTN

Meds: nitro, ASA, carvedilol, simvastatin, HCTZ, Klor-Con, insulin

Allergies: PCN

Vitals

HR 35

BP: 110/70 with +orthostatic changes (90/60 sitting accompanied by near-syncope)

BGL: 110

RR: 20 NL

SpO2: 92 RA

4-lead: junctional rhythm rate of 35 with brief (<10 sec) moments of regular sinus rhythm

12-lead: non-diagnostic

With exertion patient's skin becomes paler and mottled, especially in the face and extremities. No change in mentation, only complaints with sitting the patient up/exertion is generalized weakness.

Treatment?

What kind of clinical opportunities are available? (Locations, how busy the hospitals are, opportunities to intubate, average number of skills performed per student during clinicals, average number of intubations per student, support from the local medical community, etc.)

What are the hourly requirements for clinicals and field internship?

What additional resources does the program have available to prepare the students for passing the NREMT (or the equivalent in your country)? (I.e. emscat.com, etc.)

How many lab assistants are available? What kind of teaching experience do they have?

Is the program accredited? And if so, what sort of standing/ranking does it have?

What kind of pre-FI training is available to actual field work? (That is, simulated scenarios on a more massive scale than lab, involving full equipment and possibly actual ambulances.)

Well, now that's getting pretty high, isn't it? Do we have a transport ventilator or are we gonna be bagging this guy all the way in? I'm not especially familiar with them, but if I'm not mistaken it's recommended to ventilate with a tidal volume of 6ml/kg to help reduce the incidence of ARDS (though I'm doubtful this kid'll last long enough for it to be a concern). Also, did the doctor at the local ER place a central line or an art line so we can keep an eye on those measurements as well (MAP and JVP)? Did we get any labs or imaging done before initiating transport? I'm interested in knowing the patient's serum osmolality and the location of the bleed, if available.

If possible, let's transport with his head elevated at least 30-45 degrees if possible. You said he has a spinal injury, but he obviously still has vasomotor control intact so it's not a complete disruption. Were we able to assess neurologic function in the extremities before RSI'ing the kid? Did he have intact reflexes (+Babinski's)?

You are a member of a dual paramedic county EMS truck stationed inside the limits of a large city dispatched to the far edge of the county thirty minutes outside of the city (that side of the county has been dumped and you're the closest available unit) to respond to a "sick person" in one of the smaller towns of the county. You arrive at a rural house that appears pricey and well kept with no medications/oxygen/other pertinent findings present. The town's volunteer fire department is first on scene (BLS/first responder only) and advises the patient is a 400 lbs male located in the back bedroom of the house who complains of "feeling cruddy" since yesterday.

Patient presents alert and oriented x3 lying supine on his bed with no shirt on, a patent airway, unlabored respirations that don't appear brady or tachypneic, with warm, dry skin maybe a little pale in color. You have plenty of firefighters available and the only obstacle to extrication is a five step patio and a "mega-mover" tarp for moving bariatric patients.

Looks like Cushing's response to me. Also with the other RSI drugs can we throw in some lidocaine for that ICP too? Also, what is his ICP? The flight to the hospital is going to be all about that airway, the head injury needs surgical correction. Did we find any other injuries?

All right. I'm not a fire/rescue/anything guy, so to begin with my role is going to be to stand back and let the fire guys do their job. Whatever they need to do to secure the scene for my entry, let 'em do their thing and as soon as it's secure I'll move in. It looks like accessing the truck driver shouldn't be too hard, though I think climbing into the truck might potentially cause the roof of the car to collapse more so ideally I want to get the passengers of the car out first if that's the case.

It sounds like the patient in the truck is more critical, however, so if there's any way to safely get the truck driver out without endangering the car occupants (again, this is gonna be fire's call, I don't know about that kind of stuff) I'd prefer that but I'll defer to their judgement.

Does fire advise a prolonged extrication? If so, I'm going to consider the air transport but I want to get a better idea of what's going on first. Can we access the patients enough to assess them or at least get a verbal account of the verbal patients' injuries?

Also, in this scenario, are we assuming the role of BLS providers or can we input ALS care as well?

