vs-eh?

Yes, and you've seen how she answers questions... I assume these are not "correct" answers "according to your assessment". Again, so what if she answered like I did? EDIT - Because MS edited his initial question. Altered LOA? Ok... So why is EMS making this decision when a DOCTOR is involved in the reason that this patient is going to the hospital. This appears to be a relatively chronic issue, one that the MD is likely to be (at least superficially) involved in.

You forget one thing...there is a DOCTOR there/readily available that was part of the whole reason that EMS was called and is a much better person to make that call. You don't have to/shouldn't have to make that call. If my family called for me, disagreeing with the choices the I have made (relatively lucid, the religious context aside) and I am the maker of my own demise, then so be it. You CANNOT decide for me, especially if there is a physician on scene/readily available related to the call that obviously cannot deem me a danger to myself within the limits of the law. Just because you are called and a patient refuses to answer any questions (regardless of anything) doesn't give you the auto-right to take them to the hospital. I could hypothetically say that my mother is a danger to herself and give a whole story (presuming I dislike my mother), if she is lucid and says no, she doesn't go. Call details don't override everything else... EDIT - So if I answered your questions as 1. John 2. Where do you think? 3. The present 4. What kind of a question is that? What would you do? Given the scenario outlined.

This is a joke right?

Huh? You still can't do that... I'm old, cranky, I've lived a good life (or bad one), and I don't want any more help from anyone. I want to die and this is the route I am taking (no meds, not eating, etc...). While it may not seem like the most rational choice to a person who is not in the other's situation, it is the patients decision in the end (all things being equal). The doctor obviously is not willing to deem this patient a danger to themselves (probably for good reason) and they are looking to EMS to somehow be a more convincing party (120 hours of education is obviously more convincing). Totally passing the buck on the doctor's and families part, at the very least it is grossly unprofessional and puts people in an unfortunate legal bind. I would be furious if I was on this call. I'd get the doctor to sign the form and leave. I'd like to know how you eventually managed to "convince" the patient to go to the hospital. EDIT - POA I assume means power of attorney.

Ok, so why would they even bother calling in the first place then? If the physician is not going to "form her" for danger to self or something, then what will bringing an ambulance into the picture accomplish? I agree that this patient, as presented in this scenario, appears "with it". The fine line of failure to thrive, danger to self, etc... is in this situation. Is there that much of a difference between the depressed person who can't sleep and took an OD of ativan with no intent of "self harm" per say or this patient? This the former more likely to be "formed"? Probably... Either way, the doctor and the family are idiots in this case. These are probably the same type of people that call 911 for granny, but stop you at the door saying "She doesn't know your coming..." :roll: And to the OP, all things being equal, unless she was eventually deemed mentally unfit by the physician on scene, you did kidnap her. Prepare for the lawsuit.

See this is what I never understand. The family and physician obviously know that she will refuse to go with the ambulance, why the hell do they even bother calling unless some legal intervention has been taken. All this doctor had to do is declare her a danger to herself and "form her" so that she now does not have a decision. Simple as that. Her doctor was there (or immediately available if you were talking to them), why would you even bother calling your medical control? This isn't a gray area, it is the doctor and/or family not doing their job.

Started an EJ on a hypoglycemic paitent? Urgh... It was the same guy who apparently tried 4 times in the same spot with the same gauge catheter? Urgh... I know that some people just don't have any veins, but at least try a smaller gauge, the foot, anything before an EJ. The patient would have to be VERY VERY ill for me to start an EJ (which I have never done, not even on an arrest). I had a similar patient a month or so ago. Altered hypoglycemic, had bilat AV shunts in her forearms and very torturous veins all around. Attempt 1 - 24 in the arm that blew as soon as I administered the dextrose. Attempt 2 - 20 in her saphenous, she kicked, I was like forget it just give her glucagon. We gave her a sandwich at the hospital, and even the ER nurse was like "I'm not even going to bother with a line on her".

Pupils? Temp? Lung sounds? It could be a lot of things but I'll go with CVA +/- aspiration pneumonia. The post laryngoscopy/intubation attempt vitals could be explained by iatrogenic complications. Further increasing ICP (again secondary to airway maneuvers) could have caused the progression to asystole.

