Mateo_1387

Yes, my gps devices are a map, a compass and a wife. Usually the wife is pretty spot on.

Don't even think about asking for directions.

Why spend 400 bucks on a garmin when you can have a priceless wife by your side.

Wow, I think the garmin would be cheaper than getting married. I always heard marriage was expensive

A hearty "BOOO" for the joke, and a hearty "Welcome" to the city!

You have to read the joke with his accent in mind ! It makes it even better.

Welcome to the City

Please feel free to correct me, I've got my big boy pants on and can take it, But I always thought DNR meant " Do Not Resuscitate ", not "Do Not Treat ". A " Golden Note " ( DNR's in NC are on Gold paper, no copies please ) in hand is not a free pass to do jack squat.

The DNR to me is never really clear. To me it means treat them until their heart stops beating. There is so much grey area though. You know the patient is ready to die, they have the DNR in place, the patient is terminal with all kinds of bad things that make their life horrible to live, would you feel comfortable intubating them? I do not think there is a right or wrong answer. My point is that the DNR is just not very applicable in my opinion.

I like the new MOST form that is out. It stands for Medical Orders for Scope of Treatment. The MOST form has four parts to be answered. The parts are: CPR, Medical treatments (including intubation, electrical therapy, and comfort measures), antibiotic usage, and fluid/nutrition administration. I think the MOST form is more appropriate than the DNR because it gives providers a clearer picture of what the patient's wishes are.

Jake, are you familiar with these forms?

The situation you're mentioning is mentoring. It's a different ballgame than sharing tasks in school.

In my experience it has been the other way around. Quite often the paramedic is put in a situation of teaching. Students have questions that they expect the paramedic to be able to help them with. Also while doing patient care and afterwards the paramedic must be able to teach them why certain things were done, what presentation the patient gave, and yada yada. As for new employees they often times must be taught the ways of their new system. Not only should they tell them this is how its done, they must also explain to them why its done. They are in this case (and in my opinion) teaching. To me its more than monkey see monkey do.

Also, a student riding with me assumes that I have at least minimal authority to control their behavior. That is lacking in the classroom.

I do not follow you on this one.

I agree that this is an important skill, but should be taught separately, not tied to my academic success.

Where should it be taught? I agree that it should not be tied to your academic success. If someone does not want to contribute, then do not worry about them.

Later folks !

Matt

When I take a class, I pay my money to get an education, not be a resource for other students that don't share my near freakish need to get good grades. I do absolutely agree that teaching is the best way to learn, but that implies that the person you're teaching is motivated to learn and excel. If not? I don't have the time to carry them.

I agree that you should not be a crutch for another student to pull them through. At the same time, I think that working in groups (or with a partner) is a fine idea in Medic school. Especially if you are paired as one weak one strong student. Let me explain why.

One day in EMS, your job will be to teach someone. Be it a student that comes and rides for a few days, a new employee, an observer, or whoever, the point is that you will be in charge of guiding them during that time. By being exposed to it in class you can already start to get a feel for it in the field.

In just about any college class these days, you are expected to work in groups. The reason for that is that they are giving you a feel for what employment is like. You will be required to work with other people, and you should start to get exposed to it while receiving your education.

Its these experiences that help prepare you for the "teaching"/ working parts of the EMS field (or any field for that matter). That is also why I feel a methodology course should be required for medics, along with all the other hardcore classes that everyone feels should be required for a Medic degree.

A question for the OP, what kind of work are you and your partner required to do?

Dwayne, while I absolutely do not think you should have to "carry" anyone, I do think that you should have dynamics in your group. Not everyone is as "freakish" as you are about getting the grade. That does not mean they lack the aptitude to contribute in a positive way to the group.

Later folks !

Matt

Are you in a truck by yourself? No partner? And how many others show up? Does the code commander come separate?

Each ambulance consists of a two person crew. Mostly they are dual medic. The only single medics are the District Chiefs (which are supervisors, they also carry the hypothermia supplies for ROSC). It is not uncommon to have two ambulances (=4 people), one district chief (=1 person), and an engine (=3-4 people). So on a cardiac arrest there is between 6-9 people on scene.

The code commander is a paramedic on the first paramedic unit to arrive.

