UMSTUDENT

Doc, Hopefully I can provide some answers and potential solutions to take to your local elect-tards. 1) I work for one service that is 3rd service, private not-for-profit that works in cooperation with several volunteer fire departments and one large municipal service. At my other job I work for the fire monkeys... While I have never encountered a fire department that bills EMS for service, there is a potential solution to take to your local council. Fire departments can bill auto insurance companies for crash response and clean-up. Additionally, if they respond to a call on Interstate or Federal highways and perform extrication functions, they may receive reimbursement from the DOT. MVCs are probably the most lucrative types of calls for EMS and fire. Most plans provide anywhere from $500 or more right-off the bat to be provided to fire companies that respond to these types of calls. EMS organizations almost always receive 100% reimbursement under the patient's PIP (personal injury protection/policy). 2) There is no IAFF recommendation, since they're just a union. The NFPA (National Fire Protection Association) sets consensus standards for most types of fire response. Depending on where you live, your state's Occupational Health and Safety agency may be what is called a "NFPA state." Some states, instead of spending the millions of dollars necessary to develop their own administrative laws regarding fire response, may simply elect to follow, word-for-word, all NFPA standards. This essentially makes these consensus standards administrative law. I'm not sure if they have a guideline specifically related to MVC response, but it wouldn't surprise me. I'd look into this if I were you. Irregardless of all of the above, it is 100% a recognized "good idea" to have fire departments respond on all forms of MVC. At the very least, simple accidents require an engine to respond for fire suppression (in case the car flashes over, or blows up with personnel inside). Most jurisdictions require that a "Class A" (large, structural firefighting engine) engine respond on calls found on major roadways (Interstate, major state routes) simply to block traffic. Fire engines provides tons and tons of steel between a 50 MPH car and working crews. This whole situation is stupid and irresponsible. I can't imagine even the most redneck fire department around here EVER wanting to give-up their response to a motor vehicle collision.

We draw blood in our service, but it really depends on whether it gets used or not. I personally believe that labs should be drawn by trained professionals. I was never taught all the intricacies of blood draw and I definitely can see how EMS labs can be skewed. For instance I have been told that if you used a alcohol prep during skin preparation that any testing for ETOH is invalid, at least in certain states. I know for a fact that the chain of custody is extremely important in DUI/DWI cases. Our service used to use vacutaner adapters that connected right to the catheter, allowing blood to shoot, under relatively high pressures, into the vacuum tubes. Apparently this was discontinued after it was revealed that lab values were off. Apparently RBCS would lyse, etc under the pressure.

Your medical director has nothing to do with establishing case law*, nor will he get the final say in saying if the care you provided was reasonable. Most likely the plaintiff's lawyer will hire a battery of experts who are more than capable of assisting the lawyer in asking the following questions: "Mr. Paramedic, did the patient want transported to the hospital?" "Mr. Paramedic, did you deny the patient transport, against her wishes?" Mr. Paramedic, is there a giant CAT SCAN machine in the back of your ambulance?" "Mr. Paramedic, do you have the capability of rapidly assaying a series of basic blood chemistries?" Again, I'm talking about a wrongful death case here. If your patient dies 24 hours after you last saw them, and the reason is determined to be of an acute cause, you're probably done. I mean, you're talking about administering a narcotic analgesic and a antiemetic. I mean, as an EMS provider you're essentially treating symptoms. I understand that there are tons of patients who have chronic problems that can be mitigated with these medications, but aside from that, it is hard for the current model paramedic to really make a more informed decision. *Note: If your medical director specifies exact instances where you may treat, release, or deny transport without there being significant medical decision making on your part, you're probably ok. Hopefully he'll hold any liability that may arise.

Don't get me wrong, I am a huge advocate (as some can tell you) of treat and release programs. I just don't advocate treating and releasing patients who may rapidly decompensate and die within 24 hours of our release. Get my drift? If you can make a field diagnosis, given presentation, that will generally result in the patient both surviving and giving them "reasonable" time to properly advocate for themselves, I'm all for it. What I mean is: A) Better educated Paramedics who are capable of understanding the true implications of releasing a patient, with a given presentation, to home. Making sure the patient is reasonably well to come home, mentate, and remain well enough to involve the health care system in any further deterioration. Doctors release patients to their homes all the time without necessarily running a battery of test, but they understand those implications and they definitely release them in a state of being where they're capable of recognizing any increase in illness. All too often we (EMS) leave chest pain patients, unstable diabetics, and demented elderly patients at home without much of a chance. I There is a perceived finality to calling 9-1-1. We are the safety net of health care. If someone calls for us, they generally believe it to be such a severe predicament that they need transportation to a hospital. Granted we all understand there is severe abuse in the system, but I haven't seen a good way of properly filtering these patients out with the current toolset available to EMS providers (mainly education wise).

