runswithneedles

From the Medicarenhic.com website, "Ambulance Billing Guide" PDF:

"Advanced Life Support, Level 1 (ALS1) Non-emergency - ALS1 is transportation by ground ambulance vehicle, and the provision of, medically necessary supplies and services including an ALS assessment by ALS personnel or at least one ALS intervention."

I don't think a saline lock placed at the hospital counts as an intervention. According to the same PDF,

"Advanced life support (ALS) intervention is a procedure that is, in accordance with State and local laws, required to be performed by an emergency medical technician-intermediate (EMT-Intermediate) or EMT-Paramedic. An ALS intervention must be medically necessary to qualify for payment as an ALS level of service. An ALS intervention applies only to ground transports"

I still don't think if they did it at the hospital it counts as an ALS intervention. If it was, you'd need at least an EMT-I in the back. EMT-B + Saline lock + ALS1 = Medicare

O_O than

1. Im going to be in a world of hurt

2. I have countless runs ive classified as ALS I

Far as I know it's called Teratology of Fallot oh look its a case of shut the hell up and dont say things to make Kiwi look stupid

There is also a movie called Something the Lord Made about Blalock, Thomas and Taussig

At least three of the four known defects are always present; the fourth is a ventricular septal shunt which was not curable until the mid 1950s when a surgeon named Walter Lillehei became the first doctor to repair the hole and thus prevent the mixing of oxygenated and deoxygenated blood. Now, Lillehi was obviously a very smart bloke but unfortunately he was also um how to put it best, totally fucking demented, in that he used a bunch of live healthy people and anastamosed the femoral artery and vein from his patients to the healthy person so that they could act as a heart lung machine while he clamped off the cardiac vessels of the patient.

your shitting me right? He used a healthy person for a heart lung machine????

Ive watched something the lord made several times. One of my favorite based on a true story type movies.

Well, the cirilla's was nice on the outside but the skank on the inside left well let's just say, a little to be desired. errr Note to the wife, I didn't go in, I DID NOT GO IN TO CIRILLA's, honest, I DIDN't.

you mean there's a cirillas there?

It must be the Topomax making me have the selective forgetfulness that the neurologist warned me about.

my best friends mom owned the cirillas your talking about CKA

Thanks Doc, I have two chances so it's not the end of the world and if not work til I'm eek, 30 and save up large and do a four year degree in Australia.

So I am watching Something the Lord Made; the story of Al Blalock and Vivien Thomas and their surgical correction of Tautology of Fallot; it's also a PBS Documentary Partners of the Heart and it's very good

http://www.youtube.com/watch?v=llpXsaUeJp0

Thank you very much for finding this video

isnt this conditon called patent arteriosus ductus?

If you need ETCO2 to tell if your patient is not being ventilated properly, then I agree, you should not be doing vent calls. What would you do for an out of hospital cardiac arrest if you did not have it ? Just saying, Roy and Gage never killed a patient and the only technology they had was a 50lb defibrilator and a 10lb portable radio to call Dixie at Rampart.

I would like being able to have a look at what their expiratory CO2 levels are throughout a transfer. Especially with long haul transfers and have an extensive cardiopulmonary history. So once I have more training and better understand ventilatiors and settings I can (with medical directors permission) fine tune it as needed.

????????????? I agree that you cant kill a dead person with any act that you do after they are in arrest, but you have a much better chance of rescuscitation if their lungs are not full of puke, and the heart is actually getting a little oxygen.

Just a thought. But if you succeed in intubating a cardiac arrest patient that has vomited cant you use the ET tube for deep suctioning? On paper it sounds like you would get better oxygenation if you can get the gunk thats deep down in there where oral suction cant reach.(after of course clearing the gunk thats in the way of visualizing the vocal chords) And with the tube in place you don't have to worry about gastric distention (if placed properly) and more gunk being shoved down in deep because of BVM ventilations. Along with (if ROSC occurs) reducing the likelihood of pulmonary damage and pneumonia. And with Capnography should ROSC come you will know sooner.

If you ever do that I will be forced to hurt you badly. Get rid of obesity, stupidity, and alcohol and you take away about 90% of my business.

What about ignorance, denial, selfishness, greed, and complacent nurses and medics?

Is that ethical/legal? Can you intubate someone whose chief issue is agitation r/t mental illness? Very curious as to this line of thinking... to my thinking, RSI is a dangerous procedure with lots of potential sequelae involved with weaning them off the vent later, etc... can you justify it as a provider safety issue, based on those risks?

