Doczilla

IV Fluid bolus and narcan. Is she hot as a hare? Blind as a bat? Dry as a bone? Red as a beet? Mad as a Hatter? 'zilla Sly as a fox?

We love to talk about the scenario where we would do a procedure that is "outside the scope of practice", but what does that really mean to us, to the medical director, and to the patient? Things that are outside of scope are outside of scope for a reason. Either it won't help the patient in that setting, has a high complication rate, has a narrow set of circumstances in which it will work, requires a skill set that is infrequently used, or has poor evidence supporting its use. Most people consider themselves to be better-than-average drivers, and I think the same is true for our self-assessment skills as paramedics. The problem is not when an intervention outside the scope of practice is applied appropriately, but when it is done inappropriately. For example, let's say an EMT-I performs a needle decompression of a trauma patient. The patient perhaps had rib fractures on one side and maybe had some difficulty breathing, but was hemodynamically stable. Mistakenly thinking that NDC would be indicated, the EMT-I decompresses the patient. Now the patient has bought a chest tube because of the inappropriate decompression. Another example: blunt trauma patient loses his pulse in front of the paramedic, who has performed a thoracotomy as part of a cadaver lab in training. The medic performs a field thoracotomy, having not been completely trained and not fully understanding about it being indicated only for penetrating trauma arrest. He ends up with a bloody mess and a dead patient. Another example, an EMT-B has a patient with a wide complex rhythm. He reads the strip (which he's not fully trained in) and administers amiodarone to a patient who was actually had an accelerated idioventricular rhythm. The amiodarone knocks out this ventricular focus and the patient goes into asystole. Or another, a paramedic has read up on the procedure of surgical cric, but currently only Quicktrakes are approved for use. He grabs the scalpel out of the OB kit, incises to perform a surgical cric (which he has never done), it's a bloody mess because, well, they are, he can't find the landmarks and can't place the tube because he has never physically performed the skill. It's easy to imagine yourself being the hero who thought outside the box and saved a patient's life. It's much more difficult to imagine the alternative scenario, where an intervention is applied inappropriately to the patient's detriment. Things outside the scope of practice are likely not things on which you are completely trained or perform frequently, and therefore far more dangerous. 'zilla

He makes 100 grand for being the medical director? I've been had. 'zilla

Our intrepid hero screams down the interstate! Sirens blare to all around.. help is on the way! But the roads are icy! Our hero has no choice but to throw caution to the wind and risk his very life to get there seconds sooner! But Oh No! The wheels lock on the icy roadway! The ambulance is hurtling sideways out of control! Will Spaceman Spiff be able to regain control in time? For sure he is doomed! Only our hero knows for sure! 'zilla

I'd love to, but probably don't have the experience they are looking for. That, and I don't have the money to pay back my signing bonus here yet. 'zilla

Agreed. It's very easy to find an MD with little understanding of the field to simply sign the paperwork once a year and let the service run itself however the chief sees fit. 'zilla

It's interesting how there is some shuffling around of names we know. Jim Augustine went from Atlanta to DC, Racht headed from Travis to Atlanta. I'm curious to see who takes Racht's place. 'zilla

"Are you kidding me? I'd kill you for a Klondike bar." -Achmed the Dead Terrorist

Basenjis are the most evil dogs on earth. So says my huskies. 'zilla

Mecklenburg EMS Agency in Charlotte. http://www.charmeck.org/Departments/Medic/...emedic911%2ecom 'zilla

Wow. In the 3 whole days you've been here, you: a) failed to do even a preliminary search, which would have yielded quite a bit of information on the topic in several threads in this section. pissed all over the responses of several other members, who actually do this job you wish to find out about. c) copped an attitude with one of the most experienced members of this board, who knows quite a bit about the subject. Interesting way to get things started. Don't unpack your suitcase. 'zilla

It was about 2 years full time when I knew that I would not be a career paramedic. I had entertained the idea of medical school since basic EMT, but hadn't come to any conclusion about when would be right. It was 4 am, I had just gotten off shift, and I was sitting in a diner having a late night breakfast, and I had what alcoholics refer to as a moment of clarity. I couldn't see becoming a medic supervisor like my supervisors at the time (though I respected their experience and knowledge), and it seemed that was the only career option in EMS (though now I know a little better). It just seemed to me like I would be 50 years old in a little supervisor's office, filling out employee paperwork, wondering what had happened to the years of my life. I wanted to do more, see more, and know more in medicine, and I wanted to make the tough decisions, not simply execute orders. Looking back, it was the right decision and I would do it all over again. Is that what you were looking for? 'zilla

I fail to see how this is murder. According to the article, the patient communicated her wishes that she wished to be taken off the ventilator. The ventilator was withdrawn as consistent with the patient's contemporaneously stated wishes. 'zilla

