fiznat

Probably not exactly the same, but one of the towns where I moonlight as a medic has a volunteer department that is under the purview of the local police department. The chief of the agency is a paid police officer who wears a police uniform and carries a sidearm (don't know why), EMS is dispatched by the police and the organization is part of the police budget. The volunteers (and paid medics) aren't considered police officers by any means, though, and the day-to-day operations are pretty much the same as anywhere else.

It sounds like yours is a fairly rare and interesting setup. Are you considered a police officer? Can you function as a law officer at times? Can you arrest (or write psych committal paperwork) for your own patients? How does your relationship to the police department affect your work as a paramedic?

A number of Doctors who called for an EMS transport, to my experience, almost refused to even advise me what they suspected was wrong with their patients. I suspect they felt we were dumber than some stereotyped cab drivers.

The doctors around here like to try that with me every now and then. I don't stand for it, haha... I hunt them down in the office and don't let them get away without getting a report. I've had to shame a few in front of other patients-- "so, doc, I really need to know what's going on with this patient if you want them to go to the emergency room. You're the doctor who evaluated this patient, right?" They'll give you a report-- just push the issue, act professional, and ask questions like you know what the hell you're doing. (not you specifically - just general commentary)

Why is the 12 lead non diagnositc? Artifact or is the ECG itself borderline? If the problem is artifact, just do it again!

I think that while regular folks oftentimes call 911 out of fear or laziness or ignorance, the cause is different with doctors offices. There, I think the main factor at work is liability. Doctors aren't interested in having patients crump on the way to the hospital, and who can blame them. Play it on the safe side, reduce your risk, and make your patient happy. Its win win win.

Benign Early Repolarization

What I know:

BER is one of the classic STEMI mimickers. The repolarization phase of the action potential, for some reason I don't know exactly, occurs slightly earlier resulting in an elevation of the ST segment of the ECG. I know that BER occurs more often in the young, especially thin African American males. Also, the usual presentation is precordial ST elevations in the absence of supporting cardiac signs or symptoms.

Research results:

There is no Wikipedia page on BER. LOL.

BER is a benign condition that exists in approximately 1% of the population. Interestingly, however, the percentage is much higher among patients presenting to the emergency department with chest pain. I've come across several estimates ranging from 25 to 50 percent. Of those patients, 80% will have precordial ST elevations of less than 2mm. Only 2% will have elevations above 5mm. Almost all of BER ST elevation occurs in the precordial leads V2-V5. Limb lead elevations are rare and usually much smaller (80% of the time less than 0.5 mm).

The etiology of BER has not been formally studied and to the best of my knowledge is not known.

BER is a STEMI mimicker and in the emergency medicine setting should be used as a diagnosis of exclusion. That means that patients should not be assumed to have BER until more dangerous conditions have been ruled out (AMI and pericarditis especially). In fact, though the condition has largely been considered benign (hence it's name!), recent studies (here and here) are suggesting that patients with BER actually have poor outcomes down the line.

Specific criteria for diagnosis of BER (from here):

1. ST segment elevation.

2. Upward concavity of the initial portion of the ST segment. (**like a smile not a frown**)

3. Notching or slurring of the terminal QRS complex.

4. Symmetric, concordant T waves of large amplitude.

5. Widespread or diffuse distribution of ST segment elevation on the ECG.

6. Relative temporal stability. (**ECG does not evolve, clinical condition remains stable**)

Also, here is an excellent 14 minute video on the subject that I found.

Sorry I couldn't find more information!

Next question: DKA is a fairly common condition that we run across. It produces a special kind of metabolic acidosis called an anion gap acidosis. Can someone tell us about DKA and how exactly it produces an anion gap acidosis (and what that is exactly!).

Bieber if that is really the information you had off the top of your head than hats off to you. That's some pretty thorough knowledge.

Stand by for a reply on BER.

LOL, awesome.

I actually did my initial EMT training at BU a loooong time ago.... pity this wasn't going on when I was there!

Oh come on. I've met a lot of prick doctors. I've also met a few prick medics lol....

