eb1040

I still have a problem with this collision being almost at the end of the driveway of the hospital. If you have time to send a Paramedic up to the hospital, you had time to take that patient there. If there was entrappment or some other reason the patient could not be moved, the doctor should have been requested immediately or this made clear during the repeated communications. This is the location according to the newspaper. Weeks St. and Dewey St. intersection is just north of the hospital drive. https://maps.google.com/maps?hl=en&ie=UTF-8&q=southwestern+vermont+hospital+bennington&fb=1&gl=us&hq=southwestern+vermont+hospital&hnear=0x89e096592f93e6d1:0x36093b92bf32d7c0,Bennington,+VT&cid=0,0,8019787768181511999&ei=7BNrULWrF-KliQKysoHQDA&ved=0CH0Q_BIwAA

I guess the thing is how long ago was the training and what had he done to review the procedue. The settling part right away and quietly may prevent the others from telling their version of what happened. It could be even more damning especially if this guy was the type to brag about what he had done in his previous state. There is also witness testimony on record which can be used. Some of this is probably public record. Between the scope of practice, the very short distance to the hospital, sending a Paramedic to the hospital, the doctor telling him to come into the ED and whatever else was on that list, this is not something an ambulance company would want to linger for the zeros to add on.

I doubt if pericardiocentesis was in his Paramedic training if it was not in his state's scope of practice. Where he got the training for this procedure was not mentioned. It was also not mentioned if he had done one before, how long ago and if he actively kept current in this skill. He did make two unsuccessful attempts. That also leads to a path of considering what other injuries and what other interventions had been done. It would be interesting to see the autopsy report. I also doubt if this lawsuit will drag out many years. The ambulance's insurance and lawyers may already have an offer on the table especially with so many witnesses who advised him against doing this to the patient with a doctor/hospital in view of the scene.

By a map of this location, this crash occured almost right in front of the hospital. It was not like this occured in some very distant place where there might have been no other options. The part about sending a Paramedic into the hospital to get the doctor is just weird. The Paramedic acknowledged what he was doing to others and they disagreed with his actions as did the doctor. There seems to be enough here to make a good case for relieving him of his license. Each offense separately is pretty serious. Collectively they are a disaster.

Was anyone here working in the Toronto area in 2003 with the SARS outbreak there? http://wwwnc.cdc.gov/eid/article/10/9/04-0170_article.htm During the H1N1 season a couple years ago, some CCT trucks had EMTs refusing to go with known H1N1 patients who were being transported to a hospital of higher care. It brought back memories of the 80s and HIV/AIDS and TB.

Since the Hanta Virus made headlines again this past few weeks a little too close to home and H1N1 a couple years ago and with TB still prospering in the United States, I will give WHO some credit for giving notice. We are connected by mass transit to all parts of the world and can not take anything for granted especially if you work in health care.

Hospitals have national agencies for quality reporting. When something happens, it runs through the system and expectations are raised. http://psnet.ahrq.gov/primer.aspx?primerID=18 http://www.jointcommission.org/sentinel_event.aspx Electronic orders have also created more or a different source for error along with preventing others. It is easy to select the wrong patient and enter an order for medications or procedures. A nurse will usually have to verify the correct patient by scanning the ID ban before the med is given but if it was not meant for that pationt, it might still be given unless the RN or pharmacist questions the order.

Medical errors happen. Sometimes it takes a major muck up like this to get everyone checking their own policies. This hospital will settle and settle big with the family. That is a given. If the nurse does not have insurance, he or she will also probably stand to lose alot and will probably have to defend his or her license as well which will cost several thousand dollars. The RN will probably never work again although this was likely the result of poor policies (system error) in place rather than just incompetency on the nurse's part. The check, double check for meds and time outs before any cutting came out of some pretty bad errors. The hospital will be hurt in a big way by having their accreditation scrutinized. This makes them fair game to have CMS in their face for the next few years with the risk of losing major reimbursement for other patients. Employees not directly associated with this incident will probably lose their jobs. But, while this is a major error for the hospital, maybe it is time to examine some of your own policies. EMS has had headlines with lax oversight of RSI protocols, bad intubations and inadequate monitoring which has resulted in deaths. Medication errors due to bad placement in the med box, similar labeling or just a lack of understanding of the dosages have resulted in deaths. The unique thing about EMS is that some serious errors don't result in major changes in education or policies. Usually a reprimand is issued and it is back to business as usual. There isn't alot of oversight with many government and private agencies which will sit on your shoulder for the next several years to see your program is ran properly. This hospital will probably be one of the best places to get a transplant if it survives this.

