Doczilla

Sorry, I was making the assumption on the hospital's expense that the patient isn't going to pay for their visit and doesn't have insurance. :wink: 'zilla

TBS- welcome to the board. I think your perspective here is a welcome addition, as we don't get to see much of it. Presence of a paramedic does not automatically mean that the ride is ALS. An ALS run is any run where the following is done: IV line or IO line started dialysis port, picc line, mediport or other central line ACCESSED (flushed with saline, IV line hooked up, or meds administered), not just assessed medications administered, with the notable exception of aspirin (ASA), nitroglycerine (NTG), epinepherine 1:1000 via epipen, or albuterol by metered dose inhaler (MDI, not nebulizer). Anything given IV, IO or by a nebulizer makes it ALS. endotracheal intubation, LMA or combitube placement attempted, whether successful or not defibrillation (except with an AED) cardioversion transcutaneous pacing EKG monitoring chest decompression Also, if the patient already has IV's running, chest tube in place, is on a ventilator, is in an incubator (neonatal transports), it is an ALS run, even if the medic doesn't do anything but monitor them. These things are common on interfacility transports. And generally if there is a nurse on board, it's ALS. Emergency transport codes vary by agency. Some will refer to it as "emergency traffic", "code 3", "priority", or some such. I would contact a supervisor at the EMS agency directly to find out which they use. Some agencies use priority codes, so Priority 1 would be emergency transport, and priority 3 would be non-emergency (though others use the reverse). Others will use the term "scheduled transport" or "NET" for "non-emergency transport". And if it says "911 request", then it's emergency (I don't know if you back up the local 911 service or not). If the destination was the ER, it's an emergency run. Others refer to it as NAB transport (non-ambulatory body) or lizard-hauling, but hopefully you won't see that on anyone's run report. In order to be billable for medicare for a non-emergency transport, there needs to be a "statement of medical necessity" completed, often by a physician or his/her designee. Usually this is a little form that has the patient's diagnosis and why they need an ambulance. You may be able to make a good case for this if the patient has the following conditions: bed-ridden, non-ambulatory fractures of the legs, pelvis, back, or multiple extremities unresponsive bilateral leg amputations requiring ANY medical intervention besides oxygen. Any medications administered, IV lines or EKG monitored, etc. For emergency transport, it's easier. Essentially, anyone who calls 911 gets a ride that's paid for by medicare/medicaid. 'zilla

I did respond once to an annoying bystander (who was insisting on an ambulance to transport her friend with a minor laceration as there was, in progress, a shooting down the street) with the following: "Well, gee whiz, ma'am, we got the fire truck and hoses here, ya want us to wash your car for you too?" That shut her up. And got me some props with the fire crew. 'zilla

The 25mg is not an absurd dose, though I'll start with 12.5mg when giving IV, particularly in the elderly. Phenergan is an antihistamine, and it can be difficult to predict who will respond poorly to it (i.e., with oversedation). The elderly tend to be more sensitive to CNS effects of many drugs. I got burned once on an elderly patient on the trauma service who started sundowning. After a few days and an extensive workup which revealed nothing, we determined it was the Pepcid she was being given in-hospital for ulcer prophylaxis that did it (standard practice in hospitalized patients). Once switched to Protonix, the sundowning ceased. Zofran (or Anzemet, depending on which facility I'm at) is my DOC for nausea in patients with head injury or altered LOC because phenergan masks the LOC changes if they become sedated. The real problem is expense: actual cost to purchase the medicine is about a dollar/dose for phenergan vs. $20/dose for the Zofran. The thing is, Zofran is FDA approved right now only for chemo-related n/v and pregnancy-related n/v. We can be reimbursed for using it in-hospital, but many insurance companies won't pay for it off-label as a prescription at home, so the cost falls entirely on the patient. 'zilla

That's the thing. I doesn't usually look that bad from the outside, but inside the infection is spreading extremely rapidly, following the layers between muscles and other tissues (fascia). Surgical debridement, washout, and possible amputation are needed to prevent sepsis and death. This can kill someone very quickly, like in a day or two. Diagnosis is by biopsy, but we'll go to the OR with it on CT findings (inflammation, fluid or air where it shouldn't be) or just a high suspicion. HBO can be tried after surgical debridement, because usually the patient is left with huge gaping wounds after surgery. I've seen several cases of this. Bad juju. 'zilla