Hmmm... Honestly prehospital, there aren't going to be many options besides anti-dysrhythmics's and electricity. I would definitely be calling a doctor regardless. With a ventricular rate that high (assuming this isn't atrial flutter that actually has a lower ventricular response) finding the underlying rhythm would be difficult to say the least. Are these doctors thinking a-fib that is compensatory and using an anti-dysrhythmic would knock that out? Electrolyte imbalance and needs potassium? SVT with abarancy vs. V tach? Meh... All things being equal I would agree with Scara, but add ASA.

When you have 2-3 year of college/university EMS education, come back to me. The above speaks volumes...

Ninety percent of the calls (or more) I don't update the hospital, regardless of acuity. We generally don't update hospitals at all unless it fairly significant (ROSC cardiac arrest, severe SOB, STEMI, etc...). For the general calls how do you get triaged? Do they just want the gist (i.e. abdo pain N/V/D x 2 days, etc...) or do they want more in depth (prior but with XYZ, meds, hx). It's like 50/50 here. Triaging they may want all or minimum. Then when transfered to the RN for care, they want the full story. How often do you have to "sell" your patient to the RN (with an acute [you think] patient)? PS- Do you think I'm awesome? I asked Jesus himself on this holiest of days, he said "meh". I was like "WTF Jesus!"

It must be awesome to work in a system where you could literally ask 20 single questions (CP? SOB? dizzy? hives?) and be able to treat in 3 minutes with every drug available. I would NEVER work in a system where you HAVE TO administer a drug given a "chest pain" PROTOCOL. Now you're adding the "cardiac history" thing but whatever. It's a fucking joke. You probably also HAVE TO blast them in the face with 10-15L/min of oxygen. This shit is such a joke.

Hey... Canada's largest (and therefore best) EMS service can wear t-shirts from between May 2-4 and Labour Day. I have like 20 of them, we get 4 new a year. Admittedly I look like a bum when I wear it (Hello ma'am, what's your medical emergency?), but it's comfortable. You don't really have much to play with when your uniform contract goes to the lowest bidder. I'm still disappointed that they put out on SOP banning jumpsuits at the beginning of this year. That was a big hit for me. Amazingly enough though, on any day in the city, I bet you'd find 15+ different "styles" of our uniform...

Population of 3+ million, 300k+ calls a year, 99.9% of treatment (acute immediately necessary if feasible) done on scene. I really, really dislike the mentality of the "let's get going to the hospital, I'll do everything enroute" mentality. Obviously factor's perhaps can be city dependent, but generally speaking unless you see an acute life threat that can basically only be managed in hospital, manage it prehospital. The major points of assessment, inital vitals, and treatment are basically initiated on scene. If the patient is not in a public place and we are going toward the ambulance, they are going to the hospital in my book. Do all people in such system go to the hospital? Unconscious diabetics? Post-ictal patients that have "3 seizures a day"? Johnny Abdopain? Cardiac Arrest? Are there no treat and release options? Or do people take them in the ambulance, give them say dextrose, wait, then ask them if they want to go? What about cardiac arrests? Do you work them out in the ambulance staying on scene, pronounce and take them back in the house or do you transport to the coroner? What does the family think about this (i.e. why aren't the ambulance drivers going to the hospital with Joe-Bob)? FYI - I don't consider certain treatments potentially necessary given certain patients and extrication situations. CP consistant with past MI in the basement of house? I'll assess, vitals, EKG, ASA, O2, but I won't start an IV (our locks suck, basically only use lines) necessarily +/- nitrating them prior to getting into the ambulance. Nitrating is not key (as much as ASA) in your average query ishemic CP pt. Acute CHF'er is generally different given the same circumstance. SOB asthmatic who "can't walk" because they are SOB? Same assessment, vitals, +/- EKG and say a salbutamol tx on scene. Wait the 10-15 mins. You feeling better? Can you walk? You want to go to the hospital? Ok, we'll help you walk out to the stretcher... Also FYI, I usually do not start an IV on your average asthma/COPD patient unless I anticipate issues.

