Eydawn

The caduceus was the staff associated with Hermes. It is traditionally the symbol of money and banking. See here: http://en.wikipedia.org/wiki/Caduceus

The staff of Asclepius is the staff with the single snake, associated with healing (and also with the Moses story). See here: http://en.wikipedia.org/wiki/Rod_of_Asclepius

There y'go...

Wendy

CO RN-ADN Student

Looks OK to me. No inferences, no assumptions...

I might leave out stuff like "transport to X facility d/t resources not available at facility of origin"- if it's an interfacility, you can just state transfer of pt from X facility to Y facility for continuation of care...

I might include MORE of why the patient is at risk; for example: "Pt transported via ambulance d/t risk of falling from stretcher as evidenced by (AEB) unsteady gait and reported incidence of near falls at originating facility" (since I'm guessing you're justifying why they were tx'd via ambulance instead of POV).

I err on the side of overcharting vs undercharting, TBH. I'd rather spell it out. After all, if I'm going to be in court with it someday, I want to be able to say "I have nothing further to add, my documentation is complete as recorded at time of charting. Please refer to charting for specific questions."

I think your charting style is JUST FINE. Be consistent in what abbreviations you use to mean what, and you'll be golden... I actually shy away from most abbreviations except for AEB (as evidenced by), c/o (complains of), d/t (due to) and r/t (related to). Occasionally you'll find me using SOB for shortness of breath.

Wendy

CO EMT-B

I personally have gotten into the habit of never looking at the machine interpretation. You make some good points, chbare, and maybe taking a look at it more often might not be a terrible idea. I'll have to think about it.

I do feel the need to point out, however, that this is how Skynet got started... =) First we're trusting the machines to aid us in interpreting our ECG's, next we're their prey to be hunted down and destroyed.

Don't forget the "smart" cars ready to kill us all ala Robopocalypse... (If you haven't read that, go out and get a copy. It's excellent!)

As far as releasing information with hospital info attached, yes, it's often against policy, and though it may be a stretch, it could be just enough identifiable information for some asshat on the interwebs to recognize that the strip belonged to grandma when she went to said hospital on said date and had her EKG run at said time by that nice tech with those initials. Ergo, part of grandma's health information, that is identifiable (by this one jerk), has been made public and it is indeed a breach of HIPAA. Not a harmful one, but one nonetheless that someone could get a hospital severely fined for. That's why they're so strict... it's all down to the $$$...

It's so easy to screw it up. Especially in small communities, where news gets around. If you're going to post strips, definitely remove any timestamps or other regional identifiers to reduce the risk of someone recognizing it. Photocopy the strip, white out anything that could be identifiable, and then take it home with you to scan...

In any case, I'm glad someone's posting strips! Great thread, technicalities aside... and I agree with looking at it yourself first and then looking to see what the machine thinks it is and comparing the two. It's like having your own robot friend... "hey man, I think this is XYZ because of this... oh, you think it's this? Why do you think that?" (Am I the only one that talks to my diagnostic equipment?)

Wendy

CO EMT-B

Congrats! Well done. Usually if you get sent for the pre-employment physical/lift test, you're in as long as you pass that and the drug test... for most companies that I've heard of...

Wendy

CO EMT-B

Ok, I'm serious now. Can we pitch in and SEND you some of this stuff, or would that get you in trouble with the muckety-mucks? I would say dipsticks would be the way to go, as you would have objective data... I agree with the pulled random sample.

However! I would also ask, are you seeing more illness and poorer overall condition among the workers predisposing them to illness as a result of this relative dehydration? Or did you just get a bee in your bonnet to "fix" this? I'm curious as to whether it will actually make an impact, and if it's worth trying to push the culture change over...

Wendy

CO EMT-B

Is that all you're getting ground on? Are you being allowed to practice appropriately? If that's all that is happening, let it roll off you like water offa the proverbial duck... and make a mental note that this particular coworker is a prick.

It's not bad to make conscious, subjective assessments of people. It's just... "information" that you file away in your head that you can refer to later in future interactions...

However, if he is saying things are misspelled, and something like this happens again, DO make him point out the "errors" specifically in front of others. If he won't, call him on it, in front of the others. My guess is that he saw you wrote an excellent trip sheet, realized you weren't someone he could mold, and got nervous that folks wouldn't think he was the "good" paramedic anymore...

