TechMedic05

OH... that's harrassment right there. I thought that maybe you thought that maybe this was funny...THAT'S DEGRADING...

Not only is it degrading, but I think you missed the basic bashing I hid in there, as well. You're a smart guy, you'll find it.

In other words:

GUILTY AS CHARGED. :violent3:

Not safe for work:

New definition for 'Road Head', I guess.

What's the transport time? Has the bleeding been stopped prior to arival or is she actively bleeding? What are the capabilities of the on scene crew, if BLS will waiting for ALS be too long?

Since starting an IV on this patient opens the chance of another bleeding site, why??If as you say, lotsa heparin. Plus What fluids and why?? What will a crystalloid accomplish and if too much, hey she has kidney problems, right??

A good BLS crew could transport this pt. O2 supine, monitor( I don't mean EKG or any other machine) the old fashioned clinical skill of monitoring a patient with your eyes, ears, nose. Cave man stuff

First off, 250 NS will probably do a rather decent job at improving her orthostatic state. Is it permanent? No. Definitive? No. But will it help her out for now? Absolutely.

As far as starting an IV, why are you worried about starting another bleeding site? And besides, just because a patient has heparin [be it overdose, or appropriate] - that doesn't mean that bleeding is instantly non-controllable.

I understand not waiting on scene - that's managing a good dual response or intercept style EMS system, kudos for the thoughts!

We apparently have a slightly hypovolemic patient in early signs of shock. Renal failure aside, how sick does a patient need to be to warrant ALS treatment? Only in very few instances should travel time to the ED be an issue, as well. if they're sick, work them up. Doesn't matter how long or short of a transport, right?

Ace, I think it does! Congratulations, you've single hanedly improved EMS for the world today. In doing so, there'll be more helpful and better prepared EMT's and Paramedics to treat the carpal-tunnel syndrome that you've managed to give yourself today through all these posts.

Hi-5!

I guess GAMedic never heard of pulmonary hypertension as well. Although, that may be an indicator of CHF, not all CHF patients has hypertension when in failure, in fact most patients in sever distress presents hypotension (shift from right side to left side) and decreases the work load for about 10 minutes.

Remember the true etiology of CHF is caused by poor pump failure such as in an AMI, poor ejection fraction, which the patient may not have hypertension. Dependent on just those findings is asking to eliminate other clinical symptoms as well.

R/r 911

Excellent points, Rid!

And definitely, those pulmonary hypertension patients are rahter difficult to manage.

Above all, understanding that not all CHF is hypertensive, not all pulmonary is non-hypertensive, especially with multiple disease processes taking their toll.

Suddenly the last

all four directions

I would prefer not to intubate myself, and I would discourage my patients from doing the same.

Niiiiiiiice! 8) 8)

I'm loving it.

Although, I would like to intubate myself at one point or another just to say I could.

I know it sounds to simple to be true -- I will site you the threads you need (I am working, and do not have these stored on this computer), but its really common sense if you think about what happens to the body in CHF versus COPD or asthma (think alpha/beta) for your first clue. And I meant it works as fast as D50 in reversing the condition, not that it was a carbohydrate (and note that I said Dobutamine, not Dopamine -- many get confused by that). You will also note that I said Dobutamine for those who are drowning, not every CHF patient. Nitro is still the first drug followed by Morphine -- Dobutamine is used for those who do not respond, or who are already circling the drain. Dobutamine does not cause tachycardia -- that is dopamine (although many believe the two drugs work on the same receptor sites, they are totally opposite).

And techno, please cut back on the caffeine or increase the prozac -- you get worked up way too easy. I know it sounds to good to be true, and too simplistic, but it is, and it is the deciding trigger we have used for the past 3 years, and we have yet to be wrong. In fact, our Doctors are amazed at our accuracy in the absence of a chest x-ray.

Okay, thank you GA for making this post, then editing it afterward, and still not actually answering our questions.

I had attempted to make the point that blood pressure alone is not a reliable determinant for assessing dyspnic patients.

Thankfully, AZCEP jumped in, as well with:

"The biggest issue is determining what the problem is. Is it truly pulmonary edema? Is it pneumonia, that is moving enough air to sound like coarse pulmonary edema? Is it in fact cardiac asthma?

Too many possibilities to say that the blood pressure will make the determination. If it could, don't you think someone would have used that method already? Blood pressure will guide treatment, but it does little to tell you what you are dealing with."