Did you ever think that one ED has to put up with the mess of EMS you just described with 6 different EMS people crowding into the ED with one patient? Now, multiply that by 50 - 100 times per shift minimum for some EDs. Add a 100 or so walk-ins to that. You have ONE patient with at least 2 - 6 EMS providers. The RN as 2 - 6 patients and some of those pts may not be very stable either.

I am sorry about the confusion. I forgot to put in the above paragraph that we work all codes on scene. There is no transportation until ROSC.

Obviously the 3 paramedics on this truck don't share the same success rates as you if the best they could do on this call was a King tube and no IV. Maybe your perfect system could give them some pointers.

Well, the first problem is IMHO, is that they transported a code. The success rates are much lower when a patient is transported. The patient should have never went to the ED unless there was ROSC.

I am not trying to make my system out to be the best in the world, because it is not at all. We do have some good things going for us, and what I previously mentioned was one of them.

Again, who didn't not know their place in this situation?

Nurse starting IV.

Doctor intubating. (probably an RT somewhere around there also)

Student doing compressions.

Things were definitely getting done.

I agree things were getting done. I just got the impression from the OP that things did not run smoothly and that he probably did not feel that the code was done properly, and that the patient probably had less of a chance of survival. IMHO I think the patient probably lost his/her chances when the patient was transported.

You are probably right. A hospital shouldn't expect much from Paramedics.

As EMS stands now (for the most part) I agree with this statement. I hope this changes in the near future where ER staff can trust EMS to have done what is the highest level of care paramedics can provide. Of course this will come with education and everything else the old, dead, and beaten (multiple times) horse stands for.

I still think that everyone should be prepared to change gears, ER staff or paramedics alike. ER staff may have to change gears from what someone tells them in a radio call report. Paramedics need to not rely on dispatch for all information and be prepared to change gears when the patient presents different from the dispatch.

Are there statistics that measure if RSI is improving survival rates of patients who qualify for it in the field vs those that do no receive RSI?

You misunderstand me. I meant the report on arrival in the ED.

'zilla

Oops, my bad, I totally missed it :oops:

Yeah, I can't remember where I saw it, but it seemed to say that most of the air would be moved from the bronchial tree, but over time that air is mixed with that from the alveoli. It is not much, but perhaps enough for the short term until intubation can be initiated.

Of course, I'm also just yapping, as I don't remember where I got the info, and haven't seen the studies.

Dwayne

Check this link out

http://emscapnography.blogspot.com/2006/08...hould-know.html

On this link find the LP12 about half way down, and three strips below that is a strip showing the gas exchange with CPR alone.

And you too are assuming. Just because there is a visible IV does not mean it is functional. There was a tube sticking out of the patient's face but not the most appropriate airway. The doctor was dictating but with the wrong assumptions. So yes, he was making the wrong assumptions.

I Kind of have to assume without actually being there to see it. I see what you mean by it being there but maybe not functional. My idea of 30 seconds may be a bit off, but it does not take long at all to figure these things out.

The doctor may have been a rent-a-doc and did not know who anyone was in that ED. The other staff may have been PRN or floats. Unless you are going to work in the ED environment, there may be little you can do to change that or even understand it. Some days things run smooth as silk and then there are times when things just don't click. This may have been a very off day for whatever reason. It seems that it was a very off day for the 3 Paramedics in the back of that truck.

This is no excuse to me. In my system there are multiple agencies that respond to codes, you have a chance of getting two trucks from six different EMS agencies, 1 of five supervisors, and 1 Fire truck from 22 different fire departments. So there is a large degree of not knowing who you will respond with. Yet in every cardiac arrest there is an established code commander, and the cardiac arrest always run smoothly. In the cases reviewed where mistakes were made, there was not code commander present.

We boast high resuscitation rates. Everyone knows there place on a call. Same should be the case for hospital staff.

Let's not forget the importance of a good prehospital report on arrival at the ED. Maybe one wasn't given, or the doc wasn't listening, but the IV and airway issue should be known on arrival with a good report. "Down time...yada yada yada... attempted intubation unsuccessfully, so placed a King airway... attempted IV unsuccessfully.... put a 20g IV in on this side but I'm not sure if it's working....summary of drugs that have been given...last drug given....time since last epi..." These things will set the priorities for the physician and let him know what to address immediately and where we are in the ACLS protocols.