Wendy

CO EMT-B

Sounds like it is within the best interest of the patient and for the safety of the flight crew. Depending on whats the status of the cardiopulmonary system it seems that it wouldnt be hard to wean him off the vent once he has arrived at the receiving facility. And I have seen a patient RSI'ed for the reason that systemt pointed out. I can see it as a type of chemical restraint. What about something on the lines of a depolarizing paralytic and after the intubation is complete place him on a maintenance drip of diprivan ?

I do not agree with anaesthetising, paralysing and intubating somebody just because they're a bit agitated from a mental illness. Give them some ketamine and he'll be having a great snooze with none of that cardiorespiratory worry.

Can ketamine intensify psychiatric conditions such as schizophrenia? Especially since the gentleman was presenting symptoms

An INT does not meet ALS 1 requirements, if you are billing all calls with an INT as ALS 1, you will get a visit from the Feds at some point.

Not all calls are ALS I

Most we run are bls.

It was billed ALS I because the patient had an IV saline lock which according to medicare guidelines qualifies as ALS1. However, not all emts are allowed to take these and bill them as ALSI. The reason why I could was my supervisor selected me and two other emts who are paramedic students and had an instructor put us through additional "training" and our medical director signed off on it.

. But again, to answer all of these weird freak occurence calls, you should always have on-line Medical Control to hash out these problems. I wonder if a manager was involved, I may have missed that part of the conversation.

My manager was driving and lead emt on the box. (EMT-B not P)

IT's all them damn drug seekers that makes the US health care system so freaking jumpy

which now days is starting include the very medics, nurses, and doctors, administering them

I have not seen faked injuries in a long time, but I have seen a lot of faked pain, but I just realized how much that has dropped off since the "pill-mill" pain clinics have flourished. Guess they do not need the ER as much anymore.

Pill mill?? Never heard about them. Do enlighten me.

Sorry it took so long to get back to my post

First car was a 2003 chevy trailbazer that I had in my family since I was 12. Then I got rid of it because gas sucked. and now I have a 2000 buick lesabre.

As much as I like the Lifepak 12 it's bulky and somewhat awkward to use and store; the LP10 is a much more practical shape

I have to admit the NiBP, 12 lead ECG (although you could do a 12 lead with a 10), ETCO₂ etc are nice

I know for a fact that I will never commit myself to transferring a intubated patient without ETCO2. Had a close call that wouldve been prevented if that was utilized during a vent run a medic took. I like the zoll just because its what im used to. To me it just looks less intimidating.

If that Lifepak 10 comes with a taco then where do I apply?

I miss the LP10

funny as much as I bash it...its whats I used to perform my mega code for my ACLS cert. they are nice but I like my Zoll M series

Unfortunately here are the 5 choices I have for employment within a driveable area and still make money

Names of the companies will be changed so I cant be hit for slander. (not sure if I can be but Id rather be safe than sorry)

Taco Med- Contracted with a nearby Level III hospital. Their equipment/protocols are crap (lifepak 10's, trucks are either broken or on the verge of exploding, same protocol book as ours, and equipment is always breaking and never fixed) 99% of their ENTIRE call volume is discharges and ITFT within 10 miles of their contracted hospital. Hell even a basics skills will die there. Management treats their emt/medic staff like ****. And they pay less.

Big city FD #1: within driving distance. dont have my fire cert so ill have to be a cadet which hours are limited to 12-18 hours per week. I will not be near a box. I will be doing BS errands. And once I get my medic. Again no narcotics, or anything resembling a decent protocol book , very similar to ours with the exception of adenocard, amiodarone, and terbutaline on their drug box. And having worked in private for a year now. I learned they think they are better than private medics because they are one the frontlines of real emergencies. (should've put real emergencies in quotations) And with my mouth I have no doubt that job will forever stain my resume. But more importantly. No box time. They run almost 100% medic& medic boxes. The few who are emt-B's or emt-I's are firemen.

Big city FD #2 Same as above and since its in the same town as my current employer same stuff applies as above. And despite having diazepam, and morphine theirs not a whole lot of difference between the other FD as far as me staying there after I become a medic. But most importantly, no box time as a EMT.

