pyroknight

I had an "oops" several years ago that I did not realize was my fault until I took a paramedic refresher a few months ago. I walked into the house of a chronic COPD/CHF patient. My partner had been running EMS in the county forever and had run on this patient multiple times (the patient was the mother of one of the volunteer firefighters present, no pressure, lol). I was inclined to initiate transport and treat enroute, but my partner wanted to try a nebulizer treatment on scene first. The patient was not really wheezing, but I have had patients who stopped wheezing once their air movement decreased to a certain point. We provided the nebulizer treatment and the patient appeared no better. As we began moving to the truck, she started looking worse. Halfway into a 45-minute transport, the patient became unresponsive as her sats continued to nose-dive on 100% by non-rebreather. We wheeled the patient into the ED while providing bag-valve-mask ventilations. She was intubated immediately and proceeded to gush a beige-colored liquid from the ETT. I visited her several days later in CICU. She was not out of the woods, but had been extubated and was moving in the right direction. She survived to discharge. What I failed to appreciate was that CHF patients sometimes have a compensatory bronchoconstiction. They are basically giving themselves PEEP. They are attempting to keep enough pressure in their alveoli to hold out a tidal wave of edema. When my partner bronchodialated this patient, she could no longer hold back the fluid. I had always considered albuterol virtually harmless unless a patient has an allergy to the medication. I will never look at a CHF patient and think that again.

Okay, I support the premise of NIMS, I really do. I spent a week PLUS of my life getting the training necessary to be an ICS-300 and 400 trainer. Some of the information is good information (some of it is federal CRAP, but there's good stuff in there if you sift through it). I knew that resource typing was going to be difficult. Trying to get firefighters and police officers across the country to agree on what constitutes a Level 1 Firefighter, or a Level 2 Law Enforcement Officer, or, heaven forbid, a Tactical Law Enforcement Officer, is going to be a long, arduous process. So, if you're the contractor or federal employee faced with this particular headache, what do you do? Why you come up with typing for a bunch of easy, but completely useless bunk, of course! They had already done the typing for animal rescue, now they have created the "PATHFINDER TASK FORCE". There's no controversy surrounding them because they don't exist! They were created as they were typed. Yeesh! http://www.fema.gov/pdf/emergency/nims/path_1507.pdf I am likely the only ICS geek who even cares about this stuff, but I feel better for having vented. We now return you to your regularly scheduled EMS rants already in progress.

Can privates do the job better than government? Yup. Is it easy? Nope. 911 is a loser business for the reasons Dust pointed out. The money is made in the interfacility transports and even that has many of the issues previously mentioned (plus more difficulty in hiring personnel because all the hotshot young EMS providers want to run 911).

Don't you know it's not cool to point out the size of a guy's treatment area? You obviously have never worked in the back of a Type II, much less a hearse-type unit! The US is way behind in vehicle safety as far as crash-worthiness goes. I have only seen equipment mounts even available in the last few years. The fire service in the US has ignored this issue as well. I have seen MANY lethal pieces of unsecured equipment (like halligan bars) laying in the floor or between the seats of fire apparatus. I've worked on plenty of ambulances where monitors, oxygen cylinders, etc. were laying around as well. A TON of attention needs to be directed at this issue.

Because it was "Superior North" I suspected as much, but, since I was already calling you a geek, I thought it only appropriate to lambaste your "Superior" attitude as well.

Is a patient who is basically demented by pain making a truly informed decision? I would say no. If you are so distracted by pain that you cannot listen to the risks of your options, how do you decide? Most people in significant pain just want you to do SOMETHING, ANYTHING to make it go away. Physicians can be sadists, lol, but, so can medics!

I have never transported Jesus, but I DID transport a guy who was hanging out at the 7-eleven waiting for the bank to open because his brother, Jesus, had given him a checkbook and told him to cash a check at the bank so that he could get money to go home to see their mother, Mary. The checks did not bear Jesus' name and address.

Has anyone ever accused you of being a geek? I thought we "Americans" in the US were arrogant. Who names their ambulance service "Superior". Boy, that's a pretty high opinion of yourselves, lol. The ride in the back of 4x4 ambos DOES suck, but I would rather drive THAT in the snow than a big Freightliner rig with only one drive axle!

Ye olde conventional wisdom is changing on this topic. Most physicians have figured out that patients in excruciating pain will not allow a thorough examination. By reducing the pain to a tolerable level, the pain can be localized more effectively. I believe this is beginning to filter down to EMS. Treating pain is a hot topic in the clinical setting and many EMS medical directors are allowing more administration of analgesia. The service that I work with administers fentanyl on standing order for abdominal pain.

