becksdad

I have no idea how much this one patient weighed, but I helped move her from the hospital to the ambulance. One of our trucks was transferring her to a nursing facility. She was so large that she was placed on top of a tarp on a bariatric hospital bed. The "antlers" that lock the stretcher in the ambulance were removed from the floor of the truck, and the patient was pulled into the truck on the tarp. She barely fit - was actually "squeezed" into the back of the ambulance. Her arms were so huge that there is no way she could reach her face with her hands. Someone literally had to feed her. Amongst other things. I can't help but believe that there is some medical basis for someone to be this morbidly obese.Some physical abnormality beyond the control of the patient. I really don't think that these people are deserving of disdain any more than an emaciated terminal CA patient is.

Great post, Michael! I like that!

Chaser - you know you can be on the naughty and nice lists at the same time....

This post could probably be considered hijacking, but I would like to clarify some things about Florida and accepted BLS skills since this was discussed earlier and misinformation was provided. In particular, I would like to add some things concerning Lee County EMS, which was a specific area brought up previously. EMT-B's can in fact establish peripheral IV's in that particular system. The medical director decided to offer training, certification, and permission to practice this under his license. However, once that IV is established, that patient becomes an ALS patient. The EMT can collect blood samples through the IV he/she established, and flush with saline, but cannot administer any medication, including any other fluid bolus. The EMT should not be the transport provider of any patient with an IV established - even if it is just a lock. Lee County does invest well in education and training of its providers - including EMT's. I believe that this is a good thing, but carries some danger with it, as evidenced by some comments made earlier in this thread. I am becoming acutely aware that a little knowledge can be a dangerous thing. We BLS providers are notorious for "wantin' to do more". And that zeal to do more is often misguided through ignorance. We just don't know what we don't know yet. Lack of complete knowledge can lead us to make poor decisions. For instance - that little old lady who was "dehydrated". She may well have been. But was her lethargy really caused by dehydration? That "junk" in her lungs may have been pneumonia as suggested, but could it have been fluid due to CHF? If so, additional fluid is the last thing she would need. Just an example of how often we EMT's do not see the bigger picture in our patient assessments. Not saying that was the actual case. But skills without necessary knowledge can be dangerous things. I do not want to take any action with any patient that I'm unsure of and can't take back once it's done. That's why we have ALS partners. They have more education than we do, and are more equipped to make those decisions. That's why we are limited in our scope of practice as EMT-B's. I do not believe for a moment that LCEMS's Medical Director gave anyone carte blanche to do whatever they want as long as they can provide evidence that it was in the interest of the patient. That physician (who I have known for several years) has clear cut guidelines for BLS providers. And while that physician has very high expectations of all providers operating under his license, he also expects those providers to remain within those guidelines. A little friendly advice for Niftymedic: concentrate more on learning physiology of the human body and how interventions can affect it. Concentrate on thorough assessments, becoming more and more efficient in assessments and interpretation of them, then communicating effectively with your ALS partner. Learn from your partner by asking questions. "Why do you give morphine to MI patients?" "what effect does it have to benefit an MI?" "why did you only give that patient 250cc's of NS?" Get into the whys of treatments before you try to get into the hows. Also, communicating effectively with your ALS partner probably doesn't mean saying "get your ass back here and do your job!" I think it would be more along the lines of: "Hey, this patient seems pretty lethargic, her sats aren't too good, and I'm hearing a lot of junk in her lungs. I think you should take a look at this." I bet it works better. OK, I'm done my ranting. Maybe this rambled on a bit - sorry. It's been a long shift and I'm about ready for some sleep!

I KNEW there was an explanation for why my money disappears so fast!!!!!

Dreaminrabbit, much good advice and good wishes here so far! I also wish you well, and congratulate you on planning ahead. Several things I see here that you might wish to consider. First, don't discount Dustdevils input as negative. It is not. It is part of reality. I had to redo EMT school in Florida to obtain state certification, and had to plan ahead both financially and logistically (time-wise). I left a fairly well paying job and went to cleaning and maintaining swimming pools to get through school. That job offered the flexibility I needed to devote a lot of energy to classes, ride times, and clinicals. Coincidentally, one of the local trauma Docs ended up being one of my customers. You can bet his pool always sparkled! Hahaha! Anyway, that's irrelevant. What is relevant is the fact that once you complete school, and obtain employment in the field, you once again find yourself in the position of time and energy constraints. I don't know of anyone who gets rich in EMS, and when you have a family and bills to pay, and you're working 24 hour shifts, and needing overtime shifts for the money, and wanting to go to school - where's the time and energy coming from? I do not say this to discourage, but to let you know that real comittment is needed. I am a firm believer that where there is the will, there is a way. It can be done, but it usually takes creativity, comittment, and some sacrifice. Just be prepared. A second point worth considering is training through a Fire Dept. Let me pre-qualify what I am about to say that I have no intention of p!ssing off fire medics, I know lots of them, some good, some not so good. And different areas have different systems. Where I live, EMS is a 3rd service - all we do is EMS. The fire districts here also train (as opposed to educate) their people in EMS (some BLS, some ALS). What is very common in this situation is that a lot of people certify because they have to, not because they want to. It can be difficult to wear 2 different hats, and it is easy to allow one field to suffer because it is diluted by the main interest being somewhere else. Personally, I have no interest in firefighting, and many firefighters have no interest in medicine. Some are good at both, most aren't. I say pick one. Whatever you do, don't allow one to be half-a$$ed. If you aren't commited to give EMS the full attention it needs, please reconsider. If you want to strive to be the best field provider you can possibly be - welcome!! Along with many others, I wish you success! Your success is our success. I hope you find many excellent mentors along the way, and continually learn more. The field is almost infinite!