And he's right-on. It may help guide, but it's not reliable to make a definite diagnosis alone, like you were suggesting with:

"You dont need any fancy machines, just look at the blood pressure."

Regarding Dobutamine - This posting by Ace844 is a good reference, which includes the following statement:" Dobutamine is a catecholamine that acts directly on the beta-1 receptor, causing both a chronotropic and an inotropic response from the heart. Dopamine is also a catecholamine that increases both the chronotropic and inotropic responses of the heart. In addition to its beta-1 actions, dopamine also works on both alpha and dopaminergic receptors."

Maybe I'm a dumbie, or drinking too much caffeine and not eating enough of my SSRI's of choice for the day, but that sounds awfully similar to me. Dobutamine appears to be a bit more selective in it's actions, not exactly "totally opposite". I, myself, am not completely familiar with Dobutamine, so I may be incorrect. If so, please correct me. Please. I hate being wrong all the time.

And second to last: "and it is the deciding trigger we have used for the past 3 years, and we have yet to be wrong. In fact, our Doctors are amazed at our accuracy in the absence of a chest x-ray"

I know I'm still new and all, but I wish I was always right.

And: Worked up, eh? A little, but when someone comes on, throws around a few numbers based on 'personal observations' and their own systems' outcomes - I want more information. Something a little more legitimate for reference would be appreciated. Not too many can jump aboard, ruffle a lot of feathers in other threads, then throw around statistics without any backing other than 'I said so' and be taken seriously, and then have the audacity to state "And yes I could give you many long paragraphs explaining why, but this thread is already too long." to say C'mon, GA. You're smart, too. Should've seen this coming.

"You are a smart guy techno, give it 10 minutes I know you will get it."

The reason why I stated I didn't completely get it is because you haven't thoroughly and adequately stated an appropriate answer, that you tried to cover with laziness. I honestly don't thoroughly believe you know exactly what you're talking about. You know a lot, sir, but some things just aren't adding up to me yet.

And the name's TechMedic05. There's actually no "n's" or "o's" in it.

Did you, or the FD request the helicopter? Quite possibly only for placing the blame, but it's a legitimate consideration.

Confusion, loss of consciousness, mechanism of injury, and the helicopter was started early, so no waiting on the ground on scene or at a 'helispot' for intercept.

We can't quarterback a call, but I don't see any tremendous issues right off. Provided it was done within your protocol, medical direction if required, etc. etc.

Where I work - most people are either "Fly right off, and get it there" or their "wait and see, and just bring to the hospital anyways" Do what needs to get done. Every system is different.

I know it sounds to simple to be true -- I will site you the threads you need (I am working, and do not have these stored on this computer), but its really common sense if you think about what happens to the body in CHF versus COPD or asthma (think alpha/beta) for your first clue. And I meant it works as fast as D50 in reversing the condition, not that it was a carbohydrate (and note that I said Dobutamine, not Dopamine -- many get confused by that).

The first half, I'm trying to follow, but sorry - I'm not completely getting what you're hinting at.

And I assumed you had meant onset - but it was not stated as such. And I think everyone knows you meant dobutamine, as myself and AZCEP both used dobutamine in our responses, as well.

Thanks for getting back to me - take your time on the information requested.

What procedures do you use to insure your blades are clean ? Do you autoclave, soak in cleaning agent, or use disposable. Would you stick any of the blades that are currently on your bus, in your own mouth. If not, why do your patients deserve less ?

We use disposables. And we're lucky enough to have ambulances.

What do you do to keep your blades clean, GA?

You dont need any fancy machines, just look at the blood pressure. CHF is hypertensive, Pulmonary is normotensive 99% of the time (yes there are exceptions, but the signs and symptoms of those ailments are far more obvious). Try it on the next few times, I promise you dyspnea with hypertension will be CHF (and no, I dont mean 142/92). And yes I could give you many long paragraphs explaining why, but this thread is already too long. Also, if you guys havent tried it yet, Dobutamine is the drug of choice for those who are drowning from CHF -- works like D50-(minutes).

NASA spent $36,000 to invent an inkpen that would write in space, The Russians used a pencil.

Hey, GA.

Use that pencil of yours, and start explaining. I want sources, legitimate sources. Now. Please.

And if you can't list sources, I want reasons why you believe so. As well as the pathophysiology that explains the 'vital signs' you're expecting.