Pieces of burned clothing should not be removed in the field if adhered to the skin. Cut around the adhered areas and remove any non-adhered sections. Impaled objects are not removed prehospital or in the ER because removal may sever more blood vessels or release tamponade on vessels that are occluded by the object's presence. This is done in the OR setting, where bleeding can be rapidly controlled and further exploration undergone emergently as needed. While the removal of burned clothing will likely not result in serious life-threatening bleeding, it will result in unnecessary pain and expose more of the subcutaneous tissue, increasing the potential for infection. This should be done under conscious sedation or general anesthesia. 'zilla

ST elevation on 12 lead. There hasn't been a real benefit established for rapid catheterization of NSTEMI or unstable angina. Most cardiologists will go to the cath lab for positive enzymes, just not within an hour. So really the debate is only over STEMI since the others can wait long enough for stabilization and transfer or for the cath lab to open in the morning. 'zilla

Once the burning has stopped (and by the time you arrive, it has), there is no benefit in cooling the skin. In fact, there is greater danger in hypothermia, since the skin's regulatory mechanisms are lost. Burn texts conflict in their recommendations as far as wet vs. dry dressings, but the practical and prudent thing to do is use dry dressings in the field. In hospital, it's dry dressings or moisture-control gel dressings over the silvadene. 'zilla

I'm not a big fan of Nubain prehospital. It is a partial opioid agonist, meaning it also has some antagonist properties and will block some opiate receptors. While this means that there is a "ceiling" or limit to pain control provided by Nubain, it also means that it will antagonize morphine that will be given in the ER, further limiting pain control provided. Morphine is still the standard of care as far as pain control is concerned. Tell the doc who gave you a hard time to get bent and read your protocols. He may disagree but he can't give you any crap about it on this particular topic. You'll run into docs who feel differently on the issue of prehospital pain control, particularly in trauma. There is some theoretical concern that it will mask injury, and some concern that the effect combined with the alcohol will worsen airway status. There are docs who have the "cowboy" approach to trauma, where pain medication is withheld from intoxicated or injured victims and they are allowed to suffer in agony because they are afraid they might miss something on exam. We give it routinely on the trauma services here. Pain itself is a distractor that will mask less serious or subtle injuries, and I have seen people who, after some morphine helps bring their white-hot agony of their tib-fib fracture under control, become aware of injuries elsewhere. There has been the same thought given to abdominal pain, where some feel that narcotics will mask signs of a surgical abdomen. The studies have shown that it just ain't so, and we are fortunately moving away from the time when no narcotics would be given to an abdominal pain patient until surgery has evaluated them. I don't think there are any good studies out there on the injury-masking abilities of morphine when given appropriately in the trauma setting, intoxicated or not. As far as masking a head injury is concerned, they are getting a CT scan anyway (especially if they're drunk), so who cares? Serial neurological exams will be performed long after the alcohol has worn off, and I have not found them to be adversely affected by the morphine which is given routinely on the hospital floors to these trauma patients. Bottom line is, I don't believe in letting patients suffer needlessly in the back of the truck. I seriously doubt that the BP or airway or clinical exam is going to be THAT compromised by 2-4mg of IV morphine given in a closely monitored environment, and if it does, then I can deal with it. 'zilla

I wouldn't mess with it. Any harm to be done by the burn cream has already been done, so wiping it off won't help, and as Rid pointed out, it's better not to further contaminate or damage the area or cause more pain. Just leave it there and treat as you normally would. It will be debrided in the burn unit or OR if needed. 'zilla

Some of it depends on whether or not your preceptor has any prehospital experience (I mean REAL experience, not some nurse who challenged the medic exam just for S&G). Many nurses see prehospital providers as ill-educated and subordinate, yet not really "one of their own". I found in my clinicals that there were many former medics/now RNs who took very good care of me, making sure to pimp me on patient scenarios and examination technique. I found also that nurses at the community hospitals tended to be more willing to take the time to teach and give me opportunities to practice skills, perhaps because they see students less as interfering with them doing their job. If more people felt that teaching was a testament to their knowledge and experience rather than just a chore, more might do it. I've met docs who were the same way toward medical students. I think you've got the right attitude and right approach. Some of your preceptors, as they get to know you, will allow you more participation and teach more. Other tools just won't, and you know to stay away from them. In the meantime, always keep the good attitude, keep showing your desire to participate, and never shy away from scut work. Be proactive, and be IN THE WAY (but don't just stand there). Don't watch from the corner, get into the middle of things and start doing. 'zilla

Assaults happen with alarming frequency. Most EMS organizations don't teach self-defense, as there is a pervasive "if we don't acknowledge it, then we can't be held liable if you get hurt" attitude. As far as protection, I wear concealable body armor on the street, as I believe all EMTs should. Much of personal defense is, as previously stated, a matter of situational awareness. A bit of verbal judo goes a long way. If you recognize the signs that someone is ramping up to becoming agitated, you can do a lot to head that off. If they are already agitated and potentially combative, flee. 'zilla

HALO 2.