There is a good guide for respiratory delivery devices which is used as a reference for nurses working in the ED. http://www.aarc.org/education/aerosol_devices/aerosol_delivery_guide2.pdf Page 13 describes the SVN and the mouthpiece. The mouthpiece is definitely the preferred method and there are studies which are listed at the end of this guide. There are also many types of nebulizers and the newer ones used in the ED are primarily designed for a mouthpiece. The mask is sometimes more convenient for Paramedics because it can provide oxygen as well as a little medication and frees up their hands. But, the mask can also present some complications. Lack of attention to the positioning of the mask for the patient who is not able to move it themselves can cause injury to the eye. The medications are also not good to get into the eye nor is the infectious droplets coughed up from the lungs. The patients who do use a mask regularly are at some time treated for eye infections chronically. Some patients and providers are also just too lax or lazy to use the mouthpiece. For some it is the convenience of the Paramedic or Nurse so they can talk to get the paperwork done and move on. This does the patient a disservice who may actually need to concentrate on breathing better with the aide of the SVN. The hard core COPDer patients often know the difference and will request the mouthpiece and will only nod to yes/no questions. If they don't they may already be well beyond the help of an SVN. I think the EMTs should be honored to have the responsibility of giving a tx with a mouthpiece since there does require a little more technique and coaching rather than just slinging a neb on someone's face with a mask. There is also a difference between charting you "gave" the medication and the patient actually receiving the best possible dose of the medication through the correct delivery method and technique. It is like saying blowby is best for a child (older then infant) or that if they scream they get more medication into their lungs which is also not true.

I think this summary by a couple of physicians and their references might be of some help to you. http://cmbi.bjmu.edu...hypercapnia.htm It also gives an explanation as to why NIV is useful which you can also find numerous studies from the manufacturers of these devices who have described how NIV offsets the deadspace and even when used as high FiO2, minute volume is restored to normal unless there is profound fatique or other disease processes which require intubation. The summary also explains why a low flow device like a simple mask is not the best device and how a venturi mask which is a high flow device is better. A nonrebreather is also a low flow device which can not always meet ventilatory demand and can increase work of breathing regardless of what has been taught about the bag. Once the proper definition of low flow and high flow devices is understood, it is relatively easy to see the importance of the proper delivery device and not just the FiO2 being given. Textbook liter flows also do not ensure the FiO2 for low flow devices. Those quoted are for what is considered a normal individual with normal lungs breathing a normal nondistressed tidal volume and minute volume. When looking at a book like Eagan or any source, it is a great idea to look at the references to see where they pulled their data from. You might find a study or article which provides the explanations you are seeking. Also, when considering the SpO2, you must look at all the factors which will shift the Oxyhemoglobin curve. 92% does not give the same PaO2 in different situations especially at that slope of the curve where the patient's PaO2 can easily fall into a critical low. Carrying capacity must also be considered and the factors that inhibit the transport of oxygen to the tissues. Unless you have a good control over cardiac output, perfusion and oxygen uptake, just focusing on oxygen by itself could be a potentially fatal mistake.

It is easy to blame HIPAA if it is not understood what the purpose of this regulation actually is. In California and a few other states, the privacy laws including those that have nothing to do with billing are far more strict. HIPAA does not regulate the use of cameras if the viewing is done only by those who need to know and some security is maintained. The same goes for the state regulations. This is common practice in many areas of medicine for education, security, patient monitoring and telemedicine. I do know several ambulances companies do have cameras in the back and some have the telemedicine links where they are viewed by the physician or nurse at the other end throughout transport. Also, if the form is worded correctly for the release of information, the recorded information can be used to teaching purposes which would be a good thing for EMS to see what could have been done better or not done at all. Court cases take time to file and get all the facts. It the photos surfaced, this Paramedic will have some explaining to do. The "delete" button doesn't mean too much now with the memory cards and some data can still be recovered.

I don't think it is about the boundaries as much as it is about the favoritism. Someone might be handing out business cards or giving the phone number of an ambulance service they work for or they like for the public to call instead of 911. That may not be the closest ambulance which might be dispatched if 911 had been called. This was done several years ago before 911 was so widespread or boundaries with contracts established and may still be an accepted practice in some areas. I see no problem in calling the ambulance of your choice if you want a routine transport and provided that ambulance has the available trucks to do routine and emergency calls.