You guys can refuse to prescribe medications to HIV/HEP patients prehospital in the USA? What medication can you prescribe to the normals? What a country... :wink:

Even without any cardiac monitoring at all and simply by going with your history as stated and vital signs, an inferior MI +/- RVI is reasonable. Add to that the fact you have a 12 lead (that showed acute inferior MI) and did V4R (with ST elevation), diagnosis becomes significantly more solid. There is this new fangled (yes I said fangled) drug called ASA. Funny enough it is actually the BEST medication that most can give prehospital for these kinds of patients. ASA actually reduces mortality, nitro (regardless of patient) and analgesics do not. Can't get an IV? Meh, I would be quite cautious anyway with SL dosing or morphine/fentanyl. Fluids would probably be equal if not more of a concern. ASA and oxygen with a proper history and monitoring are fine.

:-s So I am humble then? Unless it is sarcasm regarding the fact that Hillary acts male or in fact isn't biologically female. Fill me in on that one. TEMS CCTU will be phased out with attrition for sure (I think there are 20 or so left), or it might be "bought out" (I'm speculating) once ORNGE gets fully implemented. These transfers are very narrow in scope, however it is a scope that is brand new and unfamiliar to basically everyone. CCP's of course can do these calls, but obviously can do many more involved transfers on their own that ACP's would never be able to do without the education, procedures, and hospital staff. It's just being handled wrong and especially the continuity of (appropriate and quality) care aspect is what bothers me most. It is kind of changing the job description (adding some CCP components) without true accompanying education and pay scale evaluation. The pay in my opinion is neither here nor there (we get paid well, but I see the point), it is the lack of proper education and patient care that really bothers me. Unfortunately, because the 12 leads are seen as the starting point prehospital, it has turned many people off of their use. That is really too bad, and things need to be looked at more closely before taking things much further.

You'd think that wouldn't you. I don't know how long ORNGE is going to take to set up there land units in T.O. But from what I understand they will not be doing these IFT's. I could be wrong however, but based on the fact we already have CCTU and they are not doing them, I can't really see how ORNGE would suddenly start with them instead. IMHO, this whole thing is being rather rushed and poorly executed, especially due to the fact that we have never done these types of IFT's without hospital staff before (minus CCTU). It's like they are seeing this as simply a 911 call that is being diverted to a more appropriate hospital. It is ruffling a lot of feathers here for ALS providers.

Within the last moth my service has decided to step into the 1990's and put 12 lead monitoring on the Zoll's (E series). This is to be a starting point to a relatively rapid progression of being dispatched to another hospital (approx 15 mins away from the core cardiac hospital for this study) to do these cardiac transfers (sans RN). Now some people may be like "big deal", but for my system any inter-facility transfer that is more involved than a monitor and observe (not continuing treatment), an RN comes along and there isn't really a true transfer of care. This is regardless of the ability of the ambulance (PCP or ACP crew, CCP crew I'll leave out). So here's the thing, while I have yet to have the CME outlining all the facets of this new "transfer system", I have been told a few things. The most surprising and head scratching is this... We are not being educated on the use of pumps at any point in the near future (no ambulance service in Ontario uses pumps without an RN). If this cardiac patient is on a nitro drip or dopamine pump this is apparently what will happen: The hospital will discontinue the pumps and we are to continue nitrating the patient with SL nitro spray. The dopamine pump will be discontinued and replaced by a buretrol on our end... Now I don't know about you, but this sure as hell seems much more risky. I think it is safe to say that a nitro pump running at X mics per minute via IV is a hell of a lot more predictable in every sense of titration, absorption, distribution, etc... than (maybe) a 400 mic SL spray where the absorption, distribution, etc... is much more varied. The same can obviously be said with dopamine. Eye-balling that 5mc/kg/min on a buretrol and bumping down city streets is hardly the same accuracy one can assume with a pump. These are the two main examples that I have heard given. I am quite concerned. This isn't some rural or smaller service either. This is a very large (300k+ call/year) municipal system. I think we may be getting a touch ahead of ourselves with these transfers and good, safe continuity of care. Has anyone heard of similar in yours or another system? What is your opinion?

