pinymayu

"tskstorm, "

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Out Here,

pinymayu

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Floppy,

I'll again caution you to heed my previous advice..

I'll warn you don't come to an intellectual arguement with less than the required amount of ATP. You will lose, and look like a fool in the process. You wouldn't pull this crap with "Dustdevil, asys, ACE844, Ditch,"or many of the others of fame here. Don't be fooled by the low number behind my post count and think I'm an easy newbie mark. I'm not; so before you even attempt to make a personal or professional attack against me, consider what you say wisely and for along time....

pinymayu

Ok, "flopey," you went there, I didn't Remember that. Read on, you've pegged my meter:

seems to me that you would take an unstable pt out of the hospital to a place of lesser care and you clam that you would do what is best for the pt?

Please point out where I said anything of the sort and reference-post the exact quote where I said those words... I said nothing of the sort. THANK YOU FOR PLAYING PLEASE DON'T TRY AGAIN :roll:

some nursing staff at hospital would rather have a pt transferred then take care of them and they need to stood up to some times and I thought that we could have a light hearted discussion about thing I meant no disrespect but if you want to go at it we certainly can go!

Yes there are nursing staff who are as foolheady and stupid as the next EMS provider and apparently as he posts here as "tskstorm" is. I have no issue with a lighthearted discussion. Yet, I find it interesting you seem to take no issue with gross negligence as previously posted.

I'll be awaiting your 'facts' and quote as well, your position is indefensible as it stands above. I warned you not to go here, but you chose this road, so BRING IT..

pinymayu

Lets also not forget those patients who turn out to be extremely sensitive to NTG and become extremely and refractarily hypotensive from NTG as well, usually without warning. ALso I echo "Rids, Medic001918, AZCEP, Ozmedic's, Chbare's, and many others" comments above as well

Food for thought,

pinymayu

^

Hmm, I wonder who the newbie that posts a lot of pictures is... 8)

and yet strangley you have grown wiser and see that he is right..... :shock: who knew..who could it be? Are you objecting to the substance or are you making an observation?

getting a little touchy are we?

I like to ensure that my patients recieve the BEST and most appropriate care. Apparently you seem to agree with the individual above and may not. If you accept subpar care as OK and or appropriate then perhaps you need to re-evaluate your position on stayiong in EMS as well.

I'll warn you don't come to an intellectual arguement with less than the needed amount of ATP. Y ou will lose, and look like a fool in the process. You wouldn't pull this crap with Dustdevil or asys, or many others of fame here. Don't be fooled by the low number behind my post count and think I'm an easy newbie mark. I'm not; so before you even attempt to make a personal or professional attack against me, consider what you say wisely and for along time....

pinymayu

you should have seen the clarifacation post that was made before you jumped on your high horse!

I saw it just fine thank you, and it clarified nothing..If anything it begot more questions than it answered. Thanks for the unhelpful insight, and non-productive comment.

pinymayu.

If I am infuriating it's because I'm right..

okay its taken me a bit to get back to this thread, okay to clarify,

1st note is i didnt give FULL details on company policies but will attept to clarify and still keep details to a minimum

it is a bls unit, full on part 800 doh unit, to clarify,

if a pt is on the 7th floor of a hospital on his way to a nursing home, after being admitted for xyz has an elevated bp, we are REQUIRED to deny the transport, simply because the NH wont accept the pt.

ill pose you this.. what sense does it make for the company to take an unstable pt out of the hospital ? how can that help the pt ?

Your duty bound to treat the emergent presenting condition which you find and be sure that the patient recieves adequate care and get acess to continuing advanced care. PERIOD refusing to transport and leaving..that abandonment pure and simple as once you assume care you can't just say no way and walk away unless there are safety issues. Irregadless of company policies. FURTHERMORE, thoise same policies will not protect you from failure to follow the standard of care. They will just gain the plaintiff more money and make the Co, a co-defendent. Next you give no context as to what 'high' is and whether you truely have the intelligence, capability or clinical knowledge to determine whether thatn is a 'critical' or 'concerning' value for that patient. Especially when your first post put your competence in question.

now if we reverse the situation and the pt is in a nursing home scheduled to go for dialysis, and we find they are unstable elevated bp bla bla, then we refuse txp to the dialysis center and go to the nearest ER.

You have no choice, also, you must provide appropriate care as well as transport...PERIOD..

Ruffems- does that clarify it enough for you ? who would i call for the pt ? the DR on the floor or the ER and get the pt down there.

Why are you asking a question you should be answering?