My favorite all-around gotta feel good song, especially rolling to a code: "Roll it up" Crystal Method (not the same as Keep Hope Alive, also by Crystal Method, which is the theme from Third Watch and an excellent shootout scene in "The Replacement Killers") And of course, just to be cheezy, "Kryptonite", 3 Doors Down "You call me strong you call me weak but still your secrets I will keep you took for granted all the times I never let you down You stumbled in and bumped your head if not for me then you'd be dead I picked you up, put you back on solid ground..." 'zilla

I think that regardless of the presenting rhythm or reported down time, cardiac arrest victims should be transported non-priority traffic unless your agency is BLS only. Even in a V-fib arrest, what will the ER do that can't be done in the field? Loss of pulse in the field is essentially an exclusion criteria for thoracotomy, and that's probably the only thing that can be done on a code that can't be done by a medic (and it's only done for trauma). The whole point of having paramedics carry ACLS drugs is so they can treat codes in the field. Transporting these patients hot endangers the lives of the medics and the public for no real benefit. If transport is to be initiated, it should be done routine traffic. Otherwise, there is some thought to working the code at the scene, and if no response in 30 minutes of ACLS, then terminating in the field. There are some exceptions: 1) Airway problems, like you can't get one. 2) Reversible cause, such as hypothermia. 3) Pulseless gravid female, when emergent c-section may be considered to save the baby. 4) Positive response to therapy, i.e., now they have a pulse. 5) Man with gun threatens to kill you if you don't. 'zilla

The Blackhawk STOMP II pack is compatible with Camelback hydration bladders (which is what I have in mine) . It is also an extremely slick medical pack. 'zilla

Many patients have to be kept NPO (nothing by mouth) for a variety of reasons. The most important ones have been listed already: 1) Risk of aspiration 2) Possibility of surgery 3) Need to restrict/monitor fluid intake To include in that list: - Need to "rest" the GI tract, for a small bowel obstruction for example - possible aggravation of intrabdominal process, such as cholecystitis, pancreatitis, or enteritis. Since you can rehydrate people IV, there is no urgent need to give them something PO. Given the above potential downsides, it makes sense to withhold the fluid. Now if the pt. is suffering an acute case of heat illness and can protect airway, etc, and transport may not be initiated, it makes sense to rehydrate PO. The obvious example of this is a firefighter or tactical officer who has been working a scene pretty hard. 'zilla

Glucagon activates the cellular pathways that are activated by beta receptors. It essentially activates this pathway without the beta receptor, so it is a positive inotrope (increases contractility) and chronotrope (increases heart rate). For this reason, it is indicated for symptomatic beta blocker overdose. You could try dopamine/dobutamine for these folks, but since the beta blocker inhibits the receptor, they won't work very well, so glucagon is preferred. 'zilla

Actually, Culturelle is a preparation of Lactobacillus Acidophilous which is prescribed with great frequency by physicians, and is growing in popularity especially among hospitalized patients. Even more frequently, physicians (particularly FPs) advise patients on antibiotics to eat yogurt daily, which has L. Acidophilous in it (if it says "live active cultures" on the side). And elderly, debilitated patients get sepsis from UTI with alarming frequency and often don't mount a white count or grow out their cultures. 'zilla

Try "The Streetmedic's Handbook" by Owen Traynor. 'zilla

Didn't watch the episode. Thought the promo was pretty funny without intending to be. "What two words does and emergency room surgeon never want to hear?...." Emergency Room Surgeon? What is he, lost? The elevator's over here, sir. 'zilla

I agree with ER Doc here. Even in-hospital there is little call for "hot salt". I've only seen it once- today- on a patient with a sodium of 105, which is often incompatible with life. Even in the moderately hyponatremic patient, boluses of NS are used to correct the sodium level. Some in the special operations community will use it as a volume expander in trauma patients when it is not possible to carry large volumes of fluid. The idea is that the added sodium will draw water into the vasculature by the osmotic pressure, thereby getting you a lot of mileage with a small amount of fluid in your pack. This might be okay, but it makes a lot of assumptions: a) the patient is young and healthy and does not have a derangement of sodium already, they don't have kidney or serious heart disease, 3) they aren't already dehydrated (and possibly hypernatremic), which may be a stretch in a soldier who has been on the battlefield in body armor for hours already. I'd probably reach for the hespan before the hypertonic saline in this situation. Note, though, that the colloidal solutions (hespan) and hypertonic saline haven't shown any benefit in trauma patients over traditional isotonic fluids, so we stick to NS and LR when space and weight aren't an issue. This sounds like an interesting study. 'zilla