If the patient dies, especially within 24 hours of being seen by EMS, you are probably going to loose that lawsuit. Negligence and gross negligence, what I believe you describe above as "harm, are two entirely different things. Gross negligence is generally a total failure,or "blatant violation," of a legal duty (as defined by law). Negligence is generally defined as "what," if anything, a "reasonable person" with similar capabilities, understandings, and insight would have done given a similar situation. Specifically, negligence can be defined into two very important aspects when it comes to EMS: Duty of Care and Breach of Duty. If a judge can show that you should have seen "reasonably foreseeable harm" or that you failed to provide a service that would have resulted in less harm, then you're are most definitely negligent. You, as an EMS provider, do not possess the entire gambit of capabilities that a hospital does nor do you hold a professional doctorate stating that you are a "practitioner" of medicine. You are not legally able to definitively tell someone that A) There is nothing wrong with them and They will not die. Now, your example in regards to treating and releasing is an entirely different arena, but still very shady.

Not transporting a person isn't so much an issue of administrative law (Code of Regulations, etc), but one of case law (civil proceedings/lawsuits that resulted in judgements that set legal precedent). This is another reason why ALL paramedics need to have a basic college education. The way the legal system works is pretty clear. All judges rule based on legal precedent ( Stare decisis ), this is especially true when a ruling has been made by a higher court (in progressive appeals) or in a court of equal stature. A lower court's decision may be taken under consideration. For instance, say that in your state a judge has previously ruled that if you deny transport, and a patient dies, then you are civilly liable for certain damages. THEN if other similar cases are ever brought before that court, or a higher court, you also may be found liable. This is how the English system of law works. This system is true in every State except for Louisiana, which uses a French Civil Law system (laws are interpreted more literally, as a matter of legislation on a case by case basis). SO, in the United States just because there isn't a specific statute (statutory or administrative law) doesn't mean it isn't so. All it takes is for one judge to interpret an existing statutory or administrative law a certain way to essentially rewrite the way a law is interpreted and applied. Most EMS agencies choose to transport ALL patients who request it simply because they are scared of litigation. Even in cases of lacuna (non liquet-meaning "it is not clear"), or there is no current precedent, there may be one in a neighboring state or elsewhere in the country that makes it all the more likely for a judge to rule a particular way. When you ask yourself whether it is a good idea to deny transport, seriously consider this: "Is there the possibility of being sued?" This is why it is important to have a politically powerful EMS regulatory authority that has the ability to establish administrative laws. For instance, if you want to give paramedics the unequivocal authority to deny transport then you must establish it via law. Still, of the examples given on this forum, almost all of them include the caveat that there be no "true emergency." Again all it takes is for a judge, with the help of an expert witness, to determine that you used poor judgement.

I believe there is an entire body of research into the phenomenon of how people perceive pain. I think some of it has to do with how culture has begun to look at pain and how comfortable new generations are with describing their pain. For instance, I encounter patients all the time who are probably in some great deal of pain, but not a 10 of 10. I always like to describe a 10 on the Verbal Analog Pain Scale as being the "worst imaginable pain." For instance, I think of having my arm sawed off or something. I hate to pass judgement, because I constantly remind myself that it is "not my experience." I'd hate to be 80 one day, in incredible pain, and have some punk paramedic deny me medication because he thinks I'm over exaggerating. I just think a lot of people confuse general discomfort with what I think of as pain. It's hard because when you've never really experienced a big injury, or broken a bone, etc you really don't know what real pain is.

You do realize that Morphine metabolizes slowly in the elderly? Repeat doses increase the risk of respiratory depression since it will remain in the system longer. Again, use with caution.

True, good catch. No true "controls," experimental parameters, or randomization to speak of. Like I said, there are limitations to the study, but it is important to consider. I think the recent information regarding the role of inflammation definitely calls for additional study.

