croaker260

This too is NREMT Policy. It is to ensure that complaints are REAL complaints and not just "I failed now I want to cause a problem..." YOu have to submit your grievence before you are given your results. Keeps every one honest, good policy in my mind. The NREMT test is not an educational process. That was supposed to be done before you took the test. Giving your test back is good EDUCATIONAL process, but poor CERTIFICATION practice. Let me put it another way. In our FTO program, we have a very long "Phase II" where both evaluation and education take place. But then we have a "Phase III" for 48 hours. it is EVAL ONLY. No correction/education, nothing. You either have your stuff together..or you dont. Helps make sure that when you are "released"..your READY. You pass or you fail. You only learn the general areas you fail. if you fail, you go back to Phase II, for more education and evaluation. Just look at the mess in DC fire and with the FDs in collier county trying to spoof their exams by learning the questions, not the material. There are several things I would change int he NREMT abouttheir stations, etc. But the PROCESSES and ADMINISTRATIVE PROCEEDURES for the most part are right in line with national stanadards for defensibility and objectivity.

Yes it does, completely. Perhaps we are talking around the same view point. The things that would effect transport descisions are system based ones that vary hugely accros the US. Example: One of my earliest codes was a horse rollover on a mountain side with a 40 minute hike in. The dude took his last breath as I walked up with my gear, PEA, big belly, the whole bit. Worked him for 15 or so, epi, decompression, ett, etc etc. Working him down a mountain side was impractical. So we worked him, and called him on location. I work areas in my county where we are 40 minutes away during winter. and areas downtoewn where we are 5 minutes away from our trauma center. the transport descision at that point is based on system variables. But in both cases if I were to work him, I would work him hard. There is some data, useful data, suggesting CPR sucks in a moving vehicle of any type, and therefore rescusitation in a moving vehicle may be counter productive....but thats another soap box. OMG! Is this horse dead? or is it in PEA?

Interesting point, but I have a problem with doing somethings, but not ACLS drugs, etc. If you work an arrest, you WORK the arrest. (when I say that, I get images of the conversation in DEATHPROOF about CLAIMING a man... SEEN HERE AT 1:20 INTO THE CLIP...but I digress) Now, in my mind, and I think this may be different than others here....working a patient does not automatically mean transporting the patient, although in trauma especially I can understand where the pressure might be to transport...the curative power of steel and all that. But I cant see simply decompressing a patient, giving two breaths , and then walking away.

Im an confused.... 1- Define "EKG check good"? Hell , Define "BP good" becasue a BP of 100 Systolic may technically be good for an opioid, but paints a different picture than a BP of 160 systolic. 2- Define "restraint carrier ambulance" 3- Define "EMT" in your context, because in the US (with a few rare exceptions), an EMT wouldnt be giving morphine, or checking an EKG. As a side note, while he may be part of the research arm of a medtronic study, if this is a BLS/ILS ambulance, the hospital 5 minutes away is likely the best option. Simply explain that with todays technology, the ER doc can converse with MEDTRONIC's study coordinator if nessessary, and further more arrange transport by an ambulance equiped to the ALS level. If I was an EMT, I would not want to transport a chest pain patient 45 min away. Of course in some rural areas an EMT is the only option, Kudos to those EMT's. One final comment: A "little chest pain" is every bit as bad as "a lot of chest pain". If you believe it is cardiac, an opioid is usually appropriate, some services favor fentanyl over MS. Nitrates as well, yada yada yada.

I forgot to mention, this is some of the wisest words mentioned thus far in this, or almost any discussion.

Here’s the thing for me though: This is not what I would definitively call a blunt trauma arrest. Sure MOI, but come on, we know how unreliable MOI alone is . A good tool for suspicion, but that’s about it. Now if the OP had said "Chest wall was unstable, bruises to abdomen, unstable facial bones", Ok, not injuries incompatible to life, per se...but a better case for blunt trauma arrest. Sure, speed at 65 MPH? What because that the speed limit? Because he was on a motorcycle? Or bystander reports? And we know how bystander’s perception of speed is as a reliable indicator. (and yes I know he probably was going FASTER than the speed limit, but PROBABLY doesn’t cut it in this case) Also, Laying down a bike before impact can dramatically reduce the speed. Riding leathers can reduce some impact. Here is my point: Jumping to "irreversible blunt trauma arrest" with nothing more than a few soft tissue injuries and PEA on the monitor is a bit dangerous IMHO. If it is indeed a severe blunt trauma , then 99% of the time you will have more evident injuries in a MCA, MVC, or similar setting. And you would have a better case to prove your point. BUT THAT IS NOT THIS PATIENT. THIS PATIENT HAD MININAL EXTERNAL INJURIES (And Ill work that 1% blunt trauma arrest without external evidence of trauma with out losing a nights sleep. ) At the end of the day, this is a PEA in the setting of trauma (blunt or penetrating) it doesn’t matter in my book, with out severe external injuries, definitely not INJURIES INCOMPATIBLE WITH LIFE, and we know PEA has several field reversible causes. Therefore working the patient is prudent IMHO. Transporting, as I said earlier, is up for debate…… I can see arguments for both ends of it. Too much of that depends on location and system specifics. .