Wendy

CO EMT-B

Wishful thinking, O mentor! Lol

So, as most of you know, I've had my EMT-B since 2005. I'm currently in the grace period on my cert expiring (let the national go years ago, now just have the state), and since I'm so busy with nursing school and the new gig at the hospital, I've decided not to try to renew my EMT-B. Starting June 1st (when I'm all officially expired), I will be signing my posts "Wendy, CO ADN-RN Student" until I get my RN in December!

Are y'all gonna hate me if I'm not really an EMT anymore? I promise, I'm getting my WFR this summer (again), so I'll still be in the EMS spectrum somewhere...

Lots of love,

Wendy

The way you write indicates that you are younger, with less experience. You're used to having teachers/others tell you what the right answer is. We're all about self directed learning here! ;-)

Wendy

CO EMT-B

I'm OK with tats. If your profession allows visibles, and that's your style, go for it. Tattoos mean something different to the younger generation than they did to past generations. They are a way to signal your status, interests, etc... they're dead useful info on an unresponsive patient (lots of jail tattoos? Uh huh...)

I'm planning to get a tattoo this summer. An otter, on my right ribcage. Otters symbolize female/maternal strength, they play as adults just like dogs do, and I can add baby otters around the main one once I have my babies.

Know that a tattoo is different than another fashion accessory, such as a purse, style of dress, etc... very expensive and painful to change once chosen, so be very sure it's what you want before you get it... (I've considered the otter for about 4 years now!)

Wendy

CO EMT-B

It might seem obvious after you already know the answer, but to me, it's giving me fits and I don't have much more to add other than some form of anemia. Not seeing any bruising anywhere? It could be that this nice fellow has just adjusted to living with whatever hypoxemia he normally has at sea level, and has become symptomatic simply because he came up to altitude where there is even less oxygen available...

If all you got is your ears, time to bone up on heart sounds brother... you don't need to be a rocket scientist to start practicing listening to tickers. You'd scoff at any normal medic who said "ya know, I'm not real good at the lung sounds thing..." Well, you chose to be Mr. Superman In Da Boonies, so you better fine tune your capability accordingly! You told us to let you know when you were being a bonehead... *poke*...

Wendy

CO EMT-B

ABCs as your first focus is an excellent place to start.

There are a myriad of conditions that can cause altered mental status... your job is to try to find out as much as you can about WHY the patient has altered mental status, while monitoring them until help arrives. The more info you can give the transporting medics, the better... take clues from the environment.

Let's start with totally unresponsive. For example, if the person is found near partially full or empty medication bottles, take a look to see what they are, when they were filled, etc... could be something as simple as an accidental OD on pain pills, or something as complicated as an intentional polypharmacy overdose (many different drugs with different actions). Could be a diabetic- look for identifiers, insulin pumps, glucometers in their belongings, etc... could be post-ictal after a seizure; look to see if they were incontinent, etc. Could be a full blown MI... do they have nitro tabs on their person?

For those who are partially altered, able to protect their own airway, try to get a history from them. What's their affect like? Are they agitated? Quiet and kind of knocked down? Do they smell of aclohol, or is their breath fruity? What are their pupils like? Do they have friends nearby? What do the friends have to say about how they normally are? Are they complaining of pain? Dizziness? Nausea?

As a first responder, you can start gathering info, even though you can't provide many interventions.

I sense a hunger here to know more... have you considered going past the first responder level?

Wendy

CO EMT-B

Killer scenario, sorry I missed it while it was in the discussion phase! Excellent trains of thought from everyone.

Man! Definitely a call you would not have to run...

Wendy

CO EMT-B

Hyponatremia? Could be she's depleted her Na+ as well as her glucose... I want to see more! More info? More on what happened next?

As someone who does event standby, I've seen funky athletes before... my favorite was the gal who came up from Utah to CO (elevation increase), and decided to try 5 hour energy FOR THE FIRST TIME as she came over a pass. Oops. She didn't feel real good.

Wendy

CO EMT-B

Edit: Anyone still believe that this guy was fine 20 minutes prior to EMS arrival?

Yeah, I would have given the steroids following the Mag. Queering his immune system (though that wasn't on my radar until Kiwi mentioned it) at this time is secondary to getting him some air. We are providing some short term relief with our other interventions, but he's going to need something on board that will last a bit longer, at least if our goal is still to avoid intubation. Plus, won't the steroids work towards relieving the bronchconstriction via a different mechanism than the other interventions employed so far?

