P_Instructor

Patience.....concerning your questions....

With the original post, I did leave a lot of info out, so I do apologize for this. Many of the items you mentioned were performed, such as she did not have palpable radial pulses with the initial BP, so this is where other aspects of determing perfusion was obtained, ie. carotid pulses, etc. The patient does use a cane, however mentioned that she has to hold on to furniture to get around the home. No walker with the patient (she has no hx, no rx, no MD - very independant). The patient was continuously monitored for any changes during the contact.

The premise for this post was to see if any instructor's out there actually lecture on the geriatrics in detail concerning the multitude of things that could present themselves to the provider, especially the new provider that needs to reflect on only the limited knowledge of their paramedic class, as many do not get the clinical/internship experiences dealing with these unique situations. No patting myself on the back by any means, but I lecture extensively in this field as this is the majority of patients we deal with. The new medic I was working with did come from a different program and really did not understand that pathways that he could investigate on the patient's behalf.

Down time short period. Patient stated had been up and down thru morning, latest event about 30 minutes. Denies unconsciousness at any period of time. Yes the non-auscultated BP did 'alarm', but further investigation due to cooler extremities, age, size, etc, carotid pulses were present and regular with adequate strength. Not all 100's have a pressure above 100. Further assessments of vitals were obtained during the course of the call, did leave patient with pressure in 108 systolic range, no neuro deficits, no complaints either from patient or family. Hairdresser actually remained with the patient for rest of day and thru evening per our/family/her request and patient approval.

1. The woman is 100, anyone over the age of 70 with any medical problem or injury should be transported, if you can talk them into it, regardless of how stable they appear. If you newbies do not learn anything else from the crotch, transport everyone over 70 and all drunks.

Rply: You have the patient that has all their facuties, is over the age of 70, has no complaints, and doesn't want to go.........kidnapping.

2. He states he could not auscultate a B/P

Rply: Look for other ways to determine perfusion. BP is the last thing you are using to determine inadequate perfusion. If you can't other determinants of inadequate perfusion and have to rely on BP, get more instruction. Waiting for the BP to determine shock.....your patient will die.

3. The patient could not ambulate under her own power.

Rply: How many 100 year olds have you seen actually be able to do the 'tango' effortlessly.

4. You have no idea how long she had been on the floor.

Rply: 30 minutes

5. Unless you have mobile CT or xray, you have no way of knowing if she had a TIA/Stroke or fractured a bone during the fall.

Rely: That is what physical assessments are utilized for. Good assessment tools give you that information.

A more experienced supervisor may have been able to talk her into going to the hospital, if not, you can then show that you went above and beyond to get her to go. Do you really think she isn't going to fall again ?

Rply: I will not address this statement any further than with my 30+ years of experience, you should know what is best for the patient......talking them into something is not always the best circumstance and could create more problems......even legally.

Did I change anyone's mind ?

Not mine.......

The answer for all "weird" situations is the same, get medical control involved.

The problem is when you cannot get ahold of MC, then what are you to do. You need to be able to use your resourcefullness to do the right thing. By the way, MC couldn't give me much info in this situation.

OK, not many replies. Situations like this are more frequent than most realize. As instructors, open the suggestions and lead them to do what is best for the patient, or be that patient advocate, whether they want the help or not.

I ended up speaking directly with the son in another state, the State DHS, and got those entities hooked up. Also asked if the friend could stay and watch over the patient (which she was very glad to do and even would stay through the evening and night, with approval from the patient and son). All this is made aware to the patient.

EMSer's must realize that we are not there only for the physical patient care, but for the needs of the patient/family, whatever it may be. This goes along with the moral/ethical aspects which should be stressed even more in the classroom instruction.

Comfort and compassion and the wanting to do what is right goes a long way. I have been in the business over 30 years, and this was the first time that I was thanked by all parties involved. Even received hugs from the patient and friend.

We do not bite.. much.

True, but we nibble a whole lot!!!!!