Thanks for providing such a warm and friendly atmosphere to come to, and for your guidance, suggestions, and insight. Every day I learn a little bit more about EMS and how to be a paramedic, and it's great to have another route to share stories and learn from people with as much experience as you all. As far as the "youngins" comments, I don't mind. The other day at the ER one of the nurses asked me how old I was and they said, "Eighteen... but only because I assume you have to be at least eighteen to be a paramedic." So I don't mind.

Guten tag!

Welcome to the boards, Marius. Nice to meet someone from across the pond, I've heard you guys have a pretty interesting EMS system over there in Deutschland. Hope to learn more about it from you, and see how our two systems are similar and how they differ.

Sorry, the only emergency equipment I keep with me is my phone and a little keychain face shield, haha. Anything more than that and I'd just get myself into trouble. I'd check Amazon, though, I bet they have plenty of rescue bags for you to choose from.

I had a feeling I knew what the diagnosis was after I saw those lesions. I'm very familiar with the disease and I was pleased to find out after I checked the spoiler that I was right.

But I won't be a spoilsport and ruin it before everyone else is done. Great scenario though! Hope to see more like it in the future.

I've only seen one possible flail chest segment so far, and it was really, really wild. It was an older patient restrained front seat passenger of a car that went off the road and into the ditch (actually it landed so that the front and back bumpers were suspended on both edges of a drainage ditch with the rest of the car suspended about three or four feet above the ditch itself) with no airbag deployment who was a little banged up and complaining of some difficulty breathing. It actually looked like they had either bilateral flail segments or a floating sternum, they had bilateral paradoxical chest wall motion that moved concurrently and equally with respect to the other side and opposite of the sternum, which itself appeared to be moving anteriorly outward from their chest with each breath.

The patient did fine during transport with some minimal relief from the NRB, alert and oriented x3 throughout the trip, clear and equal breath sounds, good pressures, sinus tachycardia with frequent unifocal PVC's, no 12 lead changes. The chest wall motion was about as dramatic as in your video, Dwayne. We boarded them, plus IV, O2 and monitor (switching back and fourth between patient number one and the driver).

Agreed. What is the point of "proving" someone is faking it? All they need to do is complain of some vague, nonspecific problem and they need to be evaluated anyway.

Folks spend way too much time worrying whether a call is legit or not. We all know that a significant portion of our workload is BS(some areas more than others)-it's just part of the game.

Well, after four pages of some very interesting discussion, I think I'll finally weigh in on my own topic!

Your friendly disclaimer, as always (or at least till December), I'm just a student (so you already know half of what I say is wrong, haha), and my opinion is always up to revision, but here it is for what it's worth. First of all, yes, I use ammonia inhalants. Second of all, your question of "what is the point of proving someone is faking it?" I think is really at the heart of this issue, so I'm going to respond to that with my views, such as they are.

For me, I believe it's absolutely vital to know whether or not a patient is truly alert and oriented and simply non-compliant with the assessment versus truly unresponsive. After all, the level of alertness is right there next to airway in the ABCs. I don't need to tell anyone here that an unresponsive patient is a serious problem, and one that needs to be corrected or attempted to be corrected immediately. So if I have a patient that is truly obtunded, that is a serious pucker factor for me, and tells me that something has gone seriously wrong and needs to be corrected immediately to prevent them from getting any worse. And I am personally going to HAVE a line established on ALL unresponsive patients anyway I can get it, because regardless of what a person's vital signs are, if they are truly unresponsive then we're already behind the ball and I'm not going to be without a means to give them fluid or medications when the rest of their body catches up.

Now maybe I'll be able to get an IV, but maybe I won't. Do I really want to do an IO on an unresponsive patient with stable vital signs if I can't get IV access any other way? Well, I don't have too much of a problem with that. Like I said, if something has gone that wrong inside a person's body that they're unresponsive, it's only a question of time until it starts wreaking havoc on other body systems as well. I NEED to have venous access. But do I really want to start an IO on someone who's perfectly fine and just fibbing with me? Hell no. And you know what? Most of the time I'll be able to get venous access with an IV. But if I can't, and they don't really NEED the IO, well, I don't think there's much benefit to the significant risk that accompanies having a needle drilled into their bone. To help direct MY care, I need to know what I'm up against.

