cosgrojo

Cos ......To answer the Glucagon question our standing order at the NH for low BS is give it first if unresponsive ....I aggressive treat my residents because unlike some of you guys that think that Nursing home nurses are stupid and lazy I am not...I was not trained as nurse or a EMT I to not do what is needed to save a life ...I do what needs to be done when it needs to be done. I work at a boondocksville NH and honey you can bet your sweet ass that i know what cardiac arrest looks like and how to initate treatment on it.

I did not say all Nursing home nurses are stupid and lazy, that would be like saying all EMT's are intelligent, reasonable, and moderately educated. I was not taking a pot-shot at you, I was simply making an observation (as wrong, crass, and incredibly insensitive it may have been), about many of my own personal experiences. I have met many amazingly talented and intelligent nursing home nurses in my day, who on a daily basis raise the level of care for an entire facility. But I've also seen some very bad, non-chalant care being given in a lot of these facilities. I don't know which one you work at.... who knows you might work for one that is amazing with an amazing staff.... but don't tell me that you haven't seen dreadfully sub-standard care in the SNF's in our area. You don't say that, and I won't say that I've never seen an EMT give poor care in the pre-hospital setting.

I don't know who you are.... but judging by the comment about my sweet ass.... I'm wagering you know me.... :wink:

i have seen cops and firefighters get more respect then ems.... just look at the benefits they get that ems doesn't, at least in NY. i'm sorry but cops and firefighters, regardless of their abilities, do get looked upon as more professional then us. and if you don't believe that... well perhaps you would be interested in a bridge in brooklyn that i have for sale.

I will capitulate with our perceptive difference and accept your explanation, but with one caveat... I agree that police and fire get the respect of the public and so appear to be more professional in the lay-persons eyes, but looks can be deceiving. They absolutely get more respect than us, but I don't believe that that is necessarily a function of rampant unprofessionalism on our part. I believe there to be many contributory factors... in fact I believe that there has been some extensive threads on this very subject in by-gone era's (ie. 2 months ago).

On a lighter note.... despite our partial agreement.... how much for the bridge?

Is the patient on fire, or what? :?

Seems like every text I have seen in years very clearly says "dry sterile dressings."

If you have an isolated, minor burn area, then cooling is a valid option. However, removing cream would not be part of the plan. However, when you describe "a good portion of his body" being burned, attempts to cool the patient are likely to result in profound hypothermia. Not a good idea. Morphine would be a much better plan.

Mmmm... Morphine. (insert Homer Simpson gurgling)...

Ridrider and the rest of you- Thank you for posting this information. I never looked into the pathophysiology of the trendellenberg position, but I have had an on-going disagreement with a co-worker about this very subject. My co-worker is an intermediate that truly believes in the motto BLS before ALS, and will many times stop doing advanced treatments because he feels the BLS is sufficient. The one I have disagreed with the most is his assertion that trendellenburg is just as effective for the ride to the hospital as fluid replacement. Now I know why it didn't seem right to me.

I suppose that I have been too lazy to look it up for myself, but what incentive do I have to look things up? You guys answer all my questions without the research!!! Thanks!!! :oops:

The best part was he lived up four flights of stairs and everytime we tilted the stairchair back he would scream and flail around as if we were twisting his head off. Eventually we got him to walk down, albeit very very slowly. Thanks for the help!

Juilin

Stair Chair straps go over the arms, stops them from reaching out and flailing. Oh, and Real tight. If they kick with their legs, tie the legs to the chair with a flat sheet and tuck the ends in so they don't trip you. Safer than walking down stairs with unpredictable patient.

Sounds like you have a good head on your shoulders. The advice given by those ahead of this post are right on. Focus on everything, write down everthing, assess everything, report everything. Eventually you will be able to do a detailed assessment on someone passing you in the mall. That's when you know you have major issues....

Just remember... you don't see police officers that don't know when to arrest people... you don't see fire fighters that don't know how to fight fire... we're professionals and, unfortunately, we sometimes have to prove it to the communities we serve.