Complacency can kill a cat........more should have been done for her even though the complaint was only back pain. Be the patient advocate and work her needs whether complaint or not in certain circumstance. My opinion only.

How many of you instructors deal in instruction in what is really best for the patient in odd situations. Example:

I was working a shift with a newer inexperienced paramedic the other day. His rotation as the attendant. Dispatched out for possible injured party. Arrived scene and FD EMS meets us outside residence stating just to bring clipboard as patient is refusing transport. We still took the cot and jump kit, etc near the door and entered the home. Found near 100 year old female supine on bedroom floor with lower legs under bed frame. She was only dressed in nightgown, typically weighed only 90 lbs. She was conscious and alert without complaint other than having to go to the bathroom. Apparantly, has been up and down this morning, very unsteady on feet, needs assistance by way of grasping furniture to be mobile. She was found by friend/hairdresser because neighbor called friend to check on patient after not noticing any lights on in the home from across the street which is atypical. Friend activated 911 response.

Assessment was unremarkable for the patient except for slight pressure bruising to elbow and shoulder point from lying on hard floor. Skin was cool and dry. Partner could not obtain auscultated BP, but patient has good carotid pulses and regular apical heart beat/tones in 60's. The patient only wanted help off the floor to go to bathroom.

I jumped in and took over as partner seemed a little perplexed and after letting patient know that we would remove her from the supine situation, that if there were any changes (which we thought there would be) that we would take her to hospital for evaluation. Ahhh, this is the point that the ole gal stated 'no you will not' in loud/firm/demanding tone.

Long story short, got her up without changes and assisted her to commode, then to sofa in living room where she wanted to go.

The problem at hand is that the patient could not ambulate sufficiently enough in my opinion to be by herself, however, she stated otherwise.

Have you, or do you ever instruct students on what you could do in these type of situations?

It is the inevitable identify/adapt/overcome type of scenario.

Give some opinions or ideas. I will let you know what I ended up doing in leter posts.

Nature, try this link:

https://www.nremt.org/nremt/EMTServices/verify_cand_status.asp?link=2

I use this all the time and works great. It give status if registered on NREMT site, if authorized to test, and pass/fail result of exam.

Each textbook is unique in it's own way. You must remember that there are differences in opinions based upon which author(s) feel is the best way to present information. Honestly, if you are to instruct classes for the Paramedic, always remember that the finished product must be able to understand and apply all aspect of cognitive, affective, and psychomotor objectives according to the latest national standards. It would be up to you to research each text and decide which you would feel best serves this purpose. Content must be able to be understandable, and many authors go way above the student's intellect. This is where you must, as an instructor, be able to explain to the student what the author is truely stating, even though it may be their own opinion.

You will probably have many differences of opinion on which is the best text. Good luck.

Sounds like the custodian for the restrooms at the international airport......you know, like us......putting up with the shit.

No problem. Whats funny is I used the scenarios from real life as well LOL

Pedi MCI at a school for the deaf is good. Never would have thought about that one.

I was thinking of a really wacko one. One that would likely never happen ever but would test everyone to their breaking point. Kind of like wrapping several disaster movie scenes into one.

Chemical train has an accident. Responders go there. While triaging an explosion happens now a cloud of toxic fumes heads twords town. In the immediate area is a nursing home and a school. Before evac happens folks become ill. After evacing the patients out of harms way at the landing zone for the medivac flights you have a mishap that sends a copter to the ground.

So in this scenario you have the following elements:

Hazmat Situation with MCI

One set of responders taken out during triage

An evacuation with limited responders

Emotional toll from the elderly and children

Dealing with patients of all ages

Finally another accident that takes out more responders

Emotion of dealing with loss of co-workers

All this while dealing with dwindling resources and alot of different age groups, symptoms, injuries, distances and emotions.

I know its totally unreal and possibly never happen but figure it would make for one hell of a MCI scenario

Yup......I'm just glad that I retired before this happened. I can watch it all on CNN, Fox, etc., while in my recliner........ at the lake cabin.......on a beautiful summer day........drinking a brewski...........wife rubbing my feet...........