Whatever uniform any service provides to identify us as EMS providers is there to instill public trust and a level of confidence to the patients we serve - NO MORE, NO LESS. Any use of this uniform beyond it being a symbol of trust and confidence is abuse. As only one of the many who strive to improve our professionalism, and the perception of EMS as a profession, abuses of any kind are humiliating to me. They are also humiliating to the people I respect within this profession. I have witnessed a few people requesting special privileges while in uniform, and I think it is just a gross display of arrogance. What may possibly, arguably, be worse is using this uniform while off-duty for any kind of personal gain. The only time any of us should be in uniform off-duty is when travelling to- or from work. To use the uniform for the purpose of obtaining a privilege that is illegal...... we can only hope that the person doing this can look into his own heart and ultimately make the right decision. From the time that I was very young, my Dad taught me to accept praise with humility and appreciation. Conversely, if I make mistakes, I was to accept correction/criticism with the same humility and appreciation. Put another way, someone I respect immensely within EMS once said "If you mess up, fess up". We can only learn if we admit there is something to learn. I, like many others, was 17 (or 18, or 19, or whatever) once, and have made plenty of mistakes. I do not wish for AK to reveal the identity of this person. Ideally, whoever this is will look into himself and make the right decisions. Naturally, we all have our suspicions, and I suspect I know who this is also. I can say with confidence that admission of mistakes and commitment to correct them can lead only to increasing respect, increasing self-esteem, increasing professionalism, and increasing self knowledge and acceptance. Your partners in EMS can only respect you and help you if they know who you are and who or what you are striving to become. So how about it, dude?

I know this is a late entry here, but I thought this sounded familiar. How about Wernicke-Korsakoff syndrome? Etiology an inherited trait of susceptibility to thiamine deficiency, especially with a high carb diet. Even if the deficiency normalizes, the memory impairment of Korsakoffs may persist.

CCMHmedic - the service I worked for the last 3 years works a 24/48 schedule, pays O.T. for everything over 40 in a week. However, the year before I came on board with this agency they paid similar to yours. A lawsuit was filed for back pay/ O.T. abuse, and the Medics won. Everyone was compensated with a lot of back pay.

I do not know if responders to a scene who are not involved medically are bound to the letter of the law as far as HIPAA is concerned, but the spirit of the law certainly applies. Ethically, it is the right thing to do to keep confidential any and all details of the response, especially of any patients. I would have no respect for someone who failed to uphold that mandate.

Emtkelley, you are absolutely right! We need to be strong advocates for our patients. One way to do that, I think is to become the best you can be through education and practice, application of common sense, and accurate interpretation of assessments (among other things). For what it's worth Trauma Junkie, I have worked a few times with a medic who is famous for obtaining refusals (translate that as coercing signatures). The way I got around that was to get to the patient first, and by the time I had formed an impression, asked them what hospital they wanted to go to before this medic could begin to work their "magic". One of these people ended up being a stroke alert. There are ways you can maintain your patient advocacy without it degenerating into a clash with other responders. Just a follow up here - that medic talked a few too many people out of transport to the hospital and was summarily fired. Not even given the chance to resign.

Oh, by the way, I agree completely with vs-eh? about the liposuction patient. Hopefully, there's a whole lot of info you didn't tell us about that. I don't know much about liposuction either. At any rate, any post surgical patient who is fine at discharge and deteriorates 2 days later warrants a much closer look than just a few questions.

I don't think there are many cut and dried answers to the question of what calls should not be transported. A guy working in his garage who lacerates his hand on a razor knife, his wife panics, calls 911. He's cool, you bandage his hand, he just wants his wife to drive him to the ER or a walk-in for the stitches he needs. OK, no big deal, I wouldn't mind signing him off. A little old lady who lives alone lacerates her hand while working in the kitchen. She's kind of upset, she's by herself, if you don't take her for the stitches she needs, how will she get there? Drive herself shaky and upset? Maybe call a friend? I don't know, but I wouldn't be comfortable signing her off. Same injury to 2 different people, 2 different circumstances, 2 different responses. Refusals can be a double edged sword that can come back and bite you. It is a common paradox that some people who really need to go to the hospital will be the ones most adamantly refusing, and many that don't need a hospital will be the most insistent on going. You are always safest transporting a patient who calls you. Of course there are the completely ridiculous calls like splinters or pinched fingers, stuff like that. Then there are the calls that would benefit from some sort of social services referral. Did you know that if someone calls 211 on the phone it rings to the United Way, who can refer to literally thousands of agencies of specialized assistance? All it takes is a patients consent and willingness. I would be extremely careful with RMA's - especially if you are new. It takes more than just an idea of what types of illness or injury are better served by alternatives to EMS.