I have a different view on this. Say you get a good review from the medic. If they are 10 minutes out things quite possibly will change. The last drug given, tube placement, anything. When that patient comes through the door, you are going to check that the tube is in the right spot, weather they told you before hand or not. If you expected it to be in place when they came in and it was not placed properly, then you should be prepared to fix it.

In my opinion the radio report should consist of "we are en route to your facility, full code, eta 10 min." That way you know to have a team ready to do anything you need to have done. If things are done before they enter your facility, kudos to them, otherwise be prepared. I think it is bad to have tunnel vision before the patient arrives and be thinking one direction, when the patient arrives just to be slammed and have to change up. At least if you a left in the dark, you will not be surprised, and can give appropriate care in an organized manner.

In my honest opinion it does take a couple of semesters to understand enough cardiology to be paramedics. In my school, We had a semester of cardiology during our first summer. We learned quite a bit, but as I did research, I found that there was still a lot more to learn.

In my school the Cardiology course gave us a strong foundation upon which to learn. In the second year of paramedic school, we have reviewed our knowledge base from the summer, plus we continue to add to it during the spring and fall semesters, as well as our last summer semester.

The basic concepts are not really that difficult, learning the anatomy and physiology. But you add on learning the rhythms, what each wave means, what different measurements mean and you have a different story. Then you add on to that how the patient presents and what physical finding you will find with certain rhythms and you have another level to comprehend. Then add on to that treatments, what drugs do in the body, and how they affect the heart, taking into consideration you patient, and it takes a few semesters to get the full grasp of it. But still that is the tip of the iceberg in my opinion. We still need patient encounters to still understand it better. And there will always be that Cadiologist that still understands it 100 fold what even the experienced paramedic knows.

You can learn the basics, what you might get from the medic mill, but it is not worth anything to me. I think you get more knowledge from an Anatomy and Physiology class about the heart than the medic mill.

I guess as a recap that what I listed above is my idea of basic cardiology. The field of cardiology is huge, and medics just do not have the full understanding.

Medic mill = tip of a needle of what you need to know

Paramedic degree with continuous study = Basic cardiology

Cardiologist = Full Shebang.

Understanding what I described in full is a must. It just cannot be done properly in three weeks at the medic mill. It takes a lot longer.

Dr McCoy, Star Trek (correct wording)

What he was not, varied by episode.

That is a classic

McCoy is my favorite Star Trek character of all times.

My personal favorite are:

"He's dead Jim"

and

"That green-blooded ......."(in reference to Spock)

Epinephrine does not have any dopaminergic effects. That is an entirely different mechanism and does not belong here.

I was meaning dromotropic, not dopaminergic.

With the short time frame you are suggesting, allowing the pump to come back on its own would be much preferred. Dopamine is not necessarily recommended for someone that can maintain perfusion, as this situation probably could. There is a big difference between unstable and need to treat. You would be able to support perfusion with fluid boluses for a while, as you are watching this patient's MAP.

Great point. There defiantly is a difference between unstable and need to treat. When I said unstable I mean the patient in shock that is about to code again. The Dopamine in the case would be to maintain profusion to the brain long enough to get the patient to a Cath lab to correct the blockage.

I am curious. How many people were in the room working the code?

Just from what I have read, I think the problem with the code is leadership. One person should be on top of everything. This person is the doctor. Being that the OP's area obviously carries all their codes to the hospital, the ER staff should be capable of working them smoothly. Codes are so ....."cookbook"........ So, it is my opinion that leadership would have been the problem.

Even if the hospital may have expected more treatments, the commander should realize in the first thirty seconds what is done. When they first walk in they can visibly see if and IV is established, the person is intubated, the monitor is applied. When these things are not done then that is the time for the doctor to start dictating what is to be done. What I am saying is that instead of saying something like "I need and IV, epinephrine, Intubation" say " Terri, get an IV established, Josh, get the epinephrine ready...." and so on and so forth. This way everyone will know their job.

I remembered something else. My memory was triggered from another post.

ALWAYS ALWAYS ALWAYS make sure to have copies of your clinical packet !

This is why...

Here are my tips for the paramedic field clinicals.