Seeing a couple of misconceptions here. Coronary Vasodilation is really a secondary perk to both Morphine and Nitro. We give both in order to cause a systemic, peripheral drop in SVR and thusly preload. Lower preload essentially results in a decrease in the need for cardiac oxygen consumption because of less work. Please review Frank Starling's Law... ALSO, and for some reason not many remember this, but Duke performed a pretty big landmark study years ago that showed that Morphine administration for MI resulted in a 50% increased mortality among patient's who had received it. Remember that histamine release? Well histamine happens to be a big mediator in the inflammatory process. This is especially crucial given the finding, released just the other day at the AHA's annual meeting, that shows just how much of a role inflammation plays in MI. Duke Morphine Study TIME Article: "Statins May Halve Heart-Attack Risk" Your "Doctor" may not read up on the literature, but you might as well. Granted, one study from one institution does not categorically make Morphine a bad drug (I think the study specifically referred to Non-STEMIs), but it is something to think about. Pain causes anxiety and Fentanyl is definitely an excellent sedative and pain reliever. The cardiac and physiologic issues associated with anxiety can be detrimental. Treating a patient with right-side involvement (ST elevation in V4R in the presence of inferior wall elevation) is a tricky endeavor. By no means would I always rule-out nitrates, but I would heavily consider a fluid bolus so long as my patient wasn't also in eminent cardiac failure (possible APE). I like Fentanyl and I think it is an excellent EMS drug for all kinds of uses. The problem is that it gets pushed in micrograms and has a much larger potency in comparison to Morphine. I think some medical directors shy away from allowing its use for fear of abuse and incompetent administration.

When I started my current job I began with three other people from my university with Bachelor's Degrees in EMS, specifically paramedic science. On the night of our graduation from the fire-monkey academy the division director stood up and said that he "couldn't remember" the last time "so many well-qualified, well-educated individuals" had graced their service. He got a lot of jealous stares... Since I began, it hasn't been uncommon for the four of us to meet up at local hospitals bringing in patients. We hear tons of complaining and whining. "Here comes to cocky college sh*ts." The degradation that has followed us has been appalling. What's interesting though is how some people, not many, but some have started coming to us and asked us about our education. They've seen us do something in the field, or they've just been interested. They talk for a bit, maybe balk at the idea in the end, but nevertheless they are interested. I've heard more talk about "going back to school" in the last couple weeks than I've ever heard at any other gig. The fact of the matter is that education is scary for people who lack it. The idea of a younger, more qualified, more capable provider makes them...well...obsolete. In some cases people see the shortfalls in their own understanding of things. How is it that some "kid" in his twenties knew to do that? If you offer the classes people will adjust. More importantly, a degree never expires. It always follows you.

100% agree. I can only imagine how costly those cartridges are.

I was going to go there, but not everyone seems to be on that page. A local flight program utilizes I-Stats. Would love to have one, but those "dang fangled blood labs are for fools!" Get my drift? I think we can both agree that more educated paramedics would give way to a lot of solutions.

Nope, unfortunately this is an area where our system fails miserably. We have problems getting a face sheet around here, let alone actual patient care information once we drop them off. This is pure ignorance on the part of the staff at this particular hospital. At my part-time job, in a different jurisdiction, I have considerably more success. Again, I think if most paramedics knew the continuity of care once they dropped a patient off they'd be much more inclined to understand why education is so essential. I have a respect for the process only because I spent significant amounts of time throughout hospitals during my clinical education. And because I'm curious by nature...

Scenario: You bring a patient to the hospital who has a VERY symptomatic bradycardia (idioventricular rhythm). The patient, for all intensive purposes, is barely conscious and has a sense of impending doom. You're pacing the patient, having gotten good electrical and mechanical capture. You've successfully raised the patient's blood pressure to a respectable 80 systolic, which is of course much better than the unobtainable one you auscultated inside the nursing home.You're coming from a nursing home across the street so pressors are not on board... You bring your patient into the code room of the local emergency room and while the doctor is attempting to secure central venous access, your local emergency nurses pull off your limb leads and turn off your monitor. Keep in mind that they've been instructed several times by the Paramedic team (including supervisor) that you are indeed pacing successfully. The physician has asked you to keep the patient on your monitor. ALSO keep in mind that the nursing team has not turned on their LP 20, nor have they prepared to make the transition to their monitor. Finally, your patient decompensates with the lack of electrical assistance and the physician gets lividly pissed. It is only with your EMS team's assistance and the assistance of an experienced nurse that pacing is restored. The physician successfully establishes his line, dopamine is hung, and he prepares to insert a transvenous pacer. Patient is stabilized. My question: What education do RNs receive in most nursing programs regarding cardiology? How about at the BSN level? Finally, how does a CEN differ from a regularly licensed RN and what does that certification entail? I'm asking respectfully, because I'd like to think that there is a reason for this problem.

Trippl...o? Yeah, same here. Put prehospital medicine into the universities of this country...