All valid arguments against transporting the patient, and valid discussion points on our medical system in general...., but in THIS patient, the way THIS scenario was presented, THIS patient would get worked. In my system, possibly on scene and called, possibly transported...and ligit arguments for and against both.....but he would get worked, not left there because we speant 10 minitues justifying why we didnt want to instead of doing our job. Im not saying he had a huge chance of survival, but you will never know if you dont try to work him and treat the KNOWN REVERSIBLE CAUSES OF PEA..and do it QUICKLY.

Just want to make the point that although any pulsless rythm is bad news......PEA is not asytole. No where close.

I bet your a peach for your partners. I can say that If I took that attitude, I know of at least 1 if not several patients who would be dead because my EMT (through luck or skill) tagged some intervention or skill or clue or scene dynamic I missed. In our system, we teach ourt EMTS everything from medications, ETT, 12 leads, even crics, even though its all out of scope for them, because our EMTS are part of our team and our medics need relaible hands who know generally what the medic is going to do, need, or think. It also helps with retention, and gives most the bug they need to advance to paramedic school. Sorry for going off topic....

The question is better phrased, Are we ambulance drivers too stupid to determine between DEAD and REALLY DEAD? Because after this thread I am begining to wonder. PEA is DEAD, but not REALLY DEAD AND GONE. Remember that PEA is just as likely a LOW FLOW STATE as it is TRUE PULSELESSNESS in a trauma situation...The Concept of the H's and T's, while sometimes over simplified and over used, was created and designed for PEA. Especially PEA in trauma. I work in a very progressive service, with very involved medical directors, and very seasoned and experianced medics, and we run a fair number of calls, and I can assure you that while we all recognize that this patient has a SLIM chance, he is a working code at my service. Again, 99.9% of the time, this is a WORKING CODE. And not a "we ran a round of EPI and called it good" code ..BUT A WORKING BALLS OUT CODE. Bilateral Decompressions, ETT, Pericardial Tap, central lines with 2 liters or more, tons of EPI, and other drugs PRN. WHo ever said that traumatic arrest equals automatic death? WHere? Now, traumatic arrest isnt a reason to FLy, I agree. And Traumatic arrest has a very poor survival , I agree. But Traumatic arrest is not hopeless. Traumatic arrest refractory to interventions in the field likely is, but not traumatic arrest on the front end. Not as it is described here. I am unaware of any ..ANY research that says that you find a fresh patient in traumatic arrest (without injuries incompatable with life) and you do basically nothing. Some of you mentioned ETCO2, very good thought process, but this involves working the code to get to that point. Some of you mentioned decompression..again, this invovles working the code. Now, TRANSPORT is a debatable topic depending onlocal factors...but thats not what we are talking here..we are talking working this patient on the front end of the call. SOme of you mentioned using your heads to make educated descisions..I couldnt agree more. It seems in this case some of us are using our heads to find a reason to walk away, a reason NOT to treat, a reason to minimize and ignore the patient.....never a good thought process in our buisness...and we are not using our heads and efforts to find a correctable cause (wich involves working the code).

I assume you are talking about EMS initiated refusals, not normal refusals or Treat and release with out medical control contact. In otyherwords , us saying "we're not taking you, even though you want to go" There is some research on this in various medical journals over the past 10 years and the results are not encouraging. Simply put, there are unfortunately limits to EMS assessment in the field. Most of the stuff I have read over the years have indicated a fair number of ER visits, EMS recalls, and even hospital admissions (for serious conditions) with in 24 hours on patients who were in one form or another (AMA, refusal to transport, treat and release, what ever your term is...) left in the field. Any refusal to transport policy is better written , implimented, etc with an alternative destination component. In short, one should not "refuse to treat or transport" , but instead "refer to a more appropriate healthcare pathway". I'm not talking simple verbage, but Advanced practice paramedics (like Wake County's program), PA's in the field, Taxi vouchers to clinics, or other similar approaches are all safe, and IMHO BETTER, alternatives to simply EMS initiated refusals.