Try a small plane crash. One of those tiny commuter or private jet ones. 3 to 5 people on board. Overshot the runway and landing gear collapsed causing the plane to roll.

MVAs are always nice. See if you can get a local junkyard to donate a few cars, have the local FD beat the crap out of them real good. After that add patients, high school kids are good ones. Good multi agency practice and a PSA for the kids.

One I was recently part of. MVA involving an ambulance. Rig has a patient onboard. So now besides dealing with injuries from the MVA you are also dealing with whatever the original patient has and your throwing ina good dose of emotional trauma because you have a few of your own to treat.

Thanks, have done all the above, scenario and in real life (United Flt 232). Have done the ambulance scenario also as local service had deadly incident. Keep sending ideas though, I really appreciate it.

I was kinda thinking on the lines of possible 5-6 pediatrics that are sick in school, and to make it even more difficult (but will really test the assessment skill) make it a school for the deaf.

Again thanks and keep sending them.

The crucial part is determining whether or not this is a patient.

You are correct with your thinking, but to really make sure everything is documented, don't just use the 'is this a patient' idea. Document any contact whether patient or not, complaint of not, arrived scene or not. With this understanding, the paperwork stinks, but better than your butt.

We don't have an official publicized policy on refusals like this, we don't have policies for many things. Our QA/QI person is not well respected, and is supposed to be reading all my PCRs since I am new, but has not said one word to me about any of them if they are OK or not...

I think many people do look at many of these refusals as a citizen assist, as you say. But say you are called for someone who fell and needs help back up into bed/ their walker, what determination do you use to determine if it is purely a citizen assist? What if they have dementia or don't speak english and there is no translator available? I have had all these circumstance (this is not coming from only one call), and it seems like a truly gray area.

Get a policy

Get a new QA/QI person

Sounds like you need both.

P instructor is right.............

What???????????? You're kidding, aren't ya.........

It sucks, but you need to document each and every call regardless of patient contact or not. Even the documentation may not keep you out of trouble in some instances. Example:

I was dispatched to a residence for male with chest pains. While responding, our Comm Center advised that patient called 911 now and refuses any help, does not want EMS, fire, or PD. I even documented this 'cancelled call' with all particulars of address, information obtained over the radio, times and location we were at. Approximately 25 minutes later, another crew dispatched to same location for 'unconscious party.' Fire arrived scene a few minutes prior to EMS and radioed that patient 'Code Blue, CPR in progress." Moral - the wife of the patient initially called 911 because patient was complaining of severe chest pains. Patient then himself called 911 to cancel without the wife knowing. Wife was apparently hysterical because it took EMS 30 minutes to respond to her request. Was going to court until my documentation of 'cancelled call' came to light. You never know when something can or may happen, so even the most mundane call should be documented in some fashion whether you like it or not.

Secondly, it is also your responsibility even though you are the basic compared to the medic. You both make up the crew that responded to the patient's requests, and are both equally responsible.

I know there will be others responses to this thread, pro and con. Do what you need to do, even with the aspect it still may go to court.

Quit beating yourself up. These things can always happen even with patients that have no prior histories. He sounds like the perverbial train wreck that finally de-railed. About the only thing(s) you could have obtained was a more complete history of how the patient has been during his initial hospitalization and if there were any complications that could be expected........but that report could have taken hours and you usually never can get that from the floor nurse. Bad way to think of this, but he was maintaining in your presence.......he only changed after someone else took over and want to pass the blame. You can only do what you can do.

Ahhh.....are you the true descripton of 'klutz'??????

Just be happy you have all three options available. Use what is best for the patient and especially your own well being. Make sure you have (or obtain one) an agreement with other public service agencies for lifting assistance. It is common in my area to use the FD for lifting assistance, especially the bariatric patients. It has come to the point that the FD responds to places for 'lift assist' requests only, and if they have more than they bargained for, call us for assistance if we're available. Heck, most of the time they're just sitting around anyhow.