I have to agree with much of what has been said here. 12-Leads, when placed in the hands of paramedics who do not have institutional or system support for recognition, are pretty much useless. Our system specifically transmits suspected STEMIs to the local center so that the cath lab can be activated. Where I think the 12 lead fails prehospital providers is in the rarity at which a provider will see a true STEMI. I have seen very few true, "look at me", STEMIs in my practice. I find new onset BBBs, T-wave abnormalities (hyperacute, inverted), and noncontiguous/nonspecific ST abnormalities more often than true ST elevation. I think patients simply access the system during one of two phases in the disease process: Early or Late. First onset of chest pain or other abnormality and people seem pretty quick these days to dial 9-1-1 OR they have a latent MI that manifest as chest tightness, abdominal pain, or nonspecific pains later in the continuity of the illness. I have a lot of patients where I see suspicious 12-Lead presentations, but that don't meet criterion as STEMIs. This is where I really wish I had enzymes... The problem is, IMHO, is that we in EMS are taught to alarm the bells every time we see the slightest hint of ischemia. We take this very seriously, administering nitro and aspirin and aggressively transporting to ERs for evaluation. The problem is that we don't necessarily get to see the whole picture. We never get to see the enzymes that allow physicians to determine general onset. We often don't get complete medical historys that tell us if that BBB is preexisting... In the continuity of care, in-hospital providers are able to develop experiences that let them gauge the severity, specificity, and sensitivity that certain signs (aka ECG changes) represent. They also have many more tools at their disposal to properly diagnose the issue. I think this problem could be better solved through better education both in and out of the hospital. ED physicians and nurses need to understand that we're doing what we believe to be right with the limited resources we have. They need to take our sincerity, well seriously, and look at our ECGs with an inquisitive eye. They also need to realize that for all intensive purposes, most prehospital 12 leads are of diagnostic quality. I understand that JCAHO has the 10 minute requirement, but that doesn't mean you can't take a look at our good work. Paramedics need to be better educated on the sensitivity and specificity of these test. We need to learn how to properly identify real issues. What is essentially nondiagnostic and what requires immediate notification and intervention.

Oh lovely, another misnomer of our profession. You shouldn't be wrestling with your patient following the administration of Narcan. I personally believe this is one of the most poorly utilized drugs in EMS. I had this argument with a paramedic from another service a while back. Their service would automatically intubate any patient with respiratory distress, regardless if they had a strong suspicion of narcotic overdose. Then, they would push that naxolone, the patient would wake-up, pull the tube, and get super pissed off. Naxolone should be gauged based on desired effect. Do you really need to push 2 mg on every patient? Probably not. For some reason we push it like candy in EMS. "What you took some HER-ION?" "Let's slam 2 mg of Narcan 'cause that was what I was taught in class 15 years ago!" If you strongly suspect Narcotic overdose, you probably don't want to get rid of any sedative effects (situation dependent). Push to increase respiratory sufficiency, maybe bring them out-of-it a little, and let them be. When you slam Narcan you have the risk of causing sudden withdrawal, seizures, and tremors (I see this a lot). You piss your patient off, they get violent, and you cause everyone more problems than it is worth. Granted, I understand that there are some patients who have an "all or nothing" reaction to the drug. Likewise, some patients legitimately require intubation and respiratory support, but you have to increase the sophistication of your assessment and utilize this skill as appropriate. Note:Obviously, follow your protocols. But if you can, and you're allowed, just be cautious with the administration. Remember: Do no harm.

I was under the impression that this was United States Code... Wait, found it: Electronics Communication Privacy Act of 1986. This statute generally applies to criminal "wiretaps," but has been interpreted to expand the rights of employees within their place of work. http://www.informationweek.com/news/securi...icleID=26806697 ECPA, as interpreted through case law, generally only allows silent video recording. This is of course if the employee is notified. However, as the article above states, many states now consider video with or without sound as a criminal violation. Also, there generally has to be a "reasonable business justification," of which spying on a union probably doesn't cut it. The only reason I know this is because we spent considerable time on this during my management education. Most employers severely overlook the number of federal and state statutes that govern how they treat their employees. An industrious employee with even a hint of motivation can severely screw you, if you don't know your stuff.

It's still illegal to visually record an employee without first making them aware of the possibility. You can engage in video only, no sound, so long as the employee is fairly warned ahead of time that they may be monitored. The easy way for AMR to win this battle is to prove that there was no audio recording. What good does it do you to record video without sound at a union meeting? If they've got sound...all over.

It appears we're talking semantics...kinda (they're obviously different things). I was always taught that on modern ventilators that SIMV and PSV are kind of in the same, with regular SIMV being replaced by ventilators capable of providing mandatory breaths with "pressure support" for spontaneous breathing. I was taught/told that newer processor technology had greatly improved the capability of SIMV to adequately predict where to place mandatory breaths while simultaneously providing adequate pressure support. It makes sense that there would be a PSV only mode. I'll be the first to admit that I have limited experience with ventilators. My knowledge is limited to purely what I was taught and used while I was still in clinical training. Thanks!