If the job description says you will be dealing with insurance and other paperwork which might concern payment, chances are you will need to keep your skills as a Paramedic separate. Hospitals try not to give health care providers who have direct patient care the responsibility of asking for payment. Check the job description again. A general basic EMT cert is okay for a clerk position since some understanding of medical terminology may be needed. Over selling yourself for a position that really does not need that requirement or where there might be a conflict between medical and money might not go in your favor.

Is this a Jackson Rees bag or a self inflating one? If it is a self inflating bag I doubt if any alert patient who has a RR of 40 is going to allow you to hold a mask to his face firm enough to make a seal. CPAP is best done with Continuous flow for a continuous positve pressure in the airway. The fact that the lungs were clear is a little concerning which gives rise to several other differential diagnoses as I mentioned 2 earlier. Not knowing the medications also does not give us the necessary information. There are some situations where high FiO2 oxygen will be the treatment until intubation can be achieved. With intubation being considered, the high FiO2 would be an appropriate choice unless your bag was a Jackson Rees and not a self inflating where you could provide continuous flow with a high FiO2 for intubation. Some CPAP devices also allow for a high FiO2 and can be used with the intubation pre oxygenation process as can a high flow nasal cannula. I don't know what ventilator you have at your access but there are a few available that can also provide pressure support which is what Mobey mentioned in his post. That could help but depending on the ventilator used for noninvasive, asynchrony could occur tiring the patient more. If using a ventilator, a self inflating bag or a good prehospital CPAP device, PEEP would be helpful in some situations with pulmonary fibrosis such as with atelectasis and PNA

Lungs clear? I would have expected some chronic crackles with the pulmonary fibrosis. Any history of pulmonary hypertension and if so, what meds? What anticoagulant was this person on since he had a history of Atrial Fibrillation? Had anything changed with that? This may have been something other than the pulmonary fibrosis causing the shortness of breath. In that case the CPAP or PEEP probably would not have been of much use. It also would depend upon the device and how much FiO2 can be delivered especially if pulmonary hypertension or pulmonary emboli are to to considered. Also, with this degree of distress it is doubtful many of the prehospital CPAP devices would have made a difference and may have worsened the situation in the set up. This is also one of those situations where you might have to overcome the fear of giving too much oxygen and go very aggressively. These patients have little to no reserve.

Not giving an oxygen concentration of 100% for Persistent Pulmonary Hypertension of the Newborn (PPHN) can be deadly. Not knowing the causes, history or differentials between a ductal dependent lesion and PPHN is deadly. Generally in a stressed delivery outside of the hospital with a term infant whose mother may have had prenatal care, PPHN would be suspect or be aware of the potential with appropriate treatment. Continuous monitoring of both pre and post pulse oximetry should be done with any distressed infant initially. The high flow generator or device may not be necessary since an infant's minute volume is low but the flow should be compatible with the device. Depending on the device used you don't need a large liter flow to allow oxygen FiO2 consistency in babies and children since they will not have a large inspiratory demand for the mixture. The exception might be for an infant who has a ductal dependent lesion and is not intubated. In that situation if you opt for subambient oxygen therapy you may wish to use a high flow device that ensures it is well about the infants peak demand to prevent any contamination of room air @ 21% especially if running at 16 - 18%. .

If you look at a few of the recent COPD articles on the EMS info websites by some respected authors in the industry, you will see they still put Asthma in the same category as COPD in their discussion without specifically addressing differences. The similarities are more easily discussed especially for prehospital treatment. Asthma will produce a similar response as the diseases associated now in the classification of COPD. But in both situations the term "hypoxic drive" is usually not the situation for the acute as once thought. Ventilation Perfusion inequality or mismatching and pulmonary vasocontriction have been among the accepted explanations along with a couple of other concepts or theories to explain the rise in Carbon Dioxide (CO2) and assoicated somnolence. There are also distinctions in Hypoxic Respiratory Failure and Hypercapnic Respiratory Failure which can be similar for Asthma and COPD although their pathophysiology deserves a more indepth understanding to appreciate the differences. Once this is understood in disease processes, it can be anticipated with the appropriate treatment ready and not feared. They hypoxic drive was also poorly explained in many allied healthcare and nursing textbooks for years like it was an on/off switch without any explanation of pH and only a vague overview of the chemoreceptors. This includes nursing, RTs and EMTs. Many, as seen in this discussion, may only have gotten a very general overview of both COPD and Asthma to where the differences are not fully noted or understood. Treatment may sometimes be provided in a shotgun style and sometimes there are situations where both diseases are present as well as a situation where one is not well recognized or treated because of the predominant facotrs of the other.