Three weeks was way to short. Six months full time is a touch long in my opinion. I'm not saying it's a bad thing, just long. I believe the CMA standard is a 40 (maybe 50) shifts precepting ACP. BCAS is basically doubling this. Most of Ontario does the 40 (or 50) shifts, while my service does 60. We also have 40 shifts of consolidation (supposed to work with another ACP) following successful completion of final ACP testing (OSCE). The weird thing is the BCAS requires this 6 month mentorship for out-of-province ACP candidates regardless of experience working as an ACP. Again, not necessarily a hugely bad thing (you have to get to know the system), but it may become a little tedious being "mentored" by someone for an extended period of time after your own X antonymous experience. I've heard I may have to redo my applications to BCAS again (I was granted equivalence) because I've procrastinated for so long? Man that may suck, guess I should give them a call... PS - I have heard that BC ACP's are basically not supposed to do any lifting. Is that true? The whole white shift uniform thing may still be balanced against other things if the former is true...

http://www.snpp.com/episodes/3F15.html

I think the fish distracts me... EDIT - I was going to make a Simpson's joke regarding Troy McClure and his fish fetish, but nobody would get it. If anyone remembers the episode or has any idea of what I'm talking about... Kudos... PS - Canadians are still right on this one...

Are you able to provide a link or reference that explicitly states for MI EMS that you cannot stop under any circumstance (save for I assume an accident/vehicle failure) while transporting a patient (regardless of acuity)?

Come on Scara, yes of course you would stop and get out if you had a critical (I'd call a cardiac arrest that I am actually transporting, critical) patient :roll: . Come on dude, absolutely not the same thing. Twenty years on and never experienced the above? Less than 5 years on and experienced basically the analogous twice...

This thread is still going? I just want to be clear on the "stopping is wrong" people's opinion. You are an ALS crew that just picked up a 30 year old businessman, who is a baby and called 911 because he slipped and fell on the ice. He cannot weight bare and is put on your stretcher. His left ankle is pretty banged up, maybe query fracture, but he is tolerating things well with a splint and some ice. As you take your leisurely drive through the city, discussing the finer points of investment banking, a rapping comes upon your window pane... You - "Hark! Thou hast startled me citizen!" Citizen - "Ya ambulance man, someone collapsed over there..." On the sidewalk, 20 meters away you see chest compressions being performed on a middle aged female. Do you: A) Tell the citizen that you have a patient and that you will call your dispatch and an ambulance (quite possibly BLS) will be around ASAP (perhaps 10 mins). Don't worry the fire department might be there in 4 minutes, may continue doing what your doing, but will not be transporting and generally will aid via the stare of life (kidding guys). or Tell your partner that it looks like somebody may have arrested on the sidewalk. Call dispatch and ask for fire and another unit. Get your defib and drug bag and walk the 20 meters to the patient (who is in cardiac arrest btw) and leave your partner with Johnny Kneepain in the back. Fire arrives in 4 minutes (the boys are good) and assist you with CPR. A PCP (BLS) ambulance ends up arriving in 8 minutes. You direct one of the paramedics to the back of your unit, and your partner swaps with her. You package up your patient (following a ROSC on the street, cause your wicked awesome), switch off patients with the PCP crew and take your ummmmm significantly more acute patient to the hospital. Think that doesn't happen? I assure you it does... Again as long as your initial patient does, 1) not require acute intervention with EMS or in hospital. 2) not remain by themselves in the ambulance with a provider that cannot adequately respond to their needs. It is not cut and dry. EDIT - I just realized something. We have the luxury of a pretty seamless hand off of patients because we are municipal and the only 911 EMS service for the city (or on the rarity of a neighboring municipal service). Could this entire issue of "stopping" be more a facet in the US of: 1) Money 2) The possibility of loosing money, especially if another service comes to render care 3) The lack of continuity of care should you hand off your patient, especially when another service (for profit) comes to back you up on the above call