This is simply a group of medics who don't understand the principals of respiratory physiology. I mean seriously guys... We breath by allowing positive atmospheric pressure to enter expanded lungs, which have an overall negative pressure. Sucking through an ET tube without mechanical assistance is essentially like sucking through a straw without the assistance of numerous accessory muscles. SIMV settings on ventilators work by coordinating assisted ventilation with those of spontaneous breathing. It also allows a physician or respiratory therapist to prescribe a certain amount of pressure support during spontaneous breathing to assist with the problems created by breathing through a tube. Again, we need to actually educate paramedics. Ugh!

Yeah, that used to be fairly common around here as well. At least south of here. The birds would self launch towards accidents where they heard ground crews requesting assistance or where they were fairly certain there was entrapment, etc. As long as the weather was right, some of these crews could be greeted by a bird hovering overhead. It's good PR. To my knowledge that is a thing of the past. I think a combination of high fuel costs and heightened safety awareness has now led most to require a call from the PSAP to launch. What is still fairly common is for PSAP's to call and request a bird go on "stand by," essentially asking the bird to begin pre-flight check-offs, spin the rotors, and await further instruction. Up until the recent protocol changes in Maryland and the recent crash it was not uncommon to have the Troopers literally dispatched as first due units to scenes that were reported serious. You would occasionally hear Ex:"12345 George Washington Blvd-MVC, reported serious with entrapment. Engine 8-2, Rescue Squad 4, Medic 702, Trooper 3 respond." The dispatchers would be simultaneously speaking with SYSCOM to have the bird launched. It also wasn't uncommon to then hear: "Engine 8-2, Rescue Squad 4, Medic 702, Trooper 3 responding." As the bird entered the county they often marked up on the air essentially as an incoming unit. See in Maryland, up until the last year or so, the helicopters weren't just seen as a resource for critical patients-they were seen as a resource period (in certain counties). Any MVC or incident where there was the anticipation of prolonged entrapment or multiple patients the Trooper simply served as another ambulance that could bypass the local trauma center, who may be overwhelmed, and take the patient to Shock Trauma, etc. In Western Maryland and the Eastern Shore this was actually necessary because the local Level III centers were (and still) not capable of handling more than one serious trauma. Maryland also practices the whole "right patient to the right place" thing. Specialty centers abound. Hand center, Wilmer Eye Institute, Hyperbarics, Spinal Trauma, Burn patients, Pediatric trauma, and severe priority 1 patients pretty much all used to get flown from rural areas.

I have a close relative who works in the air medical industry for a great company that is extremely safety oriented. Obsessively... One of the things that seems to come up time and time again is the capability of ground providers to triage patients who need transport via helicopter. Local dispatches will try to self-dispatch commercial helicopters to scenes. Crews arrive on scene to find patients not injured. Even still, if none of the above happens they may look up to see another commercial helicopter inbound that they were never made aware of! Not only does this raise the costs of providing service because of unnecessary launches, but crews really can't lecture the "customer" about their poor choice. Local EMS agencies/fire departments get to make a choice when they start calling around for an available helicopter. EVERY single agency needs to follow standardized procedures when making request for aviation. PSAPs need to be made accountable, by law, for their decisions as well.

Very true. In fact I made the final decision to choose the major, because not only did EMS interest me, but because I did complete that very same cost vs. benefit analysis. My mother had been in education much of her life and she forecasted the extreme rise in tuition along with a slumping economy. One of the most attractive things about the major was the relative guarantee of employment immediately following college. Add to this the fact that it is the only major at our school that results in a license to do...anything...a skill. To me this is one of the most attractive things about the major, because if you want to go back to school, you have a steady income to make it possible immediately following graduation. I graduated with just enough debt to make a fifth year risky and unaffordable, so it offered a quick route to relative financial stability. I have friends who graduated with history majors or degrees in chemistry who can't find a job. They're working at malls making far less starting with no direct career path in sight. I started with a salary solidly in the middle class, health care, and a pension. This would have been all ideal had the economy not took a crap. The rising price of everything post-Katrina really put a hurt on the possibility of an affordable post-college existence. I can't even imagine what some of my friends are doing. I struggle to save, which I thought would be a sure reality. Most of them have no job, much more school debt than I, and no route out. I've met some of them who are just diving into graduate school, master's degrees without a focus, simply to defer student loans.