Even if pulmonary is "normotensive 99% of the time" - can't CHF also be remotely normotensive? what do you do then?

Thread length has nothing to do with it. Longer the better, provided it's a well thought out, well written response that's legitimately relevant. Don't go being lazy and having all the people that come through here "Just trust you" because you said so, and you're too lazy to explain your thoughts, beliefs, and disbeliefs.

And if you treat your dyspnea calls based on blood pressure "99% of the time, and no, not 142/92", you might want to at least try a few other assessment techniques. Although, throwing dobutamine at everyone who can't breath I guess is a good idea, no?

Works like D50? I didn't know Dobutamine worked as a carbohydrate. Why not just give D50 to CHF patients, then?

Ace, pal.

I seriously think I just had a seizure while reading your line of animations.

I'm going to try and do it again now.

G'morning, Ace.

Perhaps we should rename ourselves...

You can be Benjamin Franklin Pierce, and I'll be BJ Honeycutt.

Nice graphic, I always knew you were a straight shooter.

I'm trying a new approach - It's called "playing nice." We'll see what it gets me. Apparantly I angered a few local squads around here at one point. Things are better - but my partner at the time made a good point: "Whenever you say something stupid, or someone's angry, just compliment them, like: "Dude, who's got that wicked sweeeet lightbar on the truck out there?" and all will be good. It's worked the one time I've had to use it.

So, yeah. We'll see if we can get Lordie there some constructive education here. Again, not out here to be the bad guy [all the time] :wink:

System-

"and I rag on the nurses.. who cares??" We do. They're professionals. In many cases they know more than you or I. We want to be professionals, too. Professionals don't go 'ragging on' nurses in forums all that often. If you don't wish to be professional, bye

"because you dont share my point of view on my own opinion is rather sordid!!! You must be the belle of the ball! " No, we don't share all of your points. And that's okay. Not everyone needs to agree on everything. Others were trying to converse about logic and reasons why someone would think that, and even a little further education. Which leads to:

"So I did my research on eclampsia...." Thank you.

" I think we can all differentiate btw an emergency where u need to go NOW.. then something where we first have to fix the problem and then go." NOW. There's only about one or two times when you need to go NOW, opposed to now. I'm thinking prolapsed umbilical cord or breech presentation could result in rather hasty transports. If the patient is already in a semi-appropriate facility [an ER] and they can effectively initiate treatment to help stabilize her for transport of any length, they should. Wait, no. They NEED to.

"We dont really use fixed wing and our helicopters are unfortunately reserved for " true emergencies " this one not being one!" If this is not a "true emergency" in this system, then helicopters must never be used there. Nobody, I believe, was trying to quarterback the call, but as far as 'sick' patients go, between mom and baby, it doesn't get too much worse in this field.

All food for thought.

"unfortunately I dont deal well with " wanker " and glib comments! " Well, when things don't make sense, and it's tough to differentiate who panicked, it happens. Thick skin. Get as much as you can. Buy, rent, steal, borrow, take, lease, obtain any way possible. And as far as ribbing goes - as mentioned - It's not so nice to rib nurses, doc's, janitors, patients - but we sure as hell can do it to ourselves. most often it's constructive in nature...sometimes.

"As I roam around the forums I do hope to learn some new stuff..." Glad to have ya, hope you enjoy yourself here! Input is always welcome, and there's centuries of advice to be given. We're all here to learn, too.

That's all. I can't speak for everyone [Right, Ace?] about not being antagonistic, but if the general consensus brings up a few good points, there's probably a good reason. That's it.

:wink:

Tech

43 year old B/F, on the 2nd floor of her residence in a rather affluent neighborhood, alert and oriented, complaining of moderate hemmoraging.

Patient began her at home dialysis treatment in her brand spanking new R arm skin graft, finished her treatment, and hemmoraged significantly (1200-1500 cc's) of a rather thin looking blood (lotsa heparin).

c/o "lightheadedness" which seems to change orthostatically. Supine in chair 134/88, 84, 99% ; Seated 126/84, 78, 98%; Standing 118/78, 76, 99%

Hx: RF, HTN

Meds: unsure

Allergies: PCN

Skin: clammy

PN: all but chief complaint.

Reports normotensive pressure 140's/90's

This go ALS or BLS? Explain your position.

XOXO, PRPG

ALS.