Hypertonic saline will draw water into the vascular container, expanding circulating volume and worsening the fluid overload on the heart. For this reason, CHF patients often find themselves in trouble if they do not watch their salt intake. Some just can't resist that piece of ham. Renal insufficiency or renal failure compounds this problem, since these patients cannot get rid of excess volume or excess salt easily. CHF and renal insufficiency/failure often go hand in hand. Renal failure patients in acute CHF pose a particular problem for prehospital and ER providers since you can't really remove the fluid. You can reduce preload with nitrates and improve pump function with dobutamine or dopamine, but dialysis is the only way to get the fluid off. There are a handful of absolute indications for dialysis: 1) electrolyte disturbance that is severe and/or refractory to treatment 2) metabolic acidosis/alkalosis that is severe and/or refractory to treatment 3) fluid overload that is refractory to treatment 4) BUN >90 5) Poisoning with certain substances, such as aspirin, methanol, or ethylene glycol Low doses of dopamine (the "renal dose" of 2mcg/kg/min) hasn't been shown to do much to improve outcome, so it's a practice that has fallen out of favor. There are some old school docs who still cling to it, but their numbers are dwindling. Good kidneys are very forgiving of salt intake. A young otherwise healthy person's BP doesn't usually flutuate too much even with large salt loads taken orally (mmmmm.... canned soup). At first, the kidney senses the increased salt concentration. Thinking that you're dehydrated, it retains more water expanding the blood volume. This increases the pressure on the kidney and flow through the glomerulus, increasing filtration, dumping the excess volume. The volume will normalize within hours, and when combined with the compensating effects of vasoconstriction/dilation and pump variability, the BP doesn't move too much. In a person with hypertension, atherosclerosis, or preexisting heart disease, the vessels can't compensate for the increased volume, and hypertension and/or CHF results. 'zilla

The fact that you have friends and loved ones mostly outside of EMS is to your advantage. It helps to keep this kind of perspective. It also helps that your wife will have other friends to hang out with when you're working. Expect that when you hang out with your EMS friends that your wife will be VERY bored unless there are other non-EMS folks to talk to there. As a rookie medic, you can expect the shifts that a lot of folks don't want: overnights, really bloody early am, weekends, holidays. The advantage of this is that you can be home when most others are not. The disadvantage is that if your wife works normal-person-hours, you may not see a lot of each other. Job availability varies by area. Many busy systems are very competitive and may not want to take you right out of medic school. Others will ONLY take rookies, hoping to train them up in the ways of that particular service. Getting a job running non-emergent transports for $9.25 an hour is very easy, and those services are always hiring no matter where you live. Not as exciting and glamorous as 911 work, but it's a steady job with a fair amount of job security. The job is what you make of it. Very few people retire from it, having moved on to other career fields or stepped up to RT, RN, or MD/DO. Being 60 years old banging around to calls in the middle of the night is just not that appealing. The career ladder is limited, being that your choices of moving up usually entails becoming management or going into related work like teaching (ACLS, PALS, Paramedic) or consulting. Ditto on what ak just said. Just remember, like in the ER, you can never beat the rack. What I'm saying is, there's always another call to be run if you hang around the station long enough, and there's always someone else that's sick (there's always another chart in the rack). Avoid the temptation to hold out for "the big one" or spend extra hours on shift waiting for it. Do your thing, clock out, go home. It's a job like any other and a job like no other. You get to see some very neat things, make people feel better, and perform a valuable service to your community. It's an adrenaline rush at times, which is why many people get into it. When that rush wears off, it's easy to become disillusioned, or to spend your time and effort looking for the rush again. At the same time you will see many things which will bother you, which will defy explanation, and Barbara may not really understand that part. As ak said, don't live the job, and this will help stay in perspective. 'zilla

To clarify Ohio's policy... DNR- Comfort Care means that all aggressive resuscitative measures such as surgery, pressors, pacing, cardioversion, and intubation will be withheld, and care will focus on palliation of pain and maximizing comfort. DNR- Comfort Care Arrest means that everything listed above will be done up until the point of actual cardiac arrest, at which point resuscitation will cease. 'zilla