I couldn't disagree with this statement more. I agree with your ideals, but if you think that PD an FD are completely educated/professional/competant, then I have some real-estate in New Orleans to sell to ya'. Maybe everyone in NY is top-notch, don't know, never worked there, but I have seen some major bafoonery on the Fire and Police departments where I live and work. PD and FD have better marketing machines, that's all. They have all the same problems we do, just a bigger budget to hide them.

Our new friend is just that.... new. Allow him to grow, learn and understand. We all have come into our situations under a variety of circumstances. I hazard a guess that your view of EMS, and your subsequent knowledge of EMS, has changed dramatically since you were new.... you just didn't have an open forum to announce your FNG status.

Dust- Agreed, on every level.... arse suckers....

"Seacoast dispatch dispatching XYZ ambulance to 123 Hippaa st. for the 45 year old male with right foot stuck in snowblower."

2 minutes later...

"Update from scene to responding units..." (giggling) "the foot's no longer stuck....."

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"Please start priority 3, non-emergent to 123 Hippaa St. for a man having problems with his penis...."

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Dispatch: "Take the response into the Reservation for multiple trauma patients."

US: "Could we have an address for this incident?"

Dispatch: "Uhhhhhhhh.... No."

US: "What?"

Dispatch: "Sign on with fire for the rest of your info."

-after we called fire-

Fire: "Uh... we have no knowledge of this incident, sign on with your own dispatch."

If you decide as a BLS provider that you need to go code 3, or priority 1, you should consider calling ALS just for CYA. Call them, even if you know that you will get to the hospital before they intercept with you. Ask them their ETA, when it's more than your transport time, cancel and say you are going to the hospital. You made the right decision, just didn't cover your bases thoroughly enough. It's sad that we have to justify our decisions like this, but we are constatly under scrutiny, and we need to accept this and play the political game along with everyone else. I know I've done this same thing before. I still feel to this day I made the right decision, but was yelled at just the same for not calling ALS (we were less than 1/2 mile from hospital). Just cover your a$$ and when you get questioned, you'll have an acceptable explanation to the people who ask.

Whacker: (noun)

(see also: Fredwin, Hoopie, Randy Rescue, Willy-Whacker (m), Wilhelmina Whacker (f)

An EMS enthusiast. One who delights in all manifestations of emergency services, including fire, police and ambulance operations. Can be identified by multiple antennae sprouting from their personal vehicles, as well as extraneous lights, including halogen strobes and LED's. Can be identified at night by the faint but ever-present sounds of their scanners and portable radios sounding in the distance. These scanners, like lullabys for infants, are necessary to induce sleep.

At this time there is no known cure. Doctors are working on a vaccine, which sadly will not halt the disease, only slow it down.

*Not an original* this was created by one of my co-workers and has made the rounds on our company fax machine to all our stations. I saw the thread, thought I'd pass this along.... I laughed my buttocks off.

This sums up my point beautifully. Go on, read it again. And then consider a number of things that scream out to me from this piece:

1) 4 hourly signs are not the norm in any Nursing facility, if you're that ill you need to be elsewhere i.e. in hospital. I believe that's the reason why you were there.

2) So you ask for a DNR, and because the nurse in question can't produce it there and then, you decide to totally ignore him/her. Potentially also ignoring the wishes of a dying man. The man had been in that condition for some time, you could and should have waited for them to find it. I find it arrogant that you can't find the time to listen to staff at the home and felt that at that time they had no more useful input.

3)"an 18 gauge in th eleft arm and a 1000 bag wide open" Yes, but did you guys hold the man's hand and talk to him?

4) Despite the EMS heroics, the poor man died 2 hours later in a strange place full of strange faces........

This is not a personal attack, I would just like to offer a different perspective on things. I genuinely believe that the job would be made a whole lot easier if we just listened to one another instead of just bitching. There is no excuse for sub-standard care in any field of healthcare, but just because a nursing facility doesn't speak the same language as an EMS crew, it doesn't give us the right to stop listening to one another.

I wish you all a very fine day from a very sunny (but oh so cold) Holland.

Carl.