If you thought that was interesting, you should read more about the good Doctor Forssmann at NNDB. As the not-so-proud owner of a three-month old cobalt chromium stent, I am profoundly grateful that Dr. Forssmann and those who followed took up their folly and made such treatment available. Though I missed my 90 minute window by approximately 18 hours (you get a private jet to the cath lab from Southeast Alaska and no one guarantees that the weather will cooperate), I believe my stent was the right treatment for the huge clot right in the middle of my LAD just past the first diagonal. My angiogram was remarkably clean except for the lesion that they stented. I was not morbidly obese, but I was two weeks into a new exercise regime attempting to reduce my body fat. I credit the aspirin a day that I started taking at 30 for saving me from the deadly fate of my grandfather and an uncle. A very small plaque ruptured and turned into a HUGE honking (that's a technical medical term) thrombus. Maybe it would have fully occluded if not for the ASA, maybe not. I think it made a difference. They don't call the LAD the "widow-maker" for nothing. As far as the Arkansas BMI part of the story, I am pretty sure that they are discontinuing the program because too many ignorant parents think it makes their children self-conscious. Good grief! Heaven forbid they get embarrassed, lose fifty pounds, and live a longer healthier life! No! Let's coddle them, fatten them up, and pay for stents for THEM at age 25! That will be an improvement! I like the plumbing analogy. I have used it dozens of times in referring to my own procedure. If you think about it, if you do a little maintenance on your household drains occasionally (clean out the hair, don't pour grease down the drain, give your plumbing some enzymatic "supplements") they won't clog either. Americans (sorry Canada and Mexico, we've commandeered the term, we're arrogant like that) love our disposable society. Every couple of years we toss our cell phones for new ones and we cherish our disposable diapers and paper towels. We don't maintain anything. If it breaks or wears out, we toss it and buy a new one. Why should it be surprising that we treat our bodies the same way? If you want to see obesity taken to extremes, see the article on erotic weight gain in this month's Details magazine (Details). (No, I do not work for Details)

Reminds me of being called one time to assist an ambulance crew who could not get their cot back in their rig. After we put their patient on my cot and loaded them for transport, I took a look at their cot. As the son of an engineer, I got their cot to fold, put it in my rig, and took it back to the shop. It's always good to know how your equipment works and know how all the parts fit together (unless it's the brains of the LP12 or something, probably ought to leave the case intact on that beast). As far as restraints go, I don't think compliance is going to take a big hike until they develop a chair that not only slides fore and aft, but also moves toward and away from the patient and swivels. Give me THAT chair and I'll stay belted the entire time. Until then, I guess I'll keep putting my life on the line kneeling between the cot and the bench, straddling the stretcher, etc. We have come a long way and we don't have a high incidence of crashes with attendant injuries/fatalities each year (that I'm aware of, if I'm letting my ignorance "hang out" as we say in the South, tell me). You just cannot reduce the dangers of every day life to zero. SOMETHING is going to kill you. It may be an ambulance crash or it could be choking on a Gobstopper, you just never know.

This patient was obviously undergoing paroxysmal, spontaneous gender reassignment which has resolved. Now that he has fully transformed into a she, the pain and vomiting should go away. Seriously, though, I would list cholecystitis at the top of my Diff Dx with IBS following in second. I would start a saline lock, get an ECG, 25 mcg fentanyl, 12.5 mg phenergan, a generous serving of bedside manner, and before you know it I'm handing my new friend over to ERDoc for labs, US, and the like.

With two decades of EMS experience I have been assaulted exactly ONE time (it is beneficial to be 6'4" and 120+ kg). I've been on calls with drunks, I've assessed guys who knew they were being arrested, but the only patient to ever assault me was a 70+ year old woman with dementia. My lieutenant and I were trying to assist this "frail" little woman to the ambulance from her car. She was upset because the sheriff's deputies were going to tow her car (she had no idea where she was or where she was going). She jerked her arms out of our light grasps and hit me twice in the sternum before I could say "what the f---?!?" My chest was sore for two days. I did not use any Jujitsu on granny. As previously mentioned, your best weapon is your brain. Do not let your guard down. Learn how to avoid situations that would put you in danger and how to de-escalate situations that you were unable to avoid.

Let's face it, a large number of these patients are headed for the eternal care ward anyway. That does NOT mean that we should see how much fun we can have bouncing their BP up and down. A review of any number of recent published studies will quickly illustrate the dire consequences of dropping a patient's BP too low even ONE time. We have no idea how long the patient's BP has been elevated. Does it need to be emergently treated? Doubtful. I think the risk-benefit on this one is heavily weighted toward conservative treatment.