Do you refer them to law enforcement or do you just leave the scene and let them fend for themselves.

WE do not except them from the hospital, fend for them selves? nope the rn's and dr's on the floor help them.

More than likely the Dr's and nurse take cover and run and the patients fend for themselves. This statement shows you are ignorant to the realities of ER care and policies...

Ridryder 911

Not all patients need an ER, but may require critical care transport

we dont have CC, and again i will say the same thing why would i take a pt outta the hospital in an unstable condition.

ALOT of CCT transfers go via the ER and are done only after an ER doc has been consulted with and agrees. Your staement is thusly false and misleading.

BLS such as oxygen to even a residence. when i said o2 the first time i meant o2 with a vent, of course we dont refuse pt's who are on o2 all the time.

It's good to know you don't refuse to do everything you should.

okay 1 im a Marine, i dont flake out on work, nor am i worried about psych pt or otherwise, i havent EVER denied txp for that reason personally, doesnt mean it isnt done.

Kindly clarify this statement..Also explain what being a marine has to do with refusing to do psych calls? Unless of course your a marine psych pt?

okay and then back to ruff, like i said it is isnt 9-1-1 it isnt ALS it was BLS TXP not an ambulette or "wheel chair van"

i think that clarifys it for the most part .. any other thoughts or anything else need explanation ?

No it begs mnore questions than it answers. These two astuite and highly capable and experienced individuals were just being nice and trying to politely tell you that you're wrong. They believe in being PC, I am not going to coddle you like they do on Parris island with stress cards and counseling and such. I'm kinda like the clue bat that you so obviously need to get educated about EMS care.

In closing I will refer you to this graphic.

Out Here,

Pinymayu

Double Post..DELETED

quick note, did this article say they were 9-1-1 services?

when i worked doing transport we can refuse to take any pt with elevated bp's unstable vitals etc.. UNLESS there destionation is an ER, but if we get called to pick up to go to a nursing home from a hospital floor and the pt needs o2 or bag or intubation etc... we can refuse the pt.

we can also refuse pt's if we deem it not safe for us ...

like 2 months ago i was rolling up to a hospital with my partner we get out the stretcher about to pick up a pt, security wouldnt let us in we asked why they said and i quote "psych pt got out" i was like alright, talked to dispatch said scene was unsafe send no more units to this location, the ER was on diversion no one was allowed in or out at all, in this case the call was offically put in as we refused to take the pt cuz we refused to wait at an "unsafe scene" ... its all political nonsense..

if its a 9-1-1 call we cannot refuse anyone period the end.

You should not have an EMT ticket. Your so WRONG and negligent in the instances you mentioned above I don't even know wheren to begin. Do your patients a favor amd apply as a janitor to work at McDonadls where you will hurt none except yourself.

pinymyachia?

Are Basics where you're from allowed to give Albuterol/Atrovent or Epinephrine?

I know in NYS, in the REMAC system I'm in that is, a Basic can use Albuterol and Epi-Pens if they've had the REMAC class, or if their squad does an inserviec training with them.

A campus first response team I'm on carries both Albuterol and Epi, and all are fully able to use them. The paid agency I work for however, seems to think that since we have fully staffed ALS rigs, Basics are somehow incapable of giving Albuterol or Epinephrine.

There have been innumerable times where I have had to meet my ALS on scene, and he hasn't arrived yet. (We run a weird program here, ALS isn't required to stay in house if they live in town)

I've beaten the ALS to the scene before, and had a patient that could have used Albuterol, but all I could do was stand there with my ass cheeks clenched.

When is Epi and Albuterol better now or later eh? lol

anyway, enough ranting, some thoughts?

The search key would have yielded you a lot of reading on this had you utilized it... :roll: Seems someone performed thread ccccccccccccpr

Hello Everyone,

Great points, and I agree with many of the ones raised above. It seems though, that we are only addressing pieces of the issues. Here are some of the things that need to happen in a loosely assembled but yet not iron clad order of importance.

1.) Unification of purpose.

We need to cast off the sense of professionalapathy that many EMS clinicians have built into their personalities as away to protect themselves and work in an austere environment. We all need to recognize, accept, and stand up to make the hard choice which are mandatory to effect the desired changes.

2.) Funding.

Everyone is worried about the allmighty dollar, euro, ruble, etc.. Where does it come from? Why should we pay more taxes, more for courses and certs, etc... Fact of the matter is the majority of funding is in placealready. It is just holding up the weak foundations of an ineffective, failing bureaucracy. If we elimeminate this and creat a national level EMS (only) agency which will also oversee and have the 'teeth' to mandate change and education on a national level.