Who gave this guy negative points for this thread? You guys are harsh.... He's not asking anything all that abnormal. He is interested in this job so he can earn a few more bucks doing something dynamic and interesting as well as have some degree of individual discretion in his medical care. I challenge anyone to say those aren't some of the main reasons they got into this work.

I hear the EMtTs make like 9-11$ and the paramedics make 13ish....

I don't know what pay is like where you live but here in CT I make more like $25 an hour as a medic, around $70k per year with a moderate amount of overtime. EMTs are around $15-$18 an hour.

Flight medic positions are usually very competetive (around here at least). You'll need to start out as an EMT and then medic anyways, so you'll have plenty of time to learn about that as you progress through the ranks. You could also approach flight medicine from the nursing side as DD suggested.

YOWZA!!! LOL this is one of my nightmare calls. I deal with so few actual OB emergencies that it feels almost like a foreign planet. The fact that you (or I!) could run that entire call and still have no idea wtf was coming out of that woman's vagina is SCARY to me haha. Could it have been placenta? Did it have a sac-like quality to it? How do you know the sac wasn't a baby gremlin and putting water on it was the worst thing you could have possibly done?! Oh, man.

You didn't follow up with the OB doc or nurses?? I would not have left that hospital until I had a conversation with someone who knows wtf they are doing!!

Of note, since it always comes up:

Peripheral intravenous catheters started in prehospital and emergency department settings.

J Trauma Nurs. 2008 Apr-Jun;15(2):47-52

http://www.ncbi.nlm.nih.gov/pubmed/18690133

The purpose of this study was to determine the rates of phlebitis in trauma patients according to where the peripheral intravenous catheter (PIVC) was inserted in a prehospital setting or in an emergency department setting. Variables investigated also included where the catheter was anatomically placed, the gauge of the catheter, and the patients' Injury Severity Score. The overall phlebitis rate was 5.79%. The rate of phlebitis was 2.92% when started by an RN in the emergency department, 6.09% when started by an intermediate emergency medical technician and 7.78% when started by a paramedic in prehospital setting. There was no significant difference in the rates of phlebitis when a chi-square analysis was performed. In addition, no variables predicted phlebitis no matter where the PIVC was started when a regression analysis was conducted. Even though the Centers for Disease Control and Prevention suggests removing the PIVC within 48 hours if placed under emergency situations, the phlebitis rates of trauma patients in this study meet the benchmark of best practice. Perhaps removing the PIVC within 48 hours of placement should be reconsidered.

Fiznat, I don't know your education level, but your making arguments that sound suspiciously close to "if it saves one patient...". That, quite simply, doesn't fly.

Well not really. This argument has gotten a little bit beyond, I admit, but my main point is that advocating for "no transport on all cardiac arrests" is going too far. My opinion is that there needs to be a protocol that is a little bit more sensitive than that. The one we have where I work makes sense to me:

NO TRANSPORT: Rigor/lividity/asystole, decomposition, injuries incompatible with life (decapitation, transection, incineration, etc), persistent asystole following 20 minutes of ACLS

TRANSPORT: Hypothermic arrests, electrocution arrests, shockable rhythms, ROSC at any point, witnessed non traumatic arrests, etc

I have a bit of an issue when people bring up arguments like Bieber has, where the main point presupposes that we can predict what physicians will and won't do. I have a fair amount of education and experience, and the lesson that has been most important to me over those years has been to respect how little we really know. When Bieber suggests in a single post that we both eliminate facets of our assessment (ECG monitoring) increase our scope of practice ("primary care"), and skip going to the hospital, it sets off alarm bells.

Open chest procedures?! Really? Let's stop CPR to crack the chest? The AHA is saying NO interruptions to CPR. Interrupting CPR is what's killing patients.

Uh, yes. Spent much time in a trauma room? Ever seen cardiac massage? This happens fairly frequently. Then again, you DO have the benefit of all that AHA CPR training. I'm sure you can make that judgement call in the field.

I don't disagree that there should be some clinical decision making with regards to transporting arrests, but I'm saying that the therapeutic value of transporting MOST cardiac arrests, unless you have a mechanical compression device, is nil or in the negatives.

"Nill or in the negatives?" What are these statistics based on? Also, how exactly does a "negative therapeutic value" play out in the cardiac arrest patient?

