Doczilla

Did someone hang out an EMT City sign at the local poser and wannabe union? Where are we getting these dumbasses lately? Or is Dustdevil laughing his ass off at this epic joke that he's playing on us? 'zilla

Mercifully, someone banned this idiot. 'zilla

I'm in favor of doing this for a pediatric DKA patient who is kussmaul breathing but requires airway protection. You don't want to paralyze these patients or sedate them too much for ventilation. If on a ventilator, I put them on CPAP alone. You just can't keep up with the volume or rate of ventilation that they can do with the Kussmaul, and if you paralyze them, the acidosis will get much worse. 'zilla

Making prudent decisions that cause minimal risk to rescuers is important for preserving rescuer safety. That said... Sometimes, you have to "cowboy up" and get it done, because it can be done no other way. Because the risks are great, possibly ending a life, but the reward is possibly saving a human life, which is the greatest reward there is. I'm not advocating all the whacker tendencies inside us all to jump up and take control. Life is better run -usually-, by rule #1 up there. But Rule#1 didn't cover all the possibilities. Good on her. 'zilla

I don't think it is illogical. You have cogently stated your belief based on many factual incidents and drawn an educated conclusion. I don't happen to agree with you on the finer points, but I respect your opinion and how you came to it. 'zilla

Pure idiocy. Why would you shoot someone through your front door? This is piss poor target identification. You don't shoot someone you can't see. There is a level of paranoia here that I don't fully grasp. I wonder if the suspect has a drug enterprise that they were trying to protect. The Hattori shooting makes no sense either. Why would you exit a secure location to chase down someone on your property with a gun for ringing your doorbell and enter into an armed confrontation when they are clearly leaving? That jackass should have gotten jail time. 'zilla

And they have horribly poisonous snakes and spiders that kill people without mercy. EMS training is a necessity. 'zilla

Yes. 'zilla

The most important dog-centered thing to include would be a muzzle. Injured dogs will bite, claw, and head butt even people known to them. BLS care is the same for dogs as for humans. Bandages, gauze, coban (vet wrap) are fine. IV fluid bags can double for irrigation. If doing extended care in a remote environment, surgical wire is necessary for repairing lacerated paw pads. For medications, many standard injection medications that you would carry for humans would work for dogs (morphine, dilaudid, versed, valium, ketamine, etomidate, propofol, saline, LR, D5, etc). Dogs suck up much bigger doses of narcs and benzos than humans do. Morphine: 0.5mg/kg IM or SQ (avoid IV administration if possible) Dilaudid: 0.1mg/kg IV, IM, or SQ Valium: 0.2 mg/kg IV Versed: 0.25mg/kg IV or IM Propofol: 4-6mg/kg IV Ketamine: 5mg/kg IV IV access can be obtained through the cephalic vein (prominent vein running down the lateral part of the foreleg), but is not always necessary. You can put 1L of IVF into the skin on the back of the neck, which will infiltrate into the bloodstream for rehydration. PO medications are very different. Tylenol and human NSAIDs can be deadly. For dogs: meloxicam, deracoxib, and tramadol are okay. A single PO dose of 325 mg of enteric coated aspirin in a large breed dog will be okay in a pinch. Disclaimer: I'm a people doctor, not a doggie doctor. Ask your vet for real advice. 'zilla