The creation of the federal administration was a crucial step to bringing governmental attention to a long overlooked part of the public safety triad. This ideal of educating providers, both individuals and agencies, to the highest possible levels. The creation and enforcement of this ideal requires the support of a federal agency (cabinet level?) dedicated to similar principles. By bringing this organization's support for the federal administration, we will in effect, help to facilitate the transition of the current system to a new ideal.

3.) Education.

Discussed adnauseaum and there is alot of 'golden' suggestions in the archives of this forum and in recent threads.

This entails that a new group of practicing EMS clinicians should be brought to fruition. The means to do so will be via a shift from the current system to one, which would provide nationwide equality in our profession. This metamorphosis will occur in concert with a progressive, innovative consortium of EMS and non-traditional EMS educators, and related medical professionals. After implementing the new national 'gold' standard education these EMS providers, will become licensed professional EMS clinicians. By establishing a national 'gold' standard EMS licensing board we intend to eliminate the current difficulties of unequal provider education, clinical competency, and hurdles to geographic provider movement and practice. This licensing body would provide a standard time frame for licensing duration, minimum education, and clinical competency standards, on going evaluation of the educational EMS process standards; and still allow for local modifications in the scope of practice for that particular systems needs. These modifications are not to exceed the new National Standards, but set the new minimum levels of continuing education, re-licensure requirements as well as professional development for each level of licensure. It should be noted though that this new body of more effective EMS clinicians will function in environments and roles as yet to be determined. These clinicians will perform functions, roles and procedures beyond the scope of the National standard as it is currently conceived after meeting appropriate training, competency requirements, and oversight in accordance to the new standard.

This benchmarks a fundamental shift from all states meeting the minimum education, and training requirements to all providers nationally being trained to the same ideals of practice and allow for professional development and advancement through out the EMS and medical community. This shift would streamline all education, allow for lateral recognition of licensure between all states and territories, thus elevate the quality of available patient care possible by all EMS clinicians across the EMS horizon. Additionally, as an added measure the national EMS regulatory body recognizes that this shift would also allow for all regions to pick and choose what skills are best suited to each practice environment. This also conversely allows regions to remove those which are not applicable to that practice environment and or system needs. By removing the uneven EMS provider education currently in place this plan allows for greater flexibility in each EMS system to provide maximum efficacy, efficiency and access to rapid, timely well trained capable EMS care for the entire populace.

This standard will be subject to continual review, evaluation, upgrade and progressive change.

4.) Legislation

With the above unity, a clear funding and educational plan standing on the foundation of a small, efficent, autonomous national level organisation at the cabinet level. Legislation should be enacted to allow for continued funding, and the ability to make states fall into line and accept the afore mentioned.

These are just a few of the steps to be taken. There are more.

Pinymayu

***NOTE:: Sadly, due to recent publicity of cases where organisations and individuals are having their professional and personal lives and livliehood put in jeopardy by postings on the internet I am now adding this disclaimer to my scenarios, posts, threads, etc... If there are any blatant violations of HIPPA, State-Local-Federal Laws or Statutes, etc.. please bring them to the attention of the author and site admin.

DISCLAIMER: This TEACHING scenario-post-thread-etc.., (authored with Q/A and learning intent) maybe real, imagined, or any combination thereof. It is not the intent of the author or (and as best the author may be able to determine the replies of the) respondents that the issues, care, and or anything else mentioned in replies previously or in the future to represent actual real events. If so this is pure coincidence and unintentional. I will refer those with any further issues to the TOS of the site. The opinions posts, and responses mentioned and posted in this and other threads, forums, etc...; like these are infact the opinions of the individual and not those of any organisation, agency, club, assn., etc... to which or with which they are affiliated. The purpose of this post is meant to beg discussion, learning, Q/A- professional peer review, and address moral, ethical, and clinical management, and other mentioned and or not mentioned concerns. All attempts reasonably possible have been made to protect the identites of the guilty, innocent, involved, treated, concerned rubbernecked bystanders, etc....

Pinymayu's AUTHORS NOTE:

Sadly for you , if your looking to hang someone out to dry, by effecting their abilty to be employed, and or effect their professional certifications-liscence due to a valid, constitutionally protected 1st ammendmendment opinion post on a professional educational EMS forum. If this refers to you; your in the wrong place. Pick on someone else, and please don't try again. If you wish to pursue your nefarious concerns good luck as I hope you like losing your case and expending useless wasted effort. If you feel your concern is valid than please first address in concert either the author and or site admin to resolve the issue and bring it to everyones attention. Thank you!