There is COPD - Emphysema from Alpha - 1 Antitripsin defiiciency which often goes misdiagnosed since the person does not smoke or is exposed to smoke. The data is still coming in from BPD and its affects in adult life.

Bowel sounds present in all 4 quadrants? Quality?

The CDC puts out the guidelines and a state TB control office, usually through the DPH, can make it mandatory for the state in certain settings. This is also why there are some variations per each state for settings such as prisons and long term care facilities in regards to mandatory TB testing. I know Minnesota and Iowa do mandate a baseline screening for all health care workers. I believe this is true in New York also. But, you might be able to use the argument that EMS is not really part of a health care setting and you are not considered a health care worker by the definition given by the CDC or the state. Here is a link to the TB control offices for each state. http://www.cdc.gov/t...s/tboffices.htm It has only been through strick adherence to testing policies and isolation that the number of TB patients has been reduced but is still high in the US and that includes the MDR-TB cases. If you don't want to be part of the solution you could become part of the problem.

In a little fairness to the family's side also, we don't know what was said to them at the hospital. I'm sure you have had some Physicians, maybe surgeons, with huge egos say "if I could have gotten them sooner". Or even something the ER doctor or one of the staff members might have said could have stuck in the family's mind. What if a Paramedic from another unit happened to say something like Kiwiology's post within earshot of the family? I have had to catch myself from saying something negative about a hospital, fire department or ambulance service also when a family member says how great they are for whatever reason. I have actually heard some EMTs and Paramedics openly say very negative things about an ambulance company or hospital to a patient or their family It doesn't take much especially when a family wants to find other answers to why other than asking themselves if they could have prevented something in the first place. When working in the hospital or on CCT we are told over and over to be very careful with out choice of words around any layperson who might repeat what we say to the family. A family might get caught up in their grief and hear things from everyone who has an opinion about what should have happened which may be from the well meaning EMT neighbor which then one decision after another lands them with a courts care with an attorney from an info commercial.

I prefer to read the referenced court summary rather than a bunch of anonymous comments in a newspaper. http://www.judiciary...RescueSquad.pdf Whether or not it is all the truth it does give a basis to form an opinion based on evidence presented to the courts. I do see a problem with 2 EMT-Basics working a code without calling for ALS or going to the hospital for over 30 minutes. Without an ECG, they would have no way of knowing the person was asystole. They also may not have known if they could not feel a pulse due to a pulseless rhythm or severe hypotension. I think the new AHA CPR guidelines have addressed. I am also going to refrain from making a judgement against the person shot or who shot him. That is not my concern as long as the scene is safe for me to treat the patient.

Apologies. I didn't see the g/L. We use g/dL which would be 11 - 16. If this patient had died at the other hospital, this complication would have been noted and the sending physician held accountable. If he attempted to correct some of his mistake or notify the rec'g they could have evacuated the hematoma upon arrival. If he survives the clotting factors will also have to be considered in a burn patient. Bad situation either way. At that point I would be contacting my own medical director for advice about this transport since this is an IFT and there are now more complications to consider other than just the burns. Additional staff from the hospital may need to accompany especially with blood products (in some states). The need for pressors etc.

Hgb 6.4? Any chance they shot a KUB plate? Since there is some fluid going in urine output should be better unless the increasing abdominal compartment pressure is high which the bladder pressure can not overcome and/or bleeding. A rare complication of a femoral CVC is an abdominal hematoma. The scenario did not indicate a trauma to the abdominal area. For the ETT cuff, you could try a stopcock to the pilot balloon to see if it stop the leak. If that does not work and it is suspected the cuff is blown, changing the tube with a tube changer would be the best option but maybe not for this ER. In that situation I would ensure adequate ventiation by physical and monitoring data and leave it alone.

Is there an OG (or NG in some parts of the world) in place? Was it seen on the CXR as good placement or at least below the diaphragm? When doing a placement check do you get the gurgling noise at the same time? Does decompressing the belly alleviate the gurgling?