The other facet of this is how we direct the hospital's care. And I don't know how it works in your guys' system, but here a code red (I think most of the country calls them code III?) unresponsive patient is automatically limited in the number of hospitals they can be taken to. Which is no big deal. However, what IS a big deal is whether or not I'll be dragging away a doctor and a code team from patients who may truly need them not to mention automatically freeing up a portable x-ray and a CT for someone who doesn't need them. Now, I have no problem erring on the side of caution if there's any doubt in my mind, but I'm also not about to expect the folks at the hospital to pull themselves away from folks who may actually need them because I don't want to investigate the matter a little deeper and really find out, for myself AND for them, what we're up against.

I don't think highly of those people who decide to shove any amount of inhalants up a patient's nose, but I don't think it's inappropriate to hold one under their nose and pop it to see if that'll elicit a response. As providers, we need to know our patients' status, including their mental status, to help direct our own care, and also to direct the care they get at the hospital.

Surprises me when people still use such archaic methods to "catch" a "faker". Hand drop, why? If turns out your wrong you have done harm.

The hand drop isn't very likely to hurt them, and even the ammonia inhalants have, at least according to the British Journal of Sports Medicine, never caused harm to any patients. Though I must ask, what "non-archaic" methods do you use to assess responsiveness? Is it just the painful response and corneal reflex or do you do something else to differentiate between the truly obtunded and those who are playing possum?

That's a good point, Dwayne. And hopefully, regardless of whether or not anyone or anyone's service is using ammonia inhalants nobody is withholding care from a patient that remains unresponsive following attempts to elicit a response. Unresponsiveness of unknown etiology is just that until it can be ruled out by either eliciting a faker to respond, or by field examination that indicates another cause.

So. Ammonia inhalants. They're controversial, and I've heard everything from "never use them" to "hey, why not?" but I want to know what YOU guys think. For anyone who's not familiar with them, ammonia inhalants are little quarter-size pouches that you squeeze to release "aromatic spirits of ammonia" that irritates the nasal mucosa and stimulates the breathing reflex.

They're most commonly used in EMS on apparently unresponsive patients who are presumed to be playing possum, that is, to give a patient faking unresponsive a stimulant so unpleasant that they will react and no longer be much interested in faking unresponsiveness.

According to a 2006 article from the British Journal of Sports Medicine, there are no reports of injury as a result from ammonia inhalant use, and though ammonia is toxic, the amounts used in the inhalants are considered too low to result in toxicity. All the same, there is the risk of, say, stimulating a person who is spine boarded and causing them to jerk their head so hard that they exacerbate an existing spinal cord injury. To my knowledge, there hasn't ever been a case of this.

So, here's your chance to weigh in. Use them? Ever used them? Do you like 'em, hate 'em, think they're the best thing in the world, loathe their very existence?

Word to the wise, learn your lidocaine and dopamine drip concentrations. And not just enough to get through class, but to commit to memory. Even if you plan on working for a service that carries both premixed. Not only is it truly a vital thing to know, because hey, you may not always have that luxury for any number of reasons, but also because you don't want to be that paramedic student who has to spend a day of internship walking around with a sign on their shirt that says "Ask Me How to Mix Lidocaine" and have your preceptors stop every nurse, doctor and tech in the hospital and make them read the sign and ask the question and then to top it off have them post the image on Facebook for all of your future coworkers to see how royally screwed you are for irking them with your lack of knowledge.

Not that I would know anything about that...

(Oh, and it's 1 g lidocaine in 250 cc NS for a 4 mg/cc concentration and 200 mg dopamine in 250 cc NS for an 800 mcg/cc concentration or alternatively 400 mg dopamine in 250 cc NS for a 1600 mcg/cc concentration.)

Deleted. Ignore this, please.

Thanks, Lone Star. I appreciate your words, and I wish you good luck in your own education. Are you doing a Bachelors in paramedicine/EMS program?