OK, neither propofol nor etomidate have analgesic properties. Both are short acting and would not be suitable for sedation beyond about 10 minutes. Repeat doses of etomidate have been associated with adrenal suppression which may result in severe hypotension. In fact, this adrenal suppression has been reported with single doses. If this occurs hydrocortisone must be administered in order to reverse the hypotension.

Propofol is usually restricted in the hospital for sedation of intubated ICU patients. Use for non-intubated patients is usually restricted to anesthesia personnel. Our ER docs are pushing my department to allow them to use propofol for sedation. Our chairman is forcing them to get capnography before he will authorize propofol. It will be interesting.

Paramedics do not have the education nor experience to administer anesthesia. That is why Rid is absolutely correct in pointing out RSI in the prehospital realm is rapid sequence intubation and not induction.

Live long and prosper.

Spock

"Spock,"

Thanks for taking the time to re-iterate and share you expertise on this. You have yet again made clear the all to important difference between sedation-anxiolysis-amnestics, and analgesic medications usage yet again.. The only two points of "Rids," statement I disagreed with were the aforementioned and who said what. Your both great resources here. Thanks,

pinymayu

***NOTE:: Sadly, due to recent publicity of cases where organisations and individuals are having their professional and personal lives and livliehood put in jeopardy by postings on the internet I am now adding this disclaimer to my scenarios, posts, threads, etc... If there are any blatant violations of HIPPA, State-Local-Federal Laws or Statutes, etc.. please bring them to the attention of the author and site admin.

DISCLAIMER: This TEACHING scenario-post-thread-etc.., (authored with Q/A and learning intent) maybe real, imagined, or any combination thereof. It is not the intent of the author or (and as best the author may be able to determine the replies of the) respondents that the issues, care, and or anything else mentioned in replies previously or in the future to represent actual real events. If so this is pure coincidence and unintentional. I will refer those with any further issues to the TOS of the site. The opinions posts, and responses mentioned and posted in this and other threads, forums, etc...; like these are infact the opinions of the individual and not those of any organisation, agency, club, assn., etc... to which or with which they are affiliated. The purpose of this post is meant to beg discussion, learning, Q/A- professional peer review, and address moral, ethical, and clinical management, and other mentioned and or not mentioned concerns. All attempts reasonably possible have been made to protect the identites of the guilty, innocent, involved, treated, concerned rubbernecked bystanders, etc....

Pinymayu's AUTHORS NOTE:

Sadly for you , if your looking to hang someone out to dry, by effecting their abilty to be employed, and or effect their professional certifications-liscence due to a valid, constitutionally protected 1st ammendmendment opinion post on a professional educational EMS forum. If this refers to you; your in the wrong place. Pick on someone else, and please don't try again. If you wish to pursue your nefarious concerns good luck as I hope you like losing your case and expending useless wasted effort. If you feel your concern is valid than please first address in concert either the author and or site admin to resolve the issue and bring it to everyones attention. Thank you!

Actually, Etomidate and Diprivan are long term enough for analgesia.. Both are very strong and have potentially dangerous side effects. Diprivan is a very potent analgesic. Remember, NO EMS is licensed or permitted to perform anesthesia. That is why the initial term RSI was changed from Rapid Sequence Induction to Intubation. This is a very touch legal issue and definitely getting into grades of anesthesia is way out of a Paramedic scope of practice.

The patient is usually only needed to be sedated for a short period of time for transport (<2-4 hrs). Albeit, it is preferred to sedate for ventilator care, it is not always necessary if coaching and patient acceptance of therapy is possible. Long term sedation can be very dangerous.

R/r 911

"Rid,"

As your my respected, learned, colleague from OK, as well I know you've agreed with the preceding statement in the past. If not tacitly, then ceratinly passively many times here in the past. Please read on and understand this is no personal attack. This statement (above) is one which you ( I believe mistakenly, I've made this mistake myself in the past) misquote (pinymayu) in the regard that it was they who stated it as opposed to the cleverly if potentially dyslexiclly (?, nuttin but love for the grizzled and distinguished kodiak of the north :wink: ) albeit certainly facetiously applied screen name "tniuqs"(aka:"squint" and is certainly one of my fav canuks :shock: 8) ).That being said it appears that the terms sedation and analgesia are being mistakenly used and or potentially mixed up.

There was a thread here sometime ago started by FL_Medic (If I recall correctly) which covered this. Additionally "Spock" also clarified on the subject in that thread as well. I'll try to dig the link up and dust it off from the database for you. My point was essntially thus. If your going to do the procedure, and administer the sequence, do all of it, completely and correctly (Unless contraindications or circumstances which warrant a change exist).