Agreed

Jeepluv, For a brief minute I though you said..."On the most recent episode of ER". I am sooo glad I reread that post! LOL Regarding the original scenario: Contrary to your statement, the patient does not meet "obvious signs of death" criteria. As in he does NOT have catastropic injuries incompatible with life, he has no signs of decomposition, he has no rigor, nor lividity. And he has no valid DNR. He is also fresh. Rescusitation is also in progress (not always a good reason to work or not to work, but worth mentioning) And assuming he was the only critical patient... you have the rescources. He would get worked. There are tons of reasons to work him, and I cant reallly seee a good one not to, although admittedly he would proably stayed dead. More specifically there are several REVERSIBLE causes of PEA as well (Tampanade, Tension Pneumo, Hypoxia) that should be addressed too. But again, the outcome likely would be the same. Finally, This sceneario is also the one that makes the newspaper because by some weird freak occurance, the patient has a faint pulse of agonal respiratory effort an hour later when the coroner was there, and everyone points to the medics for not doing their job and following the policy strictly. I just hope the transporting medic addressed those causes to the limits of his scope of pratice.

Actually, SUNSTAR EMS is a "Public Utility Mudel" (PUM) similar in theory (if not application) to MAST. Simply put there is a GOVERMENT OVERSIGHT of a PRIVATE COMPANY with a contract awarded every so often. No, this is NOT what AMR and others do in California and other places where Privates do 911 work by contract, the oversight is MUCH MUCH more aggressive. And this is different from a 3rd service model, and obviously different from the fire bsed model, and is not exaclty the same as a pure private model. Sunstar has been held up as one of the PUMs done right. Our agency has traveled to there and looked at some of their effeciencies (there are many) for our own service. Obviously there are issues with every service, and SUNSTAR is no exception, but they do have a lot going for them. Not saying its a bad thing at all. But is different, and politically and administratively intensive.

While this may be true, this is a little too specific about a person, and makes you a little too identifiable, to be a wise thing to post in a public venue. Just a friendly word of advice, take it or leave it.

Somantics somantics.....Well, we could get into an argument about the degrees of danger ..but its irrelevant. My point wasnt based soley on DANGER (in fact very little of it was) but on PRACTICALITY, something most on here havent touched on. Simply put, going too fast while doing the other parts of the transport that are inherrant to typical code 3 driving on surface roads, is counter productve to doing anything in the back effectiviely, well anything excpet cussing the driver that is. This MUST be emphasised in training. You tell someone something is dangerous or not safe, well..in some it actually encourages pushing the limit. Not saying it isnt imprtant, cuz' damn right it is. But IMHO your far more likely to effect behavior if you also emphasize the practical aspects of it... And of course follow up with ongoing training and evaluation.

I disagree here, the reason we are having problems with RSI is to many new medics dont have their basics (Basic ETT) down correctly, and to be honest its not usually taught correctly...and when they are "taught " RSI/MAI, they arnt taught that correctly either......so they should never be doing RSI to begin with. We have no one to blame but ourselves there.

Image didnt come through

I recall an old study published in the Annals of Emergency Medicine about 1995 ish discussing this topic. It was a huge study in Asia somewhere, and found that pain meds made the Dx of appendicitis easier for "blinded" surgical residents. Anyway, here are our protocols for pain meds.... In our service our supply told us that the only drug we give more of (than morphine) is albuterol. We commonly will co-administer a benzo for spasms or sedation as well. All of our narcotics are considered standing orders (except etomidate, unless its used for RSI/MAI- Different protocol though) . http://www.adaweb.net/LinkClick.aspx?filet...d&tabid=798 I qoute from page 2:

Hmmm so what are you "calling me out" on? something we both agree with? I was simply correcting the accusation that my position against sppeding was some holier than thou rant...not based on common sense. And while not exactly pert to the discussion at hand, most accidents Ive responded to, like EMS related accidents, involved interstections of one type or another. I think statistically that is true as well, if you factor in all types of intersections, not just lighted or stop sign type intersections. TNIUGS, care to elaborate the GIBBS head slap?