I would also go ahead and run a 250cc bolus and see if there is any noticeable difference at all, though I'll almost certainly run at least another 250ccs after, depending on results.

It's my limited experience that dry lungs get really unhappy (though I'm guessing that chbare might use different terminology) and get constricted pretty severely sometimes. If no significant contraindications exist, and at least a half assed belief that relative or true dehydration exists, I'll always try a fluid bolus along with the neb to see if it will create a change. It can be surprising (or at least so it appears so to me) the difference that a bit of fluid as the only treatment can make in some of these patients. Though, perhaps there is something else going on in connection with the fluids and I've incorrectly associated 'moister lungs' with at least a partial relief of symptoms. I don't know.

It's my hope that getting him some more air will satisfy his ache breaky heart a bit and we'll stop seeing those transient pissed off rhythms. But, you know, hoping and all...

It looks like, this time around maybe, that watching for zebras instead of horses was a prudent course of action?

What an excellent scenario, run perfectly. With everyone participating in the true spirit of learning...Man, what a treat.

No, but what is "fine" for this guy? Is he a multiple times/day neb tx type of COPD'r, or is he more a silent sufferer who just seems "fatigued" all the time and folks just chalk it up to him being old? Could be he had this brewing for a while, went to lay down because he didn't feel well, folks didn't bother him because he was "napping" and then someone picked up the oogly vibe that said "hey... something's wrong with grandpa... I'm gonna get my nurse to take a look." Who knows. Biebs? Got any info on this?

Significant bronchoconstriction can occur in a fairly short time frame, especially if he had underlying inflammation... I'm surprised he was only being treated with Spiriva (tiotropium bromide), which is a long acting bronchodilator, without concurrent inhaled corticosteroid use. On that note, with the high BP's we're seeing, is he med compliant? Could be the BP is secondary to the respiratory distress, but could be grandpa decided not to take all his little pills today and refused that weird powdery inhaler thing that tastes like ass... so... maybe we're seeing an exacerbation due to non-compliant med use...

Also, chronic dehydration is a serious problem in the elderly, and you are NOT misinterpreting that rehydration often leads to "happier" lungs... if your problem is not CHF and pulmonary edema, but rather acute-on-chronic bronchoconstriction, there's a very real possibility that those lung secretions are nice and thick and dry, and giving some moisture will definitely help with lung compliance and decrease work of breathing. Hydrated oxygen wouldn't be a bad idea (if you get the chance in between nebs... or you could pop a saline neb in there too).

Just my thoughts.

Wendy

CO EMT-B

I wondered when someone was going to get to CPAP... in an old COPD'r, forcing those airways open can do more than waiting for bronchodilators to creep down incrementally... give a dose, 10% opens... give a dose, 15% opens... too much time that we don't have. It will also treat pulmonary edema if that's what we have going on here. If we're closed down enough, you may not hear anything until things get opened up a little more. I might trial 10 minutes of CPAP and then give a neb, if no improvement seen initially with the CPAP continue with nebs as we transport...

To be honest, and to dive off on a tangent here, if the patient has had 911 called for them, chances are good the nurse has looked at them in the last 15-20 minutes. Most CNA's aren't allowed to make the call, a nurse does. Sure, she may not have seen him in the 3-4 hours prior, but she may have report from her underlings, and I'll bet you she looked at him and said "aw shit" before calling 911. Just saying. Since I actually worked long term care and all.

But, the answer should never be "this isn't my patient"- that's what the charting from the previous few days are for. "I'm not sure, but let me peek through his charting really quick and get a picture of what's been going on if I can. Give me 3 minutes." Anyway, back to treating the poor bastard...

Wendy

CO EMT-B

EMT-B: About to lapse, haven't had time to keep up the cert, will probably let it go. Only use it on my SAR team, and they treat EMT-B and WFR the same, so I'll be pursuing the WFR probably... *sighs*... Don't hate on my once I let my cert go, ok folks?

CNA- got the gig OF MY DREAMS on a hospital floor that absolutely rocks (Orthopedic/Spinal post surgical, medical overflow). Rocking it. Just about to come off of "orientation" (Ha! hahaha... I've been working solo since day 2...)

Nursing Student: One more semester, baby! Then I'll have my ADN. Looking at a concurrent dual enrollment through a local college's online program to start working towards my BSN this last semester.