How about, barring that VERY rare patient for whom hospital intervention MIGHT make a difference, we just sit our happy butts there at the scene, get in good, quality, uninterrupted CPR, give these people the BEST chance for life they can, and when it's all said and done either call it or transport ONCE we have ROSC?

My whole point here is that other than specific circumstances (rigor, lividity, etc), paramedics are not capable of identifying the populations of patients for which physician intervention would have a positive outcome. Turning this into a black and white decision scheme is the wrong thing to do.

Oh you can disagree all you want, but whether or not we're trained for primary care, educated for primary care, or equipped for primary care, that is what we're doing the vast majority of the time..... .....It doesn't matter what the ambulance or the paramedic was designed for......We've got to find a niche for ourselves in the healthcare industry because if you don't think there's people out there who don't think ambulances or paramedics are needed at all, you're in for a rude awakening......maybe the idea of EMS is a joke.....We need to be educating ourselves on more than just emergencies.....We're not just there to put bandaids on them and take them to the hospital. I'm not there just to treat your asthma and pass you off to the hospital. I'm there to tell you you need to quit smoking too, and here's why.......

Blah blah. This is all very inspiring, but you are forgetting that the reason you brought this primary care issue up was to justify treating non-emergent conditions in the field. ...NOT as a segway into some "we need more education" circle jerk (which every thread here devolves to), but to justify NEW and MORE procedures. You say it yourself. If we are going to become something else, then let's do that. ...But that doesn't mean we should start "acting as if" right this moment and start handing out ibuprofen and tylenol. Once again, you are far too eager to make decisions outside of your scope. How about a little humility?

So are you saying you apply the cardiac monitor to every patient you have?

Every ALS patient, yes. If I performed an ALS intervention it becomes an ALS call. I think this is good practice, because I know from experience that we find at least as many clinical signs by mistake than we do on purpose. This is true for all levels of medicine. I understand you are just starting out as a paramedic, but it shouldn't take you long to realize that our most powerful tool is DILIGENCE. You have absolutely no good reason to omit ECG monitoring on these patients. The tools are right at your fingertips, you've got the time. Cast a wide net and I absolutely promise you will catch some fish.

Pericardiocentesis requires the cessation of CPR, and the AHA states that interruptions to CPR should be kept to a minimum and they also discourage transporting patients in cardiac arrest...

Sounds like you are out to re-write ATLS based on the information you obtained in CPR class. Doesn't that strike you as ridiculous? Pericardiocentesis is the definitive treatment for cardiac tamponade, performed only by physicians, and as you said, you have very little resources to make that diagnosis in the field. That all equals up to a patient who ought to be transported.

By the way, trauma is only ONE of the possible causes of tamponade...

Surgical intervention of hemorrhage? First of all, like I said, we don't transport traumatic arrests due to the low survival rates associated with them. Secondly, if it's a thoracic injury, you can't perform surgery without ceasing CPR; and I don't even think very many surgeons will begin operating on a patient in arrest unless they coded on the table.

Not only are you wrong (I've seen several of the scenarios you describe actually happen), but your point is based in the fallacy that you understand the perimeters by which these physicians make decisions. You don't. That's not an insult, it's just the truth.

unless I'm mistaken if the pneumothorax is bad enough to cause the arrest it will correct it enough that if you're going to get them back, you will. Otherwise, you're still just transporting a dead person.

And what is this assumption based on? Are you planning on eliminating chest tubes from ATLS also?

We can reverse hyperkalemia (and by reverse, I really mean correct the imbalance) with calcium if there's a strong enough suspicion of it. Labs are generally going to take too long to be of great value in cardiac arrest, so specificity is out the window.

Wrong again. An i-STAT is point of care testing that takes only minutes. Also, treatment of hyperkalemia does not stop at calcium. Are you really sure that you know exactly what resources the hospital has to offer these patients? Sure enough to decide concretely that nothing more can be done?

Managed warming of hypothermic arrest. Are you talking about warm intravenous fluid? 'Cause we can do that, you know.