Here is the link with the appropriate resources, info and citations, etc.., to back up my statements. If your asking yourself is it worth it to read the 6 pages the answer is yes, but the debate really begins on page 3-4 and moves on.

http://www.emtcity.com/phpBB2/viewtopic.php?t=687

Hope this helps,

pinymayu

The RSI protocol we have called CAM (Crash Airway Management), is I feel very aggressive, sometimes a little too aggressive, but it gets the job done.

We ultilize the combo of Succ's, Etomidate to chemically render them useless and the Diprivan to maintain the sedation

Let's be honest here. A 2 year degree is the low ball minimum. As many of the seasoned, educated, omnicient, and well known and respected EMS guru's here: "Rid, Dust, AZCEP, CHBARE, ERdoc, PRPG, etc.." have mentioned. For ESM to come into it's own much like ERdoc and the others mentioned we need to have at least this troika in place.

1.) Sufficently intellectual, moral, able bodied, common sensical educated and experienced providers.

2.) A national credentailing system-organisation of EMS clinicians with both the teeth and support to enforce the educational, training, research, funding, etc.. One which will allow for the advancement and evolution of EMS practice and theory.

3.) The will to unite and force change as a positive thing

For more see here: www.capem.org

pinymayu

How much education is required to be a paramedic?Not a nurse,or doctor.A ambo grunt, i have to laugh at you supermedics who are impressed with your titles! Hey we're talking being a paramedic, next thing i'll here is lets do chest tubes in the field!

How many articles have you published? How much research do you participate in and or read..

How doyoupropose EMS care is improved and should evolve?

"Rid,"

Another thing which Dr Wang and a number of other 'pre-hospital ETI researchers" have failed to address is the comparison between ED-intensivist and resident sucess and complication rates in house vs the field. This is additionally an understudied area. I think those of us whom have had the opportunity to see someMd's perform these skills in house can attest that they suffer a number of the same afflictions.

pinymayu

there is a great post on this in the student section..may be worth finding it..

Honest question- wouldn't it stand to reason that with RSI, there would be more intubations?

I mean, I once met a medic from a 911 service in CT who had 26 tubes between January and September- he lost the rest of the year due to injury. His service has MAI. How many would he have had without it? Who knows. I've never watched a system go from no MAI/RSI to having a program, so I'll be the first to admit I don't know what one looks like before and after as far as numbers.

A rise in the numbers or decrease in the numbers should have no bearing. The issue is whether the procedure is clinically appropriate or not.

Personally, if given a choice of Versed or Etomidate, I'm taking Etomidate. Versed bottoms your BP, and I've seen too many patients where 10 mg wouldn't even slightly sedate them. Etomidate works faster, and doesn't cause the hypotension that versed does. It doesn't last very long, but once they're intubated I would use valium to keep them that way. But to facilitate the tube, I'd rather have Etomidate.

Not to mention the cardio-respiratory-CNS protective properties.

The idea behind using RSI in the first place is to optimize the first view of the vocal cords. By using PAI, you may not get that optimal view that we are all striving for.

"AZCEP,"

Not only are paralytics and the RSI sequences done in the manner as taught for those reasons, but additionally it is done to lessen the risks and blunt the physiological effects of direct laryngoscopy and entubation.

Pinymayu

In my system we use Etomidate and Versed in order to facilitate intubation. Can anyone tell me why a system would choose one over the over as in RSI vs. PII?

Thanks

Scott

You should buy "Ron Walls book Emergency Airway Management"; furthermore the explanations you seek could be found by doing a site search for RSI on this forum. If you expend some effort you'll find some great posts by Spock, rid, asys, ace, azcep, flmedic, and many others, etc...

Pinymayu

Hello to all my friends.

Some of you are already aware, but now I will post for all.

I leave on Sunday the 10th to go to Houston for training. After a week or two there, I then depart to beautiful #1 vacation destination of Afghanistan. My assignment is for one year.

I will try to keep in touch, however I do not know what the internet capabilities will be at this time.

Please feel free to drop me PMs and when I get to them I will most certainly respond.

Keep the chatrooms clean mods....I will not be around there much at all, maybe not at all if I have the same situation that Dust is experiencing in the sandbox.

Anyways, like I said, I will be around in TX for a week or two so I have time to say goodbye to everyone...I just wanted to give you guys a heads up now.

AK...

enjoy life at KBR, stay safe.