Keep yourself in shape and routinely practice with the cot, stairchair, a wheelchair, or whatever other device you have to become more aware of how to handle the 'strenuous' situations.

Once you train and use the King, you will find it even easier than the Combitube. As a secondary device for the paramedic, it's great. Our state has even adopted the King as the replacement for the Combitube even at the First Responder level.

At least you recognize that Paramedic School is not a walk in a park.

We're proud to fail students who deserve to fail....

Plz see my thread regarding EMT Certification Restructuring: which the majority of ppl disagree.....

Proud to fail student?????????? You have got to ge kidding???????????

In regards to the restructuring which majority of people disagree..........take a hint!!!!

The instructors position is not to try to fail students, but to prepare them for the Paramedic testing and hopefully subsequent employment. You should be trying to help the student as much as you can, and direct them to be successful. Granted, if the student is not capable to meet the standards of what is taught, then dismiss them with grace and encourage them to try again after a period of reflection or EMT experience. Being 'proud' of failing someone is not what a good instructor does.

Why would a degree program make me more marketable?

Again, not knowing how the situation is in the NE.... Many employers today seem to look for the recent graduate to be a perspective employee. This tends to make their company look better. I am not going to get into the debate of degree versus non-degree programs as this is bashed all over this site. I prefer the degree program (as I teach one), and have seen many of my graduates gain employment over students from programs that did not offer the degree. With degree programs, there seems to be more emphasis on the anatomy and physiology, base mathematical equation, and other scientific education....all which IMO tends to round out the aspect of pre-hospital care that Paramedics provide.

I am very sure that others medics that frequent this site will offer there own opinions, both for and against the degree programs. Go with what fits you best.

Every state and every program are different in what they provide as well is what is needed in the job sector. I am not familiar with what the NE does, but it sounds like there are different pathways you can venture, and is seems you are looking into this. Research farther into what your future employers are wanting and then drive that path. Be aware of many forks in the road as whichever program or level you go through requires extensive/intensive book work and skill preparation. If you are having difficulty in book work, the path you may want to travel is the EMT-I, then possibly the Paramedic. Only you know what you can do yourself if the dedication is there. Do ever forget the light at the end of the tunnel. If you decide the Paramedic route, you will have to be dedicated to the class 110 percent. I would also advise you to go through a degree program as this will may you more marketable.

One must understand the basic aspect of what Atropine is....a parasypathetic blocker. It's properties do not actually speed up the heart rate, but blocks a parasympathetic response which create the myocardium to revert back to it's intrinsic rate values (approx. 60 sinus/atrial and approx. 40 ventricular) in cases of bradycardia due to a parasympathetic response. Atropine used in bradycardic PEA is only an attempt to block the receptors that relay a parasympathetic response if it is there. Usually this is very rare...if at all. It is also why atropine is not routinely used in a slow rate high degree AV Block as this is not what the problem is. Atropine was a staple years ago in cardiac arrest after Epinephrine, however it's effacy did not warrent further use, and now it seems the same for bradycardic PEA.

Valium, Versed, Vitamin H (Haldol), Sledge Hammer.....whatever works with your safety in mind, do what you have to do. If you get the PD involved, you will probably will have to deal with the tasered patient, etc. You might want your Med Dir. to revamp the sedation/restraint protocol to meet your needs if you deal with a number of 'this' type of patient........

Hello, I have the option to begin my EMT-I clinical and field time part way through my medic class. Since i have the time and I ride with an EMT-I level service currently, I'm thinking this is worth the effort. Can't hurt right? But, I guess thats why i'm putting it out here! I live in MA and i understand that they might be getting rid of the Intermediate level at some point but thinking along the lines of getting exposure to ALS skills, I believe this is a good path for me to take. Any suggestions? Thanks!

Question....is the intermediate that is being taught to you in lines of the old curriculum, or is it based to the new AEMT standard?