LOL once again you fail to realize that there is a whole world out there of which you are not a part. Active internal rewarming STARTS with warm saline. It does not stop there, not even close. Not to mention that hypothermic arrests may benefit from extended resuscitation. How long do you plan to work these patients in the field before you decide the cause is hopeless? Maybe you should just transport.

Ultrasound evaluation of PE. So, you're going to stop CPR to do an ultrasound, find the PE, and then what? They can't surgically intervene while the patient's in arrest, and I don't think giving LMW heparin to patient's in cardiac arrest is necessarily wise--but I'm not an expert.

Damn right you aren't an expert. That's the whole point. Also, I said "PEA" and not "PE." Ahem.

Blood infusions. Again, traumatic arrests are more likely traumatic deaths.

Same rebuttals as above. Specific patients, specific populations, etc etc. This is getting tiring.

I think appropriate monitoring is (as you might guess) more appropriate than "thorough" monitoring. By that logic, we should put everyone on the monitor simply to be thorough. I don't think that SpO2 monitoring is, in general, too little when it comes to the administration of narcotics.

I do. SPO2 sucks, and it should never be the only means by which you monitor your patient. We aren't CNAs. You should put your monitor on the patient fully because (1) it is a non invasive procedure that costs you nothing to do, and there is no reason other than laziness to omit it. Also (2), "appropriate monitoring" for patients receiving pharmaceutical intervention in the field should include preparation and monitoring for adverse effects. Among a myriad of potential complications, narcotic medications can cause patients to hypoventilate or have allergic reactions: both of which require cardiac monitoring.

Could you offer some examples of treatments the hospital might, could or would do for patients in cardiac arrest that we are unable to perform in the field?

Absolutely. First though, I would caution that you are going down a very dangerous road to suppose that you can predict what a hospital can and cannot do. There is a whole world out there that you (and I) are ignorant of, and to assume you know the limits and boundaries of that world is just silly.

Just for the sake of argument, though, here are a few off the top of my head: pericardiocentesis for tamponade, chest tubes for hemo/pneumothorax, specific antidotes and expert consultation for overdoses and poisonings, reversal of hyperkalemia, surgical intervention on hemmorage, managed warming methods for hypothermic arrests, ultrasound evaluation of supposed PEA, blood infusions, open chest procedures, etc etc the list goes on and on.

Don't forget that the "H's and T's" are supposed to represent reversible causes of cardiac arrest. Think about how few of those H's and T's we can actually fully intervene on. I'm not saying that we shouldn't leave *some* arrests at the scene. We should. I'm just saying that a "no transport" protocol on all "dead" people is going way too far. ACLS is not the end all/be all of cardiac arrest management.

Furthermore, what's the point of transporting someone to the hospital if in doing so you greatly decrease the efficacy of the one thing that's one hundred percent certain to actually stand a chance of making a difference in cardiac arrest?

So don't use the lights and sirens. Drive carefully. Get help.

The thing is, we're not emergency providers. We're primary care providers who occasionally dabble in emergencies, and as such, as need to equip ourselves to more appropriately manage primary care conditions. Treating minor to moderate pain with the appropriate pain management is part of that.

I disagree completely. We are *NOT* primary care providers. The ambulance, and the emergency department, is not primary care. Just because a lot of people call us for typical "primary care problems" doesn't mean that is what we become. Furthermore, we are not trained as primary care providers, nor does the back of a moving ambulance serve as the proper environment to provide primary care. Patients don't need medication from the very first healthcare provider they set eyes on, ESPECIALLY if it isn't an emergency. Do you have any idea how much it costs to have a paramedic administer tylenol enroute to the hospital compared to just going to CVS to pick it up? If we are primary care why don't we do routine physicals, tetanus boosters, urinalysis, track hypertension and cholesterol, or any of the other hallmark duties of the primary care provider? That is not what the ambulance (or the Paramedic) is designed for.

MOI for Trauma Triage.....I don't disagree that the MOI can be one indicator of the severity of injuries, but currently it's our only criteria by which we triage trauma patients by standing orders and leaves a lot to be desired.

I don't know if you were motivated by it or not, but there is actually some recent research on this topic. I can't remember which journal it was in, but we just had a presentation on it and there were several articles which clearly showed that physiologic criteria is much more useful than MOI in determining severity of injury. When I get out of work I'll see if I can find the articles.