Get to know your preceptor(s) if you ride with them for multiple shifts. First impressions are really important. You will want to be a team player as much as you can. Your goal is for them to view you as a partner rather than a student (although you will always be "the student"). To get to this point make sure you know what you are doing, and always work for improvement.

I do not agree with the whole "ask so many questions" thing. If you just keep going and going and going they are going to think you are an idiot. I would ask questions when you have them, but I would not ask so many that they think you really are incompetent. They probably already think that just because you are a student.

I suggest you talk to other classmates and previous people you may know who have had to work with the preceptors you will ride with. Also if you are not familiar with the station location then I would suggest that you locate it in advance, and possibly drive to it. Get things ready early so you are not waiting until the last minute when things can be frustrating.

I suggest when you first get on shift make sure to introduce yourself to the crew you will be riding with, and try to have a positive attitude. Talk to them early about how things will work on the ambulance so that you are not figuring it out on a call. They will probably ask how comfortable you are with patients and etc. Be ready to make mistakes but be strong enough to work through them and improve.

You may also write down some of your weaknesses so that you know what to work on. You can bring these up with your preceptors and they can advise you and hopefully you will have calls where you can work on them.

Bring equipment (watch, stethoscope, clinical packet, extra set of clothes, or whatever is required of you). Depending on your area you may also want to bring some food.

Become familiar with equipment in the ambulance so when it comes time to use it you will be capable of doing so. Same goes along with protocols because sometimes what is taught in class is a bit different than what "the cookbook" says, so make sure to be somewhat familiar with them so you are better able to be part of the team.

I also suggest that you run as lead on as many calls as you can. The more you do the more confident you will become.

I hope this helps you out. Most of it is common knowledge, but maybe it will help to hear it again.

Good Luck !

Not a particularly good comparison. In Iraq, I wear body armour only when leaving the camp, or when the shit starts hitting the fan in camp. In America, I wear body armour at all times on-duty. In Iraq, I am able to predict potentially deteriorating conditions. In America, I am not.

I am curious how you are better able to predict potentially deteriorating conditions in Iraq. What do you do if you are caught on the other side of the compound/base/wherever you are without your vest and conditions deteriorate?

...Most shootings are the safest scenes you will make. First of all, the scene should have been cleared by LE before you even get there. Second, damn few people ever stick around to greet the cops after they shoot somebody. Third, ask one-hundred percent of all medics (or cops) who have been shot if they were expecting to be shot on that call. One-hundred percent will tell you no.

Yea, I see your point, pretty weak argument on my part to use a vest on a shooting.

The point? You have ZERO ability to reliably predict which scenes you will or will not be attacked on. That's like saying you should take your blood pressure meds only on days you expect to have a stroke on. It's quite simply idiotic thinking. Do cops only carry their guns to the calls they expect to be shot on? What percentage of cops who are shot are shot at the scene of a previous shooting? I can assure you that it's pretty damn small.

Again, what makes you more capable of predicting when thing go wrong in Iraq than in the US? I would wager that it is more predictable here than in Iraq. If I go to an area that I know is laced with crime, assaults against police, fire, or EMS than I can predict the chances of getting shot are higher. But then again you are right that I cannot always predict the situation 100% of the time.

Furthermore, Strokes kill over 150,000 per year, with approximately 32000 being hemorrhagic. Guns killing EMS personnel is "10 mostly from homicides" per the study cited by Anthony in a five year period.

I still do not see the emphasis put on the vests when there is a greater chance of being hurt in an accident. If I was provided one, I would be apt to wear it, just because it is provided. Same goes with turnout gear, its for my protection. I will not be all that worried if I am not given a vest.

...Use your head, bro. I know you've got a good one.

Thanks!

And why shouldn't we be utilising body armour to protect ourselves from vehicular accident injuries? What is the downside?

I am sure it would help. I am saying that it should not replace a proper restraint system. Like your post from 2005 where you said the vest protected you from a rubbernecker, I can see it working well. Being an MVA I would think turnoutgear would do that same thing.

Ok, so why would they even bother calling in the first place then? If the physician is not going to "form her" for danger to self or something, then what will bringing an ambulance into the picture accomplish?

Agreed !

I agree that this patient, as presented in this scenario, appears "with it". The fine line of failure to thrive, danger to self, etc... is in this situation. Is there that much of a difference between the depressed person who can't sleep and took an OD of ativan with no intent of "self harm" per say or this patient? This the former more likely to be "formed"? Probably...