As I'm sure you can appreciate, my telling was not a complete and comprehensive report of the incident, only a highlighted section to point out the problem we had. Before going into the room we attempted to get report. Actually sat there for 5 minutes trying to harangue a report out of the staff. They didn't know anything, and didn't suspect anything more than a foley change. We had already wasted enough time trying to get a report from these people, when we saw the condition of the patient, we were not waiting around for them to find some paperwork that may be buried in the lower level paperwork bin. Furthermore, by the time we got packaged and rolling toward the elevator, they finally got the paperwork and handed it to us on our way out the door.

We didn't do anything that violated the DNR. We took a 3 lead strip and established an IV for our low b/p, dehydration pt. I think well within our scope of practice. We didn't do anything "heroic," just followed protocol. And yes, if the man was conscious and able to look at us or show any sign of life, we may have taken an opportunity to hold hands. But he didn't look like he was in a hand holding mood. Non-verbal, delirious patients aren't good at fine-motor activity and heart-felt conversation, sorry to dissapoint.

Strange faces? The point is, that if the nursing home recognized the problem as for what it was "yesterday," the patient would not have died at all! He would have lived and not suffered the pain and delirium that he had in his final two days. Don't forget the part where I said this patient up until a day or so ago, was talking and coherant.

Oh and as it may not be policy to take vitals every 4 hours.... if you are sending a patient to the hospital, I would think that you might want to evaluate the patient before they go. You know..... because, they are going to the hospital..... and patient conditions change..... and well..... they are going to the HOSPITAL. Not staying at nursing home without complaints..... hospital.... a set of vitals would be appropriate.

Maybe my bare bones account of the story made you think that we neglected being kind or compassionate to the patient. Let me assure you that that is not the case, I was trying to stick to the basics so as to create a readable post that illustrated a simple point...... Some times we see stupid things and experience things that make us sad, and this was my way of constructively venting what had happened. Telling these stories can be cathartic, and I was just getting it out of my system. But don't turn this into a EMS doesn't know how to communicate thing, the nurse at the home wasn't speaking any language. It's not that we weren't listening.... they weren't talking!

Cold Scoop Stretcher? Folded bath blankets on either side... provides comfort and warmth (and cuts down on the "pinching affect").

Hard time finding radial pulse? Use three fingers instead of two, vary the pressure of your fingers like you are playing a piano until you find it. Also, elderly people with osteoporosis or rheumatoid arthritis often times have bone deformities that actually shifts the location of the artery. I've found some pulses half-way up the forearm on an extremely deformed patient.

Nasal cannula for eye irrigation.

Towels for padding when using the KED, instead of the stupid unuseable padding that is provided.

ALWAYS have extra towels.

Nail polish stopping your SPO2? Turn the probe sideways, don't fool around with the remover... Oh, and if the pulse-ox isn't reading, try using the pinky. It's the least used finger and has far less capillary bed damage than the others.

IV tips. Put tourniquet close to where you are attempting the IV. So if you are going for the hand, put the turniquette on the forearm. Vein not popping up with normal means? Try a hot pack over the vein, causes vasodilation.

Navigating for your partner while responding to a scene? Call out the last 3-4 roads that come up BEFORE the road you want. Allows your partner to be more relaxed and visualize his path better.

Lock yourself out of your car? Steal a B/P cuff off the Amb, slide it between the glass and the rubber, pump it up, then use a coat hanger to get the latch. It's like using cricoid pressure for a tube, allows better visualization.

Hope there is at least somebody who doesn't already know these....

Agreed... not uncommon, just the most recent one I have to share. If we all told our bad NSG home stories, we'd shut down the site with overload.

Joshua was killed by Indians while on a surveying expedition in Kentucky

Well..... I guess ya' gotta go somehow.... Killed by Indians is pretty distinguished, I think...

Got called to a nursing facility today for a priority 3 patient that needed to go to the hospital for a foley catheter change. The facility took a 1 hour ETA because they stated that it was non-emergent. Facility states that the patient was evaluated by an RN and he simply needs his catheter swapped out because he isn't voiding. We arrive on scene, get report (not a lot, because the nurse hasn't actually stepped in the room to see the patient), and then go see the patient. He's purple, mouth open and snoring, eyes unblinking, staring at the ceiling. Urine in foley is grey and clumpy, has been for many days. Foley hasn't been draining, they tried flushing it once.... got some blood clots to drop out (yesterday), and waited to see if it got better.

