MAMed

While reading posts in some of the threads, most recently “Kids Along for the Call”, I am once again reminded of something that I could not fathom as a Basic new to EMS and that I still find disheartening as a Paramedic. We in EMS are the red headed stepchildren of the medical community. We are Emergency Medical TECHNICHIANS, not clinicians who assess and treat in an acute setting. Rather we are considered on par with lab techs, who help the real care providers. Yet some of the most arrogant, egotistical people I have ever met are Paramedics. I am a professional medic and would not ever volunteer simply because getting injured there would also put me out of my fulltime job, without even having the “luxury” of workman’s comp. But with that said, in the outlying areas of the counties I serve in, I still interact with volunteers. Yes, some of them, especially the young ones, are in it for lights and sirens. I also see that with a lot of new professional Basics. Both groups are usually gone within a year. But many volunteers see a need in their community and sacrifice of themselves to provide that service. I hear people say that “we are talking about the real issues in EMS” in many places. But we’re really so busy infighting over things like Basic vs. Medic, Paid vs. Volly, Private vs. Public, etc. that we are incapable of discussing the real crux of the issue, our own impudence to affect change with in our profession. Is it the volunteer’s fault that the local government won’t fund professional EMS services? Is it the fault of those of us in private services that our protocols sometimes seem geared more towards the service making money than pt care? I regularly see us attack each other when someone states that things are done in a certain way their service area, regardless of whether that person has any say in governing rules. That happens here at home as well as the forum. In a striking counterpoint, here in the state of MS, the nurses association has so much political clout that large private hospitals think before crossing swords with them because they have banded to establish professional control. Yet the EMS advisory committee to the MS State Health Dept. is made of doctors, nurses, and the owner of the largest state based private EMS service. There is not one Paramedic or Basic with any say in how our profession is run! The EMS community here is so divided that no one can mount an effective campaign to change that. From seeing some of the statements others have posted about their areas, I will infer that this is more of a wide spread issue. I suggest rather than bantering back and forth over the petty issues, lets start trying to promote unity in the profession. If nurses can do it despite fractures in certification levels and work settings, then why can’t we? I don’t have any answers. I simply see a problem. All I know to do is point it out until enough of us decide to work together to solve it. I’m aware that people can pick this apart if they want to and this might be nothing more than so much fluff talk; but if we are serious about improving EMS, we have to start at the base level by implementing power with numbers. Otherwise, we will stay just where we are and those with the last laugh will be the ones snickering at us “ambulance drivers.” With all that said I’m off my soapbox. This is my opinion on the matter and if you disagree with me, I’m sorry.

We initially started talking about bringing children along with their parents. Now the discussion is talking about organized riders/observers. In my opinion, the two are not the same. I have two little girls 5 and 3. I stated earlier that bringing something home to them is one of the only things that scare me. But if you have high school kids in an organization that works with the EMS agency and does structured ride alongs, then measures can be in place to eliminate many of the hazards. When I was in school, one of the services I did clinical at worked with the local school system with some sort of junior health care worker organization. The kids worked at hospitals and with the EMS agency. That sort of thing is a good idea in my opinion.

I agree with spenac about the health issues if nothing else. When I come home from work on a weekend morning, I usually don't even let my kids hug me until I shower and change because getting them sick and climbing in and out of the ambulance on the side of the interstate are about the only two things that regularly scare me about the job.

On the H-test pt could not look up with either eye. With the facial nerve, the pt could give a grimace and that is about it. As far as the Romberg test, my understanding is that the auditory nerve deals with hearing and balance and if you are on scene, such as this case, at a restaurant parking lot, there is too much background noise to test levels of hearing reliably. In that case a Romberg becomes the next best thing. I cannot attest to drug use but I am assuming that the pt is telling the truth to see what the neuro problem might be. The pt stated that her entire face is numb.

I appreciate it. I was an idea that ran through my mind because I had to do a digital the other day on a code when the batteries died on the blade while I was attempting to tube. By the way, state health dept. won't give us "ambulance drivers" RSI and I don't have access to lighted stylets. Like I said, just an idea. Thanks

Ladies and Gentlemen I ask you to take me at face value that what I did in this case was correct in context of the situation. I don't want to eat up space with more back story but if you are really intersted, PM and I'll tell you.

I was reading an article on Jems.com today about how the concerns of post mechanism spinal insult inhibits the ability to place an advanced airway which results in hypoxia and/or improper treatment of a TBI from same said mechanism. The article goes on to state that the slight (relative term) spinal manipulation involved in direct laryngoscopy will not usually result in any injury that did not occur in the initial mechanism. I have a thinking out of the box question so please tell me what you think. Rather than direct laryngoscopy, put a OPA in each corner of the jaw as a bite block and do a digital intubation. This will minimize mandibular displacement.