What?! You told me you were on the pill! 'zilla

Squint- I do not have much to add to chbare's excellent reply. The greatest threat to a SWAT team (and a military unit) is disease and non-battle injury. The vast majority of what I do with the SWAT teams is sports medicine, minor injury and illness care, etc. SWAT medics and docs preserve fighting strength, maximize performance, and minimize disease and injury exposure. The issue that I take with your previous statement is that it completely ignored this aspect of tactical medicine, which is the heart of the specialty and requires planning and equipment on the part of the OP. As far as the armed question goes, I would rather be armed to be able to defend myself and my patient. But on a civilian SWAT team, I would rather not have the dual role of operator and medic. You cannot effectively manage casualties without tactical superiority. You are correct in that the first and best treatment for battle related injury is to eliminate the threat with firepower. This holds true in the civilian environment as well. I don't think we should wear big red crosses. I prefer my subdued shoulder patch that can only be read within choking distance. There are varying degrees of "hot zone", depending on where you are, how well defended you are, how far definitive care is, whether or not you have a safe route of egress, etc. Sometimes you have to stay and play because the tactical situation dictates it. The wise medic would be prepared for this. 'zilla

The granulated QC generates an impressive exothermic reaction. The QC Advanced Clotting Sponge was developed because of issues getting small granules to stay in place in a briskly bleeding wound. It has less of an exothermic reaction than the original QC. The QC combat gauze lacks the exothermic reaction of previous editions of QC. The exothermic reaction does not cauterize wounds, and is in fact an undesirable effect. Hemcon, like Celox, contains chitosan, which is obtained from shrimp shells. It has been purified of other proteins and therefore will not cause an allergic reaction in those allergic to shellfish. This statement demonstrates lack of awareness of most elements of tactical medicine. 'zilla

The USAISR conducted studies on the hemostatic agents, and the Wound Stat and Combat Gauze came out on top. Slightly better than Hemcon (which is far more expensive). The granulated Quikclot didn't fare so well (6 consecutive failures, and therefore dropped from the study). The TCCC committee recommended the change after evaluating the ISR study and a Navy study. 'zilla

PM sent. 'zilla

Despite taking what looked like a decent shot to the head, the medic stayed up and swinging in a decent and unexpected fight. Good work! 'zilla

Injection of lido/epi into a vein could potentially cause arrhythmia due to the epi, but it would take a lot (the epi is at a concentration of 1:100,000, so 1cc would be .01mg). Theoretically it could cause cerebral vasospasm if injected into the carotid, which lies not too far from the infralveolar nerve. A large overdose of lidocaine could cause seizures, though it would take quite a bit more than the dentist would usually inject into the mouth. If the dentist was using bupivicaine (Marcaine) instead of lidocaine for longer anesthetic effect, accidental injection of it into an artery or vein is instantly cardiotoxic and can cause cardiac arrest. We don't generally see this with dental procedures, but with regional anesthesia, since larger amounts are used. Or it might just be bad luck. 'zilla

I'd say do whatever gets the patient to the hospital faster. If they have to wait for ALS, just go. If ALS is on scene, ALS it. I agree that you can't tell how deep the wound is. Calling to ask for orders to BLS it is wasting time. Getting all pissy about it in front of the ER staff as the crew did will only make them look worse. 'zilla