Yup. In the ED you can close the door and turn out the lights (our new ED is in the dungeon, below grade, so windows are not a problem), but in the back of a rig on a sunny day, turning out the lights will not make it dark enough to do you any good.

There is a manual override so that you can use it just like a regular cot. I would hope that you keep a spare battery in the rig and switch them out on a schedule.

One of the best inventions I have seen in years is Stryker's new power cot that works on the 24V DeWalt tool battery. Think of how many back and knee injuries could be avoided every year! I was extremely pessimistic when I saw the first version of power cot, but this new version is user-friendly, fast, and very well-built.

It's a cool tool for the ED though. I have used one several times (especially on peds) when I (and everyone else I could grab) was having trouble starting an IV. I typically find the vein, mark the "ends", prep the "middle", and then start the IV. I agree that in an ambulance where you cannot control the ambient light, it would have a lower degree of usefulness.

At least it was just regular, run-of-the-mill porn and not some weird, gross fetish porn. :roll: Since my stent placement, I don't need cigarettes, no matter the discount.

Virginia Department of EMS has a great series on recruitment and retention. Virginia EMS

Even ECG, SpO2, and ETCO2 would be difficult to include in a scope of practice because they are non-invasive, diagnostic tools. As a state administrator, I only include invasive skills (or manipulative skills like fracture/dislocation reduction) and medications as part of a scope of practice. Anything you can do diagnostically that does not delay delivery of the patient to definitive medical care may be beneficial and can not cause harm. Just make sure that you are not spending half-an-hour on scene checking all the cranial nerves and doing a full neurological examination when you should be moving toward the hospital.

Amen. If you want to keep your job, however, you have to nudge and prod and gently drag the providers kicking and screaming toward the goal of EMS as a profession. Baby steps, but we're moving forward.

As an EMS administrator, this issue is one that I have to wrestle with constantly. In this vast state of the last frontier, we have small pockets of humanity separated from each other by mountains, glaciers, ocean waters, and, sometimes, miles and miles of nothing. Without local EMS volunteers, the "first responders" for many of these communities would be a turbo-prop air ambulance. Many times, the only "trained" medical professional in these villages is the Community Health Aide. These small villages do not have the financial resources to have a physician (or even a mid-level) in their village. They have CHAs who, though definitely not lacking in commitment or desire to serve, have only a few weeks training, a very detailed manual, and a satellite phone to consult with a physician hundreds of miles away. In the other 49 states, can you imagine having to spend all day on planes to visit a physician? I live in one of the "big" towns in Alaska and I had to fly over a thousand miles (across Canada to another state) to have an angiocath! We have areas of Alaska where the "local" government is the State Legislature. There is no tax base. There are no public services. No water department. No trash collection. If you need a cop, you have to wait for the trooper to fly in in a Cessna. It's different up here. The battle to "professionalize" EMS, however, is fought here as well. We DO have paramedics. The paramedics have in excess of 1,000 hours of training prior to licensure. There are NO paramedic EMS agencies outside of a handful of the "larger" (by AK standards) boroughs and cities. We have two intermediate levels of EMT above the basic level. Each level is an additional 50 hours of training. So by the time you are at the "EMT-3" level, you have had 220 hours of training. No internship. No clinicals. There are agencies in this state who do not want to pay the salary that is required to get paramedics to work here, so they write paramedic skills into their standing orders for their EMT-3s. Why pay a paramedic $50,000+ a year if you can pay an EMT half that and allow them to do the same skills? Sometimes it is hard to hold the line between EMT and paramedic and not allow skills "creep". Communities argue that they cannot afford paramedics but that their citizens should have access to ACLS. Education, even on the last frontier, is still the key.

I oversee training and certification for ambulance personnel as a state administrator (a.k.a. "office weenie"). My part-time job is as an emergency department nurse. In my SPARE time, I volunteer with the fire/rescue department. I can't just quit operations after two decades in volunteer and paid fire departments!

I REALLY hope that this is merely a humorous post that you created and not something that you copied from an actual official communique. These phrases have some gallows humor when bandied back and forth between crew members after a call, but obviously have no place in official documentation. If you stay in this business long enough, you will eventually wind up in court whether it is because of something you did or didn't do or because of someone else's mistake. Irrespective of the reason, I doubt anyone would want to explain their juvenile documentation practices in front of a jury. Every report should be written as if you KNEW you were going to court regarding the call, whether it is a patient refusal, an interfacility transfer, or a homicide. If some idiot of a manager actually DID send this out to the troops, start looking for a new job NOW! Anyone who would rather send out an email or a memo instead of doing the work to find out whose documentation is a joke is not the kind of boss you want to be working for. If he or she will take those kinds of shortcuts, they are not going to invest much effort in maintaining morale or doing any other tasks that don't come easy.