Everybody I did not talk the pt out of a transfer. The hospital she was at was sending her to a hospital for eval. They ruled it non-emergent. I stated earlier the legal requirements. I never told the pt that I would not transport. The transferring hospital provided nothing stating why this was medically necessary transfer or why the pt needed to be transported by ambulance. I was therefore required to explain to the pt that they would be billed for milage beyond THE CLOSEST APPROPRIATE FACILITY. The pt then said they would rather go POV without me ever suggesting anything about not transporting. During orientation I was informed by a regional manner that I was legally required to do this. The county sup has stated that any time we have a transfer that the hospital does not provide the required info we are to contact him as I did. If the hospital wanted the pt transported to this particular destination rather than the CLOSEST APPROPRIATE FACILITY they have been given the option to contract and pay the difference that the pt will be billed for which they have declined to do. So let me state again that I never mentioned anything to the pt about not transporting or other means of transport (which I did state in my original post) nor did I attempt in any way try to get a refusal from the pt and if the transferring hospital had in any way attempted to get the appropriate STATE FORMS (I'm using caps not out of sarcasm but to point out that these are the issues at hand in this matter)filled out, this situation never would have occurred. Incidently the pt presented to the hospital for abd pain and as far as I am aware of no labs were ever drawn. If the hospital was truly worried about the pt they might not have wanted to send the pt to another facility that was about TWICE AS FAR AWAY AS THE CLOSEST OB facility which could treat the pt. And we contacted said facility and they said they would be happy to take her. THE ISSUE WAS NOT ONE OF TRANSPORTING OR NOT BUT RATHER THE CHOICE OF LOCATIONS. THE PT SPONTANEOUSLY REFUSED TRANSPORT. The reason none of this was mentioned in the first place was that I was asking a question as to how common it was for these small hospitals to try to put bogus transfers on the ambulance service just to get rid of a pt such as the time the same hospital wanted us to transfer a pt they listed on a medical necessity form that the pt could not convey by wheelchair van because sitting upright caused pain and swelling in the pt leg but the pt had a personal wheelchair in the room and was sitting upright in bed when we walked into the room, or the time I transported a nursing home pt in on a 911 call. The pt was ambulatory on scene, complaining of chronic flank pain. The pt refused to get on the stretcher and walked to and from the ambulance, sitting in the jump seat during transport. When I asked why the transport was medically necessary the response was that she needed to go back to the nursing home (it was more connivent to call us rather than a wheelchair transport service). Spenac had it right when he mentioned fraud.

I want to apologize for the digression into bickering. But the symptoms of the numb face x 2wks is what really threw me for a loop. Any one heard of this associated with CVA or TIA

Let me explain some of the local legal background to clarify any misunderstandings about the situation. In the state of MS for a pt to have insurance pay for a non-emergent transfer the hospital sending out the transfer must provide a standard state form that gives a reason why the transfer is medically necessary. All emergency transfers must go to the closest appropriate facility. Any stable A/O pt must be informed by the paramedic if there is a possibility that insurance will not pay. At that point the pt can still be transported if they sign a concent form stating that they have been told this. The pt mentioned above was informed in the manner mentioned and was told her options about transport to the closest hospital. At that point, she refused to go by ambulance without any coercion. While I might not have all the details of the above laws that is the general basics of them as far as I have to know them. I might not like the rules but I have to play by them. Another background note is that the hospital in question above is an extension of the state university medical center and regularly send pts to the main branch simply so they don't have to deal with the pt regardless of medical necessity of transport.

I'm sorry let me clarify. I did not get a refusal. I told her that I would be happy to transport her but I am legally bound here to inform a transfer pt is there is a possibility that insurance will not pay part or all of the trip (in this case only the milage to the closest facility). The pt refused on her own. This came up because the on site doc told her that the closest hospital did not have OB. My supervisor checked with that hospital who said they did and would be happy to take her. The issue was not wether to transport but closest apporpirate facility. This would also take an ambulance out of service for extra time when there are only two in the county.

"I think what youre debating is whether or not this patient was really a psych or if she was having a cerebral event." I did post looking for constructive critism but the above statement is what set my hackles up, not the critism on assessment or treatment Sorry I have not posted in a while and forgot how to quote other posts.

Ov I do not need to be told what I thought. If I did not say I thought she was a psych then I did not (BTW I already have a degree in psychology). The only finding I left out was the CBG which I did by mistake. Thank you for your input though

Yes I did. Sorry for leaving that out. I don't remember the number but it was within normal limits.

I had a funny call the other night and would like to know if anyone has any ideas. Dispatched for a psych with PD on scene. Arrive to find a 40 yo f out with FD BLS rescue unit. Pt is behind the wheel in a parking lot on O2 by NRB. PMHx: hypothyroidism on synthroid. pt has chronic HA and ABD pain. Pt has "numb face" x 2wks. FD cleared PD off scene before I got to talk to them. FD said the pt broke down crying when they tried to assess mental status. When I assessed the pt she was A/Ox4 but seemed a little off. I did a CN exam. The pt failed an H-test because she could not look upper right on repeated attempts. pt could not fully smile for facial nerve exam and swayed when performing a Romberg test for the auditory nerve. No pronator drift but her hands shook. Pt was HTN with no Hx. Mild slurred speech but could be normal. Denied ETOH or drug use. Monitor showed sinus tach at just over 100BPM. The pt initially refused transport unless I would take her to a hospital that was close to 90 miles away with a level 1 and thee level 2 in town but med control convinced her to go. This could be a CVA or TIA but struck me a neuro. Does anyone have any ideas?