Walk this way.... THIS way, THIS way..." - Igor, YF

Holy crap, Dust is still alive! 'zilla

What exactly are you looking for here? You come to our site, give minimal information, and want us to give you some sound bites to back up your opinion that things weren't done properly. It is clear that you are not interested in an educated discussion about prehospital care or how things might be done on this particular call. From the little bit of information you actually ponied up, it sounds like you were the driver and are pissed off about what you think was substandard care given by someone of greater training. You have given no information about what transpired during patient care in the back of the ambulance, and I don't think you really have any. You have clearly made up your mind already about the care, and have no real questions regarding care, but instead want someone to join you in lambasting someone in a situation where we don't know what transpired. If you want to know what happened, why don't you ask the medic who ran the call. If you have a problem with what happened, then why don't you ask the medic in front of the supervisor. I question your motives in coming here and opening your first few posts this way. Come here as a professional or take a walk. 'zilla

Actually, they are ambulance drivers. Security employees, to be exact. They do not participate in patient care. Patient care is managed by the nurses and RRTs. 'zilla

PM sent. Maybe Careflight or Children's Dayton can help. 'zilla

"I knew it! I'm surrounded by assholes!" Spaceballs

If any details of her injury was posted, and enough information was posted that anonymous persons (TV crews) knew who she was, then he violated HIPPA. The fact that a crime occurred at that address and that someone was injured there is a matter of public record from the police department. Details of injuries and treatment are not, and are protected health information. Police and medics are not generally governed by HIPAA except in certain instances. HIPAA does not apply when disclosure is necessary in the course of their duties, which is why it is permissible to broadcast an incident location and nature over an unsecured radio frequency. It is not "within the course of his duties" to post it to a MySpace page. HIPAA contains certain exceptions for disclosure to law enforcement agencies to alert the public to an imminent danger. He says that he just wanted to protect others in the area, yet posted to an internet website that is neither confined to his area nor comprehensive as public notifications should be. There is nothing here that in any way constitutes adequate justification for posting details of a call on MySpace. There is no medical or public health benefit to posting it as he did. Really, he just wanted to share with someone about the cool/interesting/awful call that he had just run. Whacker. 'zilla

:bs:

The study is small, as are other studies on MDCT for ACS. There was a review of this topic in the January episode of EM:RAP, and the panel agreed that it may have some utility in a small subset of patient population, but not widely. The issue that we're looking at is not acute STEMI, but more NSTEMI and unstable angina. the question that we have to answer is whether or not the patient will die in the next 30 days or so before they get to some form of perfusion testing, such as a nuclear stress test. The MDCT is a substantial contrast dye load and radiation dose. The big issue is that we haven't yet done population studies that tell us how effective it really is at ruling out cardiac ischemia, and how well those patients do when sent home after a negative scan. There are segments of the coronary arteries which are not adequately seen on coronary CT angio. Another problem is that significant calcification obscures the picture of the arteries. What we're left with is telling the patient, "I think you're okay, but we can't see a couple of these segments", or "there are these mildly narrowed areas, and we're not sure how relevant they are to your symptoms today." There is also the issue of these 10-20% plaques, which are the ones that rupture and cause acute MI, which aren't seen so well on these coronary angios. For that matter, they aren't seen well on traditional angiography. The bottom line is, we haven't figured out who will truly benefit from this test, and who will fall through the cracks. There may be some use for it in older patients (less risk for radiation-associated cancers) for the "triple threat CT", which would hit ACS, PE, and aortic dissection all in one scan. This would help get to an answer faster, but probably not obviate the need for serial cardiac enzyme testing. Contrast dye load is less of an issue with healthy kidneys, but the radiation is something that is not insignificant, particularly in a young person with long expected life span. Current estimates are that we cause 1 fatal cancer for every 1000 CT scans ordered. Doing serial cardiac enzymes is harmless to the patient with the exception of the long boarding time in the ED/chest pain unit/inpatient floor and subsequent ED crowding. At some point we'll have to decide if the risks to the patient from radiation outweigh the risks to the patients in the waiting room that have to wait to be seen. The "calcium" scans are of far less utility. They will tell you if you have a small quantity of calcifications or a large one, but there is no good answer for those who have an intermediate scan. Do we perform direct angiography with the 1:1000 risk of a serious complication (does not count the radiation risk from the fluoroscopy). What if a stress test shows nothing? It's those smaller plaques that rupture and cause MI, and less likely to show up on the scan. Do we put a stent in? Muddying these waters is the fact that there are plenty of unscrupulous folks who will be happy to perform this test at the local mall for you (cash only, of course), whether or not it's actually indicated. 'zilla

A better idea, once you know you've been exposed, is to call for another unit, administer the Mark1 kit to the patient, decon the hell out of the patient (in the yard, rather than the house, to limit inhalational exposure), then turn the patient over to the arriving crew for transport, and set about decon for yourself and your partner. Once the patient is stripped naked and outside of a closed environment, inhalational exposure is at a minimum, and nitrile gloves will do a decent job of protecting your hands, which should really be the only part touching him. You don't have to be in a full suit and SCBA to do good decon on this guy. HAZMAT can help you decon yourselves and your gear when they arrive. The patient will be decontaminated again upon arrival at the hospital to make sure he's nice and clean. Significant exposure will render you relatively helpless to the patient once you get symptomatic. Watery eyes alone will limit your effectiveness, not to mention vomiting and diarrhea. Decon is not merely being a p*ssy, it limits exposure for the patient and prevents him from absorbing more and getting sicker. We carry the Duodote kits, so giving atropine without 2-Pam each time is not possible. 'zilla

He's not faking. 'zilla