PB&J ambulance: Haven't seen there protocol books (applied there Thursday and they wont let me see them unless im already hired and doing the orientation process.) But from friends they are amazing as far as equipment and truck maintenance. The NICU team almost exclusively uses them. I have heard they are very progressive with their protocols and they do quite few complex medical runs because they have the equipment. First time I applied with them when I just got my EMT I never heard back from them. I heard its because i'm not 21 (so I cant drive the trucks) and i'm not a medic (which if I was a medic and not 21 they would've just put me in the back every shift.) But now Im trying again hoping that being pretty close and already having 1 year ITFT with my ACLS, ITLS, and PALS they will consider me.

The fifth one is the one im working for now

@ mikey medic. There is excessive pain involved with it. It requires pain management and LOTS of it. Also pt had a saline lock which under medicare standards does qualify as ALS I.

You know Needles, it's easy at this point to think, "what a bunch of assholes! I was in a tough spot, you don't know what it was like!"

If I had any thought of this. I would have already removed myself from anything that involves responsibility. That would display horrendous ignorance. Im here for the criticism im receiving on this post. Its this that helps me become a better EMT and hopefully a damn good medic. I want to be a medic who covers my ass and is a patient advocate. I want to to do whats right for my patient and if its not viewed as favorable by my boss I want to have something in my hand going into her office stating "I made the right call for this patient and you cannot fire me for this". And paramedic mike, dwayne. I know your not busting my balls. How can I grow up to be a better EMT. And having replayed that run in my head my service not only failed her but I did as well. And having a mother that underwent 5 abdominal surgeries and got out of her 6th this afternoon I am very disappointed at myself.

I feel like rocking the boat. I wont stand to see another human being in agony or risk transporting a patient that can potentially need something I dont have. Theirs another service I will go apply for tomorrow and from what ive heard they are a bit better.

Something my boss understands very clearly is bottom lines. And I know ambulance chasers love to dig into bottom lines. Can lack of proper equipment or supplies and still taking a patient be a potential lawsuit and is their anywhere where I can find statistics of the total costs of lawsuits in a certain occupation.

And something my boss likes is more money. Is their resources where I can locate utilization rates of medications, cost per unit and reimbursement rates for each medication used. If the medicare/ medicaid/ private insurance rates fluctuate due to administration of medications used enroute.

Also since some of the medications used for pain require special licenses required by the DEA. Where would I go.

If a emt-b can manage this company doing over 300+ calls per month. An emt-b should have no problem doing the necessary research and compile it into a document or powerpoint to present to the owner and medical director (if im lucky for him to stop by)

If I was your patient, I would be talking to an attorney.

And this is the point I can kiss my license and what part of my ass is left goodbye.

Some confusion here. I'm post #13. I didn't call anyone Mike.

As an odd coincidence, my name isn't mike. Although this furthers my personal belief that everyone in EMS is actually named either Mike, Dave or Shane.

I didn't refer to anyone "maturing" either.

My post was directed towards runwithneedles, and wasn't intended to be offensive. All the best.

And I didnt take it offensive at all. More like constructive criticism.

I thought you were referring to me needing to mature.

Funny you should mention mike. I had three other guys I used to work with name mike

Nope. I prefer to stay in my little dust bowl.

What do you mean, exactly, that ALS boxes don't carry pain management? You guys just don't have any pain management protocols period? I'm so confused.

Wendy

CO EMT-B

This company's protocols have nothing for pain management.

No narcotics

No benzos

No non narcotics

no NSAIDS

just the basic bare bone TXDSH required drug list (ASA, atropine, epi 1:1000, epi 1:10,000, etc)

regardless of what kind of truck it is we dont carry anything to alleviate pain

I dont understand why you would be angry at management, as it the fact that you are BLS and not able to administer the meds under your license right. If your ALS dont have pain meds in their tool box why are you going for it should it not be one of them.

Happy

Im upset they sent me to get this lady and she needed it and the dispatcher didn't relay that info to me. And at the time I didnt know if I could turn this down and not be written up at work. The best I could do was get the transferring facility to load her up on pain medication and pray for the best. Which didnt work unfortunately

I hate being a ******* EMT-B. Capt If I had known I had that option to call for an als truck I would be too scared shitless to do so since it was my supervisor/COO (emt as well) that was driving. I wouldve had him and the CEO up my ass in a heartbeat.

That run made me look like an ass and a useless tool.

Good thing mine is as clean as a whistle.