SpO2 monitoring SHOULD remain mandatory with all patients receiving narcs, but I know most of the hospitals around here don't automatically put them on the EKG as well. It's more about narrowing the difference between "EMS medicine" and "hospital medicine".

Regardless of what the hospital does or doesn't do, thorough monitoring of patients receiving narcotic intervention is good medicine.

Code Blues.....In general, however, there's really nothing more the hospital can or will do other than the same stuff we're going to do on scene. Until there's a concrete benefit to transporting code blues to the hospital, which currently there isn't--at least around here--I don't think we ought to be transporting dead people.

I think it is generally a dangerous idea to suppose that the hospital has nothing to offer a patient. I am all for a sensible and targeted protocol that eliminates transport of specific kinds of arrests (asystole/rigor/lividity, major trauma, etc), but I think broadly saying "no transporting dead people" is going a little too far.

NSAIDs

I agree. And while I'm more than happy to do what I can to take care of my patient's pain, I also realize that fentanyl may not be appropriate for every patient and I'd like to have some other options. We do have Toradol, but we give that almost solely for kidney stones.

I realize other people may disagree, but my feeling is that if it isn't bad enough for narcotics then it isn't an emergency, and probably doesn't need to be treated immediately in the field.

Febrile Patients

This one I need to do a bit more homework on, but I think it would be good to have some options, especially for febrile pediatric patients.

We have Tylenol for fever where I work, but I never use it. ...For the same reason as above.

Also, you said that you did not want to wait for the Glucagon to work before alerting the stroke team. That treatment would have given you your answer as to alert them or not.

I'm not sure that would be such a great idea. Glucagon takes about 20-30 minutes before it really starts to work well, which for a lot of services (like mine) far exceeds transport time to the hospital. I don't think it is a good idea to sit and wait if you are really concerned about a CVA.

In my system (big city), police will show up to 911 medical emergencies only some of the time. Generally if they are busy they won't bother with calls that sound "low priority," like cold and flu symptoms, low falls, etc. Police almost always show up on major trauma calls. Things differ a little bit when you get into more suburban and rural areas, but that's how it is here.

If you want this scene in your book to be without a police presence, you could have the ambulance get flagged down by a bystander, or make the initial 911 call for something else that sounds more benign (drunk guy on the stairs, something like that). Both of those events happen fairly frequently, and usually both would render the scene free of police.

Best of luck with your writing!

Not to be a killjoy or anything, but with all of this talk about "aggressive medicine" and taking care of patients outside of protocol I feel it needs to be said: our protocols are our lifeline to the world of science-based, real medicine, and ought to be respected as such. The best paramedics I know are acutely aware of how little they really know. They are humble people, respectful of the opportunity we are given to practice a little bit of medicine despite our short training and limited experience.

I am all for taking care of your patient, of treating injury and illness as thoroughly as we know how. But don't think for one second that your judgement is a substitute for the system. I don't mean to suggest that there isn't room for some clinical flexibility in the field (there is!), I'm just saying: don't get carried away under this "patient comes first" emotional gush stuff. Good medicine comes first, always, and respect the fact that individual paramedics don't always necessarily know exactly what that may be.

Bieber, I applaud you for coming on here and telling us about your mistake(s). I think it is an excellent way to learn, and reveals a part of your character that I think will serve you well in the future.

I agree with just about everything others have posted. If I might just add a few small things:

-Make sure you get the initial report and any critical info. If your partner is taking the initial report then that is a problem. Politely ask him/her to refer first responders to you when they have (important/relevant) information to pass on. I've noticed that it helps if you are the first person who walks through the door. Grab the FRONT of the stretcher and make eye contact when you step into a scene.

-Focus first on your patient, not the first responders. When you are working, "being in charge" means being responsible for the patient. Make sure you get the information and the help you need, and use those opportunities to start directing people on scene. People will get the point when they see it is you who is doing what needs to get done.