My beef with this is that the patient has a right to be a danger to herself if she so well pleases, with of course the understanding she is capable of making her own decisions. I do not feel that a comparison to someone who can not oversleep is accurate. I would compare it to someone who is a risk taker simply because they do not care. But even that comparison is shaky. This is a patient (from what I am getting from the OP) who is probably ridden with medical problems, and has little chance of leaving the SNF unless she is dead. Again I think the root of her problem should be the focus of the doctor. To tell you the truth, I would be willing to wager that the patient would be a candidate for Physician Assisted Suicide, considering by not eating she is basically committing suicide.

Either way, the doctor and the family are idiots in this case. These are probably the same type of people that call 911 for granny, but stop you at the door saying "She doesn't know your coming..." :roll:

Yea, for real...

And to the OP, all things being equal, unless she was eventually deemed mentally unfit by the physician on scene, you did kidnap her.

Prepare for the lawsuit.

There always remains that possibility.

See this is what I never understand. The family and physician obviously know that she will refuse to go with the ambulance, why the hell do they even bother calling unless some legal intervention has been taken. All this doctor had to do is declare her a danger to herself and "form her" so that she now does not have a decision. Simple as that. Her doctor was there (or immediately available if you were talking to them), why would you even bother calling your medical control?

This isn't a gray area, it is the doctor and/or family not doing their job.

If she is capable of making her own decisions then the doctor would have no right to "form" her. He is not in charge.

For the scenario, if the patient is capable of making her own decisions then I think her wishes should be met. What needs to happen with the patient is find out why she has a failure the thrive. Just presuming here I would wager that the patient is severely depressed, or just wants to die, or more likely both. Of course if I were sick enough to be stuck in a SNF, with nothing to do but watch TV, look at four walls, and have pills shoved down my throat day in and day out, I would probably have a failure to thrive too.

This thread has really got me to thinking. I have had to leave it, think on it, and then return to it just to do the same process again.

I am all for safety, I want to return home by the end of the day as healthy as when I went to work. So this is how I see it.

The major issue we face as far as danger goes is an ambulance crash. Restraint systems are a must, as well as ambulance design with injury prevention in mind. I agree with wearing a seatbelt, but too many people in the profession do not wear a seat belt. I feel a bullet proof vest should not be used for injury prevention in an accident, a proper restraint system should. The money to buy bullet proof vests I think would be warranted for protection from on scene hazards such as gunshots. On the flip side, I think more emphasis should be placed on vehicle safety than risk of gunshots. But then again the information I am getting from the thread is on deaths from each category, It doesn't say how many paramedics are exposed to each category, or survive from something in the category.

I personally would not want to wear a bullet proof vest unless it was warranted, such as going to a gun shot victim, serving in Iraq, or other such situations.

We cannot be protected from everything, but why not if given the equipment use it for your own safety. We are issued gloves, turnout gear, have seat belts, and other resources (police) at our disposal. So I would say use what is given to use to keep safe.

Edited once because I forgot to use the spellcheck

Around our area EVERYONE ( except two newly educated persons (riblett and myself)) call the class B uniform as Class A. If I am not mistaking, if we wear the uniform to a special event, such as a funeral, then we add a tie to it and look "professional."

Read that post you quoted closer... I did misspell something. Look hard... you'll find it!

Wendy

CO EMT-B

Rhabdomyolysis

Yay, I win...........jk

But really, who is looking anyways? :wink:

I would say use valium. It is a great benzo that will cause muscle relaxation and some calming effects.

What I got from the OP was that "slammed" meant that the full dose was given in one push instead of titrating to the desired effect. I also think the OP felt like she learned a lesson from pushing the full dose and having to fight with a patient who was in pain.

As for the stories Ruff that keep getting better and better, how else are we supposed to be entertained with other people's stories......

My story is actually a bit different. I had a patient, a cancer patient, who was unresponsive. We determined that the patient had overdosed on their narcotic meds. The patient had vital signs within normal limits. I took the call and decided not to give any meds because I would have to make the man experience the pain from his cancer all of a sudden. We left it in the hands of the hospital because they would be able to give him other pain meds that would ease his pain without using narcotic receptors.