One of the big challenges in emergency medicine is focusing the disorganized patient into a concise statement of why they came to the ER (or called 911). At least some of that seems to be occurring by your description of the long life histories she is giving, and so you need to try some methods to focus her. It's okay to interrupt the speaking patient if they are giving you nothing relevant, and I usually do so with a gentle, "I'm sorry, but it sounds like you have a complex history. Can you tell me what is different today that brought you here?" I sometimes have to rephrase and repeat this question. Your coworker probably has some issues of her own, and while I wouldn't go as far as to say she needs her paramedic card pulled (this really isn't a medical director issue), I will say that she needs a chat with the service director or supervisor. I agree that a certain amount of nonmedical community service is part of the job of EMS, but these ladies are clearly taking advantage of your compassion and generosity and putting you in a difficult position. On the one hand, you are required by law to assist them in the case of a medical emergency or perceived medical emergency, but on the other hand, it is inappropriate for EMS resources to routinely be tied up for that which is clearly outside the scope and intent of your charter. There is nothing wrong with you leaving once you have determined that no medical emergency exists (I recommend that this process include a physical exam and vital signs). You may have to put the patient to a choice: "We have been here several times in the last few days to examine you, and you have declined transport to the hospital. Our exam is not a replacement for examination by a physician and further testing. I'm going to have to insist that you come with us to the hospital or refrain from calling unless you feel that you need to be taken to the ER." If she refuses transport then politely excuse yourself and say that you have to be back in service for emergencies. You can do this politely, tactfully, and firmly. The patient will be disappointed, but you do have to set limits. To not do so is neglectful of the other patients and potential patients served by your EMS. I agree with the recommendation for APS or Social Services referral to determine if the patient is able to meet her needs and perform her activities of daily living. In the ER, for our abusers who come in for their narcotic fix or a warm place to sleep, etc., we enact what we refer to as a "Care Plan". This is a contract which specifically states what will and will not be done for the patient, and sets expectations for them. You can do the same for these ladies, writing out a care plan that states when she calls for a 911 ambulance, it will be because she perceives a medical emergency exists and that she will be transported to the hospital. The care plans are reviewed by our attorneys. Care plans do not set the stage for a refusal of emergency medical care, but state that if the patient has a specific complaint (i.e., their recurring one, like migraine, or back pain, or sickle cell pain, or nontraumatic extremity pain, etc.), then they will get certain treatments and should not expect anything more. If it is one of our homeless looking for a roof over their head, it says that they will get a medical screening exam and if no medical emergency exists, will be discharged and expected to leave the ER. This gives us some legal backing for politely refusing the patient's request for IV dilaudid or their request to stay in the bed and sleep, or our performance of a limited workup when it appears that a more extensive one is unnecessary. 'zilla

Or you might pay the price for mangling a patient and making a bad situation worse. This discussion of knowing one's limitations. You can't expect to competently perform a complex intervention on a patient that you have not been adequately trained on. That's the problem of KNOWING that an intervention, with which you have passing familiarity, will save your patient's life. Will it really? Do you know for sure, or at least what the chances are? On a procedure which you have not performed and are not authorized to perform, and have not been formally trained or at least trained only once a long time ago briefly in an ACLS class? Do you know exactly the indications and contraindications and pitfalls of the procedure? Roberts and Hedges might make it look easy, but there are greater questions that you have to know the answer to before pulling out the scalpel/needle/drugs. The "I have the tools to save him but not the authorization" is an extremely unlikely scenario, particularly when you consider that the "tools" also include the required knowledge. For your "can't contact medical control" issue, medics are usually expected to continue with the protocol as if med control had been contacted. There is a BIG difference between giving a drug that you frequently give but which doesn't EXACTLY fit the protocol (no protocol can cover every conceivable situation) and going off the reservation with a procedure that you don't ever do. 'zilla

I would think that the patient would be better served by boluses of versed and valium rather than a drip if the patient is still seizing. That said, paramedics are trained to hang and calculate infusions and are expected to do so routinely. With online medical control guidance, I don't see a scope of practice violation here, just more of a protocol issue. 'zilla

With mutual aid agreements, medics providing mutual aid are governed by their responding agency's protocols, not those in the area in which they are providing mutual aid. This makes some logical sense, since you can not and should not be expected to know by heart the protocols of every service area which you may be asked to respond. 'zilla

Troublemaker. 'zilla

Dwayne- My reply was not a specific rebuttal to your arguments, just a general statement on deviation from scope of practice. I think you and I are talking about two different concepts. We have to make sure to distinguish 2 things: deviation from scope of practice, and deviation from protocol. A procedure that is permitted by protocol (even if it requires MD authorization in real time) is still within the medic's scope of practice. Protocols are determined by the medical director, whereas scope of practice is usually outlined by the state. I was speaking of deviating from scope of practice, performing a procedure which is not routinely permitted to be done by providers at that level in that particular state. The examples I provided are all scope of practice issues, not just stepping outside of protocols. 'zilla

It's a mnemonic for a specific toxidrome. 'zilla