I ask, "Is this his normal color?"

RN replies, "No."

I ask, "Is this his normal mentation level?"

RN replies, "No, he's demented, but normally speaks with us."

I ask, "When was the last time he was able to speak?"

RN replies, "Yesterday afternoon."

I think, "Crikey!"

I ask, "What was his last set of vitals and when were they taken?"

RN replies, "116/72 with a pulse of 76, temp of 99.6, 94% RA....... and that was at 0845."

Well it is now 1230..... We take vitals... 60/40 with a pulse 136 weak & thready (carotid... no radial pulse attainable), temp 102, 88% RA.

I ask, "Does he have a DNR?"

RN replies, "Why?"

I reply, "'Cause we're gonna' need one!"

RN: "I think so... let me check..."

Me: "No time... bye."

In truck, partner puts an 18 gauge in Left forearm and a 1000 bag wide open. Dump the whole thing into him in the 4 mile transport, B/P got up to 70/46. BS of 511, 4 lpm got him to 94%. Monitor showed rapid A-fib.

In ER, they dropped another 1000 bag NS, B/P still <100 systolic. His color is better, he isn't as hot and flushed, he's started to blink his eyes. Talk to MD, he asks me about DNR, I say maybe... He smiles and says, "Foley change, eh?" (and no, I don't think he's Canadian.) I reply, "Run 'o' the mill Doc..." Doc says, "He's not leaving this ER alive..." We shake our heads simultaneously and pray that our loved ones never end up in that place.

And yes.... the man died 2 hours later.

I dont know Dust, from where I am looking it is a BLS call for me........

If I was the incoming EMS I would not question the Tx that you have initiated in the LTCF. Unless you were trying to give oral glucose to a Pt with decreased LOC (we ahd a call like that not too long ago).

The only question I have is why would the Glucagon be given before the D50? Our protocol calls for Glucagon to be admin after 2 failed IV attempts.

I agree canuck, our protocols use Glucagon as a last ditch effort to oral glucose or D50. Takes too long for it to work IM. That's the only thing I don't understand. I think that it is great that someone in a long term care facility would take the initiative to go and agressively treat a patient under their care. Up in boondocksville NH it's hard to even get these places to recognize cardiac arrest!

16 dollars an hour for BLS starting pay? Is that normal for PA? It seems extremely high in comparison to Massachusettes who starts at 12 an hour... hmmmmm.... so you are giving preferential hiring treatment to fellow emtcity.commers? Right? :wink:

You're kidding me right? CPR on someone with a pulse? If you can palp it, you don't compress it! Isn't that what all the AHA/ARC guidelines are about? Airway Breathing Circulation... under Circulation, you only begin compressions if the patient is *pulseless* and apneic!!!! Or did I miss something here?

Eydawn

NREMT-B

Unless it's a child or infant... AHA guidelines state that a person under the age of 8 years old who in not responsive, not breathing with a pulse rate <60 should receive CPR with a goal compression rate of >100 per minute. If the scientific evidence is pointing in that direction for children, who's to say that in a couple years that doesn't become the norm across the board? It's not like CPR rules change very often right?

If I came across an elderly pt who was unresponsive, not breathing but had a pulse rate of 20 and weak.... I might start thumpin', why not? won't be long until that 20 goes to 0. If the pt went into resp arrest, it takes some time for the body to decompensate, just ventilating isn't always the answer. Every situation is different.

What I found shocking about the post was that someone actually saw a nursing home RN do CPR!!!! Amazing!! In all my years....

My service has both short spine boards and KEDS on our trucks... We don't use the short boards very often. I personally like the KED and feel that if properly applied, the work great during stable extrications. There was another thread about c-collars recently, and I think most will agree that they are not perfect and sometimes a bit of creativity is needed to secure the spine.