Thank you very much for the heads up

I completed a 5 hour trip to dallas with a patient that had a small bowel obstruction. My box carries nothing for pain to begin with and the patients demerol wore off about 1/3 of the way there. Since we are a basic crew I didnt even have a medic who could stop in the next towns ER to pick up a DR's order for pain meds. This woman was in tears the rest of the way 3 hours and 45 minutes to be exact) and the following morning was just about to bust down my managers door about to spew fire. But instead of being a thorn to my managers side I figured I would take a more constructive approach to the problem. I want to begin doing research for cost effective pain management for patients that fit the EMT's scope; what kind of paperwork/cost/licensing would be involved and each interventions effectiveness.

But since im doing the research I might as well present addtional interventions for the medic as well that are cost effective. Since ALS boxes dont carry pain management either.

Where do I begin? What would you recommend? How do I present it to give me the max possibility for it to be implemented. And who do I present this information to?

I will be doing that capt.

Then you come home, take the streets with you, and end up treating your family and the people around you who love you with the same indifference.

That actually happened to me after this post. I shouldve mentioned that this run took place nearly a week ago and im only posting it now because its been hectic between relationship, family issues, schoolwork, and work. What kinds of ways are there to prevent this from happening.

The feelings did hit me. But Im feeling for the children and his family. Prior to having the monitor placed on him I thought to myself "good quality chest compressions and early advanced life support will bring this man back". I was hoping to see a v-fib or a v-tac that after a one or two rounds of the defibrillator would put his heart back in order. He would go the ER, get admitted for a few days, and hopefully I would see him be taken by the company I work for to attend rehab where after the completion the program get his life back in order. I truly hoped my first code would be one which the patient would live. Especially for only being in his mid 30's. I became angry for letting myself believe that. Even with him being in asystole from the time of arrival on scene to transfer of care.

that would be me. Since hes referring to me maturing.

At least you should remember one thing about overtime, especially on paid services: "Ka-ching, Ka-ching!"

amen to that. since the run I did to dallas on thursday was a unscheduled ALS I instead of my regular pay of $12.00/hr I was making $15.00

Still missed a date and almost missed my PALS exam that morning

Did you feel that same indifference towards this patient's kids? Did you think that it might be good to get them out of the room while you so indifferently pounded on this guy's chest?

answer to question number one. No. I felt horrible for the children. During that call I followed orders and thats all I did. No freelancing. Second. I was ordered to do chest compression which is what I did from the time patient contact was made to the trasnfer of care at the ED. of course taking out time for my preceptor to attempt a intubation and me placing the combi tube. The family and children were asked to be outside (or so I think) which they so happened to be in the yard which they wheeled him out to

You're not there to judge. And perhaps you didn't.

I in no way shape or form condmened him for his actions. However I was pissed at the selfishness involved with the addiction that took his life. Those kids ill live with them memory of seeing their dad die and me doing CPR for the rest of their life. It could even change who they will be later and who they are now.

But what you wrote here makes it sound like you did.

I did alot of stupid things and had some very dull witted moments prior to falling asleep in my bed after a hectic 42 hour run and run shift. This poorly written post was one of them this

This all ties in to what Ruff is saying when he says to be careful what you post. I'll add to that by saying not only becareful of what you post but be careful of *how* you post.

Because that lawyer that's reading your post will infer from what and how you've posted that you are an insensitive, uncaring, judgemental person who didn't work hard enough to save the life of the deceased. You will then have to prove you're not. That'll be hard to do based on much of how you've posted content here.

Fair enough. Youve been telling me this since ive signed on. Im consistently trying to be better at popping off my relief valve. How do you guys vent without making an insensitive dick out of yourself.

As a paramedic student I, too, would hope you'd know better than to shove anything into a patient's airway.

As stated in the post above. I felt mild resistance of it sticking the sides of his oropharynx but I never felt true resistance to the point of shoving it in

You're young. You're new to the business. There are some lessons that can be learned over a longer period of time than others. This is not one of those lessons. This is something you need to learn it now

You have been telling me this since I stepped on. And by my posts im sure you have seen a relatively decreased number since our first talk back in February . Sometimes my poor judgement or lack of gets the best of me.

Learn it. Then demonstrate you've learned it. Consistently.

Working on it.

One more question: why did you transport the body away from a crime scene?

the guy I was riding along with thought he might have a little life left in him. it wasnt my call to make since I was only a student and am in no way connected with their department or medical director

my apologies. it seems like portions of the stuff we learn is so left field its hard to find it applicable in emergency care

Had this happen to me last week