A couple of thoughts, 1- Meningitis, esp bacterial , progresses very rapidly (faster than strep) , with alterations in LOC rapidly apparent. 2- Strep throat, with the associated difficulty swallowing (and thus drooling) is more likely to be confused with epiglottitis than meningitis. 3- When we see a condition constantly, we tend to suffer from the cognitive error called expectation. We see strep a lot, or train a lot to look for it, we begin to subconsciously expect that the neck discomfort, fever, chills, and listlessness is another case of flu or strep, missing Meningitis and possibly having a bad outcome. Conversely, we see or are conditioned (trained/educated) to look for life threats, we will miss the stuff like strep. A humorous example of this is the scene in "Doc Hollywood" (Micheal J Fox) where the young urban docs suspects a kid is suffering from a life threatening heart condition and the kid actually just swallowed a load of his dads chew. The young doctor diagniosed a condition because that is what his expectation was. In this thread, both sides of the argument are correct, yet both sides are potentially misleading and even dangerous. The best defense against cognitive errors like this is an unwavering, uncompromising adherence to a systematic approach/assessment wich leads me to my next point...... 4- Strep, Epiglottitis, Meningitis, even simple gastro-enteritis...all can lay a kid low (some sooner than others), make the kid inconsolable, make the kid pale, make the kid look like CRAP, make the kid limp, develop shock and dehydration, AND IN GENERAL MAKE THE KID APPEAR "SICK" by any PALS/PEPP/PCC standard you care to endorse. Therefore the treatment is all based on symptomatic and objective assessments, ranging from blow by O2 through fluid challenges to adv airway management and vaso-pressors. In this case the diagnosis, while important, takes secondary place to recognition of "sick" vs "not sick yet" ..."stable" vs "Unstable"...which Strep can manifest itself as easily as meningitis too. Therefore the right treatment and sense of urgency is as imprtant as the diagnosis. NOTE: I am a hearty beliver in EMTS and PARAMEDICS thinking beyond their scope and making diagnosis ,...but the smartest medic who cant take care of the basics, isnt a medic in my book...

While we arnt hiring as aggresively right now, we are still firmly in the black, are building stations, and generally doing very well compared to our "brothers" (and I use that term very loosely) in red. We are a County 3rd service with the same retirement, better schedule, and better bennies. Our scope of practice/SWO's are pretty good, and we enjoy good support of our medical community So I think we are thriving. That said, I would not expect another hiring test until fall, or perhaps next spring. If you have no experiance by then, then I would expect a reserve offering (volunteer to get exp) instead of a full time position.We dont do PRN/PT. Generally speaking the Pacific NW is more progressive than the rest, although there are some exceptions too. Other excellant services include Boston EMS and Austin/travis County EMS. And of course any ofthe Seattle/King County Medic One Varients. www.adaparamedics.org 22K calls/year, 95% 911 .

I think you misunderstand my statement, Our policy allows us to exceed the limit by 15. Our training teaches the new medics that in the big top heavy ambulances, weaving in and out of heavy traffic, going at 15 over is counter productive to good patient care in the back. Which is more important? Getting there 15-30 seconds earlier, or taking care of the patient while transporting? You will also notice I said SURFACE roads, as in not (major) HIGHWAYS or INTERSTATES. Surface roads are stop lighted, stop signed, speed bumped, with Medians, round a bouts, and other "traffic control" designs. In these cases the acceleration to get up to the 15 MPH over max, as well as the extra breaking, plus the extra force inturning, just isnt good sense when you have 1-4 poorly restrained passengers in a non-crash worthy box well above the center of gravity, all the well trying to do multiple tasks, many of wich require some degree of finese... Its not about the "High Road" ...its about common sense. Do I need to make my statement clearer?

Actually , I can get anywhere you caan code 3 w/in 30 seconds driving safely code 2 with opticom in 90% or our response area... Furthermore, in out academy it is stressed that ( when transporting a patient) your partner cant do his job if he has to use his hands to hold on to his seat! SO a general rule is EVEN CODE 3..we dont exceed speed limits when driving on surface roads if a patient is in the back. STrangely , at other services, this was the hardest habit to break (driving like a nut when transporting a patient, as opposed to just responding). We use DRIVE CAMS, BLACK BOXES, EVOC courses, and OPTICOMS as key parts of our drivers safety program. In addition, we also stress from a customer service point of view, your ambulance is a big bill board. Dont use the bill board to cut off the Voters who (hopefully) support you.

Vent, I think you are misreading my intent. I do not have a problem with the change over of any lines once the patient is admitted , especially if it is reasonable, and prudent and well thought out. But to rapidly change out the line in the ED, pulling the prehospital line BEFORE future acccess is gained, without regard for the anticipated clinical course of the patient (admitted? Discharge? etc) , "Just because" ...is arogant and just poor medical care, and this is what I saw in the 90s and what I took the OP's situation to be.