Borderline orthostatic [but going to assume so based on BP. Pt. may be on B-Blocker, skewing HR results], clammy skin, and lightheadedness [with the orthostatic changes] is ALS for me. I'm typically a rather conservative Medic when I triage to BLS. Honestly, it doesn't happen all too often where I currently work - It was easier in clinicals where there was a lot less true 'ALS' calls. I would not feel comfortable triaging a complicated medical patient [Renal Failure] who has an active, legitimate, ALS complaint. This isn't a bash against any BLS crew - but it's what gets me in trouble because I don't 'triage down enough' - so they say. [small, not busy service that's semi-rural...BLS wants everything triaged to them.]

Tech

soft pet chinchilla

Uh...

I think we missed some sarcasm...

maybe?

I'll go back and pick it up.

This exercise will weed-out the whiners from the dedicated professionals. Whiners will give a million excuses, and all kinds of history about why they can't or haven't caused change at their workplace. The professionals will roll-up their sleeves and fix something.

Well, I thought The City already had a system like that in place...

Dustdevil...Rid...Ace...AZCEP...PRPG...Asys...[and the list continues...]

Only because I > google - "Made"?

#1-"This is your last chance! Surrender now!"

#2- "DEATH FIRST!"

I posted a thread that asked what have you improved at your service ? After 100 views, there were only a handful of respondents who could cite any improvement. We are always quick to point fingers at everyone else in the world, when it comes to the failures in our industry, but in this area, we have only ourselves to blame. Therefore, I proclaim this challenge to each of you:

[/font:57db96ea3f] Between now and August 31st, I challenge you to accomplish ONE improvement at your service. Please inform of us of your success, through this thread. I do not care if you just retype the daily checklist so that it is more legible -- Do Something ! Test some equipment, revamp a protocol, clean that green crap out of the refrigerator, replace that "Bambi Does Dallas" porn video with a real Bambi video --- ANYTHING -- just make ONE Improvement.

[/font:57db96ea3f] Those who fail to accept this challenge, may no longer gripe about your service on this site.

Awfully demanding, must be a manager somewhere. :wink:

I can find something, somewhere. Revamp protocol? That's a lengthy process involved at the state level...Not normally on a service level.

Ill do one.

But please, GA. Don't ever slap me with a glove. Nevermind a latex glove. I have a sensitivity.

And regardless of whether people do or do not, there's always the ability to gripe about their service. Some gripe so others may learn. :wink:

I worked on that unit for 6 months. It works very well.

"Saving Phoenix 500 LBS at a time" :wink:

500 lbs? That's it? :wink: :wink:

GAmedic wrote:

How do you know that your employees educated the patient properly, and did all that they could to get an AMA patient to go to the hospital ? Is what the patient is being told consistent, by all crews, and at all times of the day or night

We cant, you just have to hope that the people you put in place reflect the practices you desire. The ones that don't need remediation or removal. This like any other field isn't perfect however our mistakes are magnified due to the consequences that could arise from our actions or lack of action in this case.

Three weeks ago I'd have never thought I'd say this...but.

Whit, I agree with you.

We can't assume that what patients are being told is consistent. Does it need to be consistent? As long as everyone covers the absolutely required minimums by your services...for example - What to look out for, multiple attempts to convince for tx, contact primary physician, and to call EMS back if worsens/ reoccurs. Granted, they need to be consistent in those aspects - but if I want to explain "Your wrist will hurt for a few days" and my partner Ace tapes 13 articles about calcification of bones, bruise formation, internal bleeding, and the possible differential diagnosis of potetially undiagnosed carpal fractures - that's fine. But not truly 'consistent'

All in all, Be smart, stay clean, and CYA.

If the AMR model is right and you only kill 1 out of every 100 that refuse (1%)' date=' that number can sound reasonable. But if you are running 50,000 calls a year, that equates to 500 patient deaths. quote']

I understand where you're coming from, GA - However your numbers are flawed. If you run 50,000 calls a year, not every call will be a non-transport. Even at, say, 25% non-transport/ AMA, your number should be [50,000 * 25%* 1%] about 125 patients.

I just saved 375 lives.

So may I now sign off people after midnight?

I believe more issues lay at certain individuals and playing number games than letting people 'sign off'.

If someone is sick, or even remotely needs to go to the hospital, I will bend over backwards to get them to go to be evaluated. I do believe also that there are patients we see who do not need to be evaluated. It's not every patient, but they're out there. Why not let them sign off?