Other: See above, about SAR... non-transporting to hospital, transport from boonies TO ambulance...

Paramedicmike, when were you a firefighter?!

Wendy

CO EMT-B

RN Student

Ye gods, riding herd on the overenthusiastic teener first responder... not an enviable task, to be sure. I don't know how my adult leaders did it when I was in my crew... we had some numbnuts in our brigade... (of course, I kicked ass from the getgo...)

Set attendance requirements. No show? No go. If he still wants in, then he MUST do something like chores around the training unit, grunt work, show commitment to the team...

Good luck! If you think he's just being a teenager and could show promise, and think he's worth investing the energy into, you may make the difference between just another whacker and an excellent provider someday. If you really feel that he's a numbnut who will never change, don't waste your time.

Wendy

CO EMT-B

Mobey: I am seeing all the classic hallmarks of PTSD here (from my knowledge base of the disorder as a CISD debriefing technician and a nearly-nurse). Good on you for recognizing something's wrong. Good calls, bad calls, anything that was a stressor is being worked back through in your brain.

I would advocate that instead of just looking at mental health care as PRN, that you make that one of your first priorities as you're working through this initial onslaught. You've got some pretty good ideas lined out, but I would advocate that you find that confidant in someone who can help you process with a professional angle. Just my two cents. It is also not shameful or harmful to consider that you may temporarily need some medication if things get too hairy. You'd take a Z-pack for pneumonia, right? ;-)

Also... my inbox is always open, and I am used to being a "vault"- once said to me, does not go further than me without permission. I am that confidant for my SAR team for the hairy, not so hairy, and just plain "I don't know where else to take this" kind of stuff.

Lots of love to you, Mobes... hang in there. This will get better!

Wendy

CO EMT-B

This kid needs a pediatric center with ICU management in case he goes into respiratory failure. With that high RR, he's going to fatigue out on us pretty soon. Prep for crashage!

Need to do imaging to see if there's fluid we can pull off via thoracentesis to help with the high respiratory rate. Also, need to give some pain control so he wants to breathe more fully... perhaps some Fentanyl, since we don't want his BP to drop for too long and it's short acting? Glad the fever came down... monitor that for recurrence... keep maintenance fluids going... that diastolic is still a tad low.

My top three differentials:

• Rodent droppings may mean hantavirus. Chills, fever, SOB, hypotension... all fits. Especially for early stage.
  
• Could be a toxicity from exposure to mold or fungus, resulting in the pleuritis, SOB and hypotensive reaction... not so sure on the fever though.
  
• Could be an exposure to a pesticide, accounting for the hypotension, SOB, flushed skin, lethargy and weakness.
  

What do we do? Pretty much supportive care, unless there's a pesticide we can identify and give an antidote for.

That's all I got...

Wendy

CO EMT-B

I too experienced the berating, the weird expectations that you'll know exactly what someone else wants, right after you've been programmed to do what someone ELSE wants that's totally different.

I don't work there anymore. I won't ever work there again. I learned to stand up for what is right and to not back down... and it's served me well in subsequent employment.

Sometimes, when it's toxic, it's best just to leave. You won't change crappy supervisors/coworkers... and if you've tried to approach it as "what can we do to reach a good working relationship" and been rebuffed, it's time to just cut your losses and get out of there before you do yourself some psychological damage (or get set up to lose your licensure).

Hang in there! Go get 'em. There's plenty agencies to seek employment with... take the fire and passion to somewhere that will appreciate it!

Wendy

CO EMT-B

RN student

Your formatting is wonky.

Funny how ONE LITTLE LAB VALUE changes your entire clinical outlook. That's why I look at labs and trends on patients I'm assigned in clinicals.

;-)

Wendy

CO EMT-B

You do what I do! Screenshots!

I'm not the only nerd... woohoo!

Wendy

CO EMT-B

ERDoc- can you PM me a link or two? I don't know where to look honestly.

I don't even lurk nursing forums... I'm kinda loyal to the City ;-)

Wendy

CO EMT-B

Ok then... any exopthalmos? He's got a thyroid storm of some sort occurring. Could have been triggered by any number of things... boyo needs some Lugol's and supportive care at this point. Fluids, cooling, quiet environment, punt to higher level provider than me...

It would explain the increased metabolism (can't get full), hyperthermia, flushed skin, agitation, and diarrhea.

Wendy

CO EMT-B