As for a pt getting a collar without a board... only if pt refuses... If you can't think of a scenario where you could get a collar on someone before refusing the board, I submit this experience:

My very 1st MCI on a I95 in Eliot, Maine (right on the border on NH). We got sent to a bunch of cars that piled up. The car we were triaged to had very minor injuries. Mother, Father, 2 children in car. Mother got her head bounced off the steering wheel, complaining of mild neck pain. Manual stabilization in the car, Mom's tolerating it well. Put long board under her butt, spin her onto board. Little child calls out for mommy. Mommy can't see child because her face in pointing straight to the heavens. Mommy freaks out. Mommy becomes irate, wants nothing else in this world than to be able to look at her kid while she's in the ambulance. We explain that we need to get her on the long board and secured or she could possible have some irreversible c-spine damage. Mommy says she doesn't care. Mommy VOLUNTEERS to fill out any form that we need in order to stay off the board and in a sitting position. What can we do? Sign here please. Hold her head and try to get her not to move (wasn't happening). Who were we to force mom to not be able to see her kid? It went against all of our training, but we had little choice.

Weird things happen, we can't afford to live by absolutes in this field. Each situation has different obstacles, and different solutions. It's our job to come up with those solutions within the framework of our training and protocols.... and sometimes we are not allowed to solve. So be it.

Some people already stole what I was gonna say But I'll reiterate anyway... In the beginning, don't bother doing your own billing and auditing, hire that out. It will become too much at first, unless you have the capital to hire your own staff to solely handle these jobs. It is easy to do the insurance and medicare/caid stuff wrong, and easy to get caught. But as you get bigger, and have more resources, you will definately want to move it in house at some point. Your job will be daunting enough (not that I need to tell you that), try to keep it simple, rely on companies that can keep the minutiae off your plate.

Good luck! I'm sure you will do well.

Chronic Renal Failure.... Reason why people need dialysis. Kidney failure. Kidney's totally unable to filter the water in your body, causing inability to urinate, retention of fluid in your system.... overall bad stuff. There are fluid restrictions on these people. Too much fluid=death.

Jesus... I absolutely stink at trying to figure out this "Quote" thing. Is there a tutorial to help me not suck so bad? :oops:

And the monetary concerns are bogus too. You don't see the county or city running any other positions or services with volunteers, do you? There aren't any volunteer city secretaries, water engineers, mechanics, road maintenance crews, janitors, or lawn mowers are there? The police and sheriff aren't dispatched by volunteer dispatchers are they? Do you think the school bus drivers get up at 0500 everyday for free? Hell no. Yep. There is money. Plenty of money. They just don't think YOU are worth it. And you know why? Because any idiot can pass a 120 hour EMT course. And more than half of those that do are perfectly willing to work for free because they think the lights and sirens are cool.

That last line is priceless! Very true, and very sad at the same time. You are 100% correct in your "outside the box" diatribe against rural EMS. What I'm waiting for is how we are to affect this type of change? Please, I implore you to put it all on paper, or post it here so that we can all hit our print buttons and submit it to our legislators at our next podunk town meeting. And don't give me the "we all have to prove that we are worth it with educating ourselves higher than the standards," because we get educated to the level we are asked to for what we need to attain. How are we to change the parameters and regulations to make the EMT's become more educated? Answer that, and show us how to implement it, and all our problems will be solved. Don't worry, we'll give you the credit.

I find that the adjustable collars run a little smaller than the old "pick your size" collars. We carry both. A large person with a no-neck size... won't even try the adjustable, just get me the regular no-neck. When that don't work... like others have said, be creative. If it works, it works. Also, don't be afraid to re-adjust. if you get it on wrong the first time, go ahead and get it right. Just make sure someone still is holding it manually. :wink:

Pose, Congrats on it all working out! But I will caution you... right now it's working, next semester you may have a problem. When I was in school, I had the same situation as you. Paying for myself, living off campus, no family around... What I did, was focus on working, doing just enough to keep the grades where they needed to be for my financial aid, and try to get the bills paid. As a Economics guy, you will understand what I mean when I say this. Be careful of what you are giving up. There is an opportunity cost to everything you do. Try not and sacrifice too much school for work. That's what I did. In trying to keep myself out of debt, I didn't do an internship, or get any experience in the field I was studying for. So when all the work was done, and I got my diploma, I wasn't marketable. No internship= no experience= no job prospects in the field of choice. If I had it all over to do again, I would have taken out more loans, ratcheted back on the work hours, and focused on the future, and not the larger than life present. Good luck! Hope everything keeps falling into place for you.