-Don't stop at random car crashes. Especially routine ones. You just cannot expect people who are at work to take direction from some plainclothes witness who claims to be a paramedic. You don't have your equipment, you're not at work, and - frankly - you're not really helping. If you absolutely must stop, your report to first responders should be SUPER short with only the bare essentials, and then you should GTFO.

-Realize that this stuff comes with time. Don't try to rush it by puffing your chest and making a big deal out of small things to save your ego. Just treat your patients well, make sure you get everything you need, and people will start to recognize you as a leader. It takes more than a patch to get respect-- remember that you still have to earn it.

You know you're having a bad day

...when your backboarded patient looks at you and says "uuuhhh I don't feel so good!"

...when your company tries to order you in for a shift while you are already working.

...when you open up the back doors and realize your stretcher ISNT THERE. Gulp.

...when you are sent to a 10 story building with no elevator for the chest pain and the fire department waves at you from the top window as you roll up.

...when the nursing home nurse follows up her report with "...oh, and uh, he's pretty big" as you walk down the hall towards the room.

...when you think it's safe to order up a hot lunch...

Excellent trollspotting, EMT-City!!!! Well handled, haha.

...why not just do away with BLS providers?

$$$.

Got mine!! Thank you Duane, this thing is really cool!! I think I'm going to use the pendant as a zipper on my work bag hehe.

There is a lot of negativity on this forum towards AMR, and usually most of it comes from people who have never worked for the company. I've worked for AMR for six years, and I'll give you my honest opinion.

First, you need to know that the working experience at AMR is going to vary widely depending on where in the country you work. AMR is a large corporation that sets up divisions all over the country, and those divisions are largely locally managed. In some areas of the country, AMR does mostly transfer work, in other areas they hold the PSA for primary 911 response. In some areas it is a really terrible and negative place to work, and in others it is the best service in the region. It really depends where you are.

There are some negatives to working for a large company like AMR. The company is by it's private nature profit-driven. That means that there will always be some tension between the employees and management over pay and benefits, and there will always be a little bit of a conflict of interest when balancing emergency work and interfacility transports. My experience is also that the equipment isn't always as top-of-the-line as it is at some volunteer or municipal services.

That said, working for a large company has it's benefits. FEMA has contracted with AMR to provide EMS services in the event of national disasters, and as a regular road medic I have had the opportunity to fly all over the country to work. I went to hurricane Katrina and Dean, and I'll be ready to go again if something happens again. That is an exciting opportunity you don't get everywhere. On a more local level, AMR has contracted with large local concert venues and sports facilities, which means I get to do EMS coverage at events like Ozzfest, Warped Tour, professional sports events and shows. I've been backstage at at more major events than I can count, and it was AMR that has given me that opportunity. AMR contracts with local towns around the city, and offers it's employees a really diverse choice of working experiences. I can work as a fly-car medic with volunteers if I like, on an ambulance in the city, or as an intercept medic in a fire-based system. A smaller company would not be able to offer me all of that choice. Even with those opportunities, AMR paramedics and EMTs enjoy some of the highest wages in the state.

As far as the day to day management, I will admit that it sometimes sucks. AMR seems to like hiring middle managers that take the job for the wrong reasons, or are otherwise under qualified. There is often a lot of frustration here about day to day things like scheduling, dispatch, and paperwork. Recently my division has been cutting the number of ambulances on the road, which has caused a lot of frustration and anger. That said, this company for the most part allows us to get in our trucks and go out for the day to work EMS on our own terms. Despite the frustrations that do exist, I really feel like I am in charge of how my day goes, and I am allowed to make individual decisions regarding my scenes and my patient care.

If you are interested in working at AMR, my advice to you would be to seek advice locally. The experience will vary widely depending on where you are, and only people in the system will be able to tell you how things really are. Don't give up on the company though just because it is large and private. I am very happy that I chose to work for AMR, and it is possible that you could be also.

Best of luck.

EDIT: Sorry, forgot to comment about the hiring process. Again your experience may vary, but around here the potential new-hires get two exams: a written that is just like the state EMT-B written (probably just like NR), and a practical that involves a few NR-esque stations. As I remember there was a trauma assessment, and an airway management station when I was hired 6 years ago. It wasn't crazy, but it is more than you see at a lot of other places.