Hey, Mediccjh, I think most of us can relate to the strain of the shift you described. I also think you're pretty accurate in determining that some of it is from the frustration of being unable to gain access to a critical patient and doing what you know you could do if only.... Plus the stress of all those back to back critical calls! It is exhausting. I read somewhere that somebody did some study on emergency workers and chemical indicators of stress (I'm not real sure of this info. - it was a long time ago). But the conclusion was something like one serious call is the equivalent of a full days work in so-called "normal" jobs. And you had how many in one shift? We had a shift once where we had 2 trauma alerts, a REALLY bad GI bleed, and a REALLY bad breather. Pretty evenly spaced throughout the day. And it was pretty much ok until midnight when we ran on a little 2-or-3 year old boy hit by a truck. As I remember it, the boy had agonal resps when we arrived, badly deviated trach., obvious extremity Fx's x 3 or 4. We did a lot for him, but he died next day. Follow-up informed us he had (in addition to extremity fx's), multiple skull fx's, lacerated liver & spleen, hemopneumo, I forget if anything else (as if that's not enough). But what we got to do is stop at the fire station that responded with us and just shoot the breeze some. We sort of went over the call, talking about what we did, why we did it, etc., etc. Maybe we just confirmed for ourselves that we did everything we could, but it was good just to talk about it with people who were there. I don't know what else to say, except that you know we know what its like. Thank God those kind of shifts are usually few and far between!

I guess I study in the sense that when I run into things on calls that intrigue me or I don't understand, I research that particular topic. Same with questions or scenarios here. I try to keep up on meds, too, since so many are newly marketed or list different name brands vs. generics. I think that is all fine as far as it goes - definitely helps on calls in day to day practice. The problem with this for me seems to be that the learning is kind of willy-nilly: a bit of knowledge here, a bit from from over there, often without the benefit of necessary connecting knowledge. That is why I look forward so much to returning to school. It seems to me that structured education will provide much more complete information, in a logical sequence, that will prove more beneficial to both myself and my patients.

I like the first one better.

Michael, your posts are always thought-provoking at the least. EMTCity wouldn't be the same without you!

I convince patient and family to accept Tx and transport, using the strongest terms necessary. Patient has S/S of head injury. Nausea/vomiting-seizure-pupillary changes. Delayed symptoms post fall to me are more ominous than immediate & transitory changes. I believe it is also common for those with severe head injury to have a lucid period before truly crashing from ICP. Patient is already hypertensive - I would expect that to increase as well as widening of pulse pressure even further. I would also expect patient to become bradycardic and develop an irregular respiratory pattern. Sounds to me like this guy likely has a very serious head injury.

Regarding the use of PPE in response to AIDS patients - It may make the responder feel better about his/her own personal safety, but the fact of the matter is that we who have normal immune responses pose a much greater threat to an AIDS patient than an AIDS patient poses to us. With the use of PPE, it can certainly be explained with compassion that this is for the patients protection so that we do not inadvertantly expose them to organisms they may be unable to defend against.

Hey Lithium - we were posting at the same time - great minds must think alike!!!

My instincts still tell me that this is very possibly a medication interaction (including the ETOH). Quick question - did the same physician prescribe all meds? If not, is one aware of what the other is doing? It almost seems like the Levodopa and the Levocarb together, along with Trihex might be overkill. Maybe the same with Amiodorone and Metoprolol. Not really sure, but it seems they could have synergistic effects greater than any one of them alone. Since the patient is very much improved, despite the refractory bradycardia and still kind of low diastolic, I would cut the fluid back to KVO, keep patient supine, and continue monitoring frequently. I also figure that the cardiac meds are prescribed for a reason that I don't want to mess with, especially since I do not have a complete understanding of cardiology. So as long as patient continues with normal mentation and V/S remain improved, I would just continue with supportive care. I hope nobody feels like I kind of hijacked this thread because I'm an EMT playing in an ALS forum, but this is good for me to learn from...

Interesting link there, AK. Never thought I could learn about manhole covers on EMTCity!

A manhole cover is round because it's the only shape that won't fall through the opening.

First we practiced dummys, then we practiced on each other, then we practiced on patients that were really obvious easy sticks, then on patients that were more difficult.

OK, I'm an EMT playing with Paramedics here, but my first impression is that this is very likely a medication interaction. The anti-Parkinson meds - Levodopa and Levocarb - isn't it very common to induce orthostatic hypotension? And isn't Trihex used as an adjunct with these meds? The Amiodirone and Metoprolol - they will keep HR low, correct? Compound these effects with the fact that patient just had wine - initially induces vasodilation, correct? Further compound that if he took any of his NTG (or Viagra as someone pointed out - dirty old man!). You said lungs are clear, no resp. distress. The fluid challenge sounds good, but honestly, the first thing I would do is to lay him down and see what changes. Is that stupid?