Niftymedi911

This season (snowbirds) in our county we have seen an extreme jump in call volume and the number of sick patients. Most of the time we would expect it due to season but this year as by far been the worst in the past 5 yrs. We've done in excess of over 11,000 EMS calls this past month. Now, the biggest problem we keep running into which I know everyone has experienced a time or two was the long offload (wait) time in the ED. I'm interested to see or find out if anyone has been part of a CQI or a committe of some sort to better the situation for EMS personel at the ED's with offload times. Our agency has done some ( as in calling into a transportation officer before transport to request a specific hospital, and based on offload times and the like are directed to that facility or must go to another destination. The ED's also update their status to better inform us on a computer program so we can see the offload issues. But in a day where close to 350-400 9-1-1 calls for help come in and maybe a total of 100 ED beds county/system wide, its kinda hard to balance things. Just wondering if anyone has advice or a situation where a study was done to help things along. FYI my average offload time this past week was 1 hr 9 mins. We're at times getting close to running out of units (status Red) bc of the ED crowding of EMS units. And we have 37 trucks. Better Info to help understand: 5 County Hospitals (All owned by health system) / 1 120 bed Private hospital owned by HMA Biggest ER is 25 beds, smallest ER is 10 beds Approx 2000 beds total county wide Out of season population: 550k-600k In Season: Approx 1-3 million Offload time is defined as time of arrival @ ED to RN taking report Offload is defined as being assigned a bed, moving the patient to the bed, RN walk in, give verbal written report to RN, Rn takes over pt care Any and all information is helpful and apprieciated!

CBVEMT... that would be me..... And to answer your question, the safest (in job security wise) currently in the state of Florida to run not private or Fire is: Lee County EMS or Lake-Sumter EMS. I work for one of the aformentioned agencies and I'm not going anywhere. We're the highest paid 3rd service, the most progressive medically with state of the art equip and trucks. We ran 78,000 calls (2008) last year. 24/48 with 12 hr optional. 9-1-1 Division / IFT Divison / Critical Care / Aeromedical (2 helos) But regretfully due to Amendment One and the economic down turn.... we're in an indefinate hiring freeze.

Any truck reguardless of 24 or 12 hr status is eligible to stand-by at another station. there are a few trucks that jump from one station to another, but usually if your sent on stand-by your normally getting bagged with a call. But it's the luck of the draw.... and it's that chance that SIREN can determine wether or not to send a unit, based on wether or not a call will drop in that zone. If no call....no truck placed on standby= more station time

Ambo, Is the double dose an effort to decrease the ICP in head injury patient's??

Our system is set-up a bit different: When we're on scene and transport is to be made, We notify our Shift Commander on one of our secure Tac channels. We give age, c/o, area of call, and patient's destination request. They either clear us for that destination, or can adivse us that an alertnate facility must be requested due to current offload times. We do not deal with the hospitals until we give report to the ED via telemetry. In other words we share the load, we're rotated through hospitals (as long as the patient has no preference) that are less busy in order to prevent the busier hospitals from getting overloaded. We give report to the ED via telemetry most of the time its an RN or the unit clerk on the other end. If we need orders or adivce we ask for Medcom and we talk directly to a MD. Usually we have a bed assignment by the time we get there, but if it's busy or no open beds are avail then we sit in the hallway until we can get a bed. (offload time) Our shift commander has a computer system that links all of the local ED's. They report their status on the computer and when a destination determination is requested. Their staus as well as their offload times are taken into consideration. If a particular hospital has an extended off load, they try to trickle the flow of EMS through there to try alliviate the flow. Offloads greater then an hour, eliminates the the possibility of a transport to that facility unless its deemed a priority 1. Then its off to the closest hospital. We don't have any RN's sitting awaiting to take report or give orders. We only take orders from a MD.

We do not use SSM and in fact, our Union contract forbids SSM. We have a more hybrid approach to keeping over 650,000 full-time residents and 3 million visitors each year covered. We don't just cover one city, we cover all of 4 cities and 50 different un-incorporated communities in our county. We have a mixture of 12 hr and 24 hr units totaling 37 trucks at any given time @ peak hours which is for us 1030-2230 The 24 hr trucks are what set-up all of the 8:59 response zones. When one zone as identified by the 8:59 sec rule,is out on a call it is deemed there's a hole, 1 truck is moved to that particular station to cover that zone. No street corner, no "post". All of our trucks have stations. The new software is being utilized so that the most appropriate unit and the most appropriate response time can be met to meet the needs of that 9-1-1 caller. That is why we didn't go with MRVLUS or any American type product. The SIREN software gives us the freedom to use what we want from the porgram. I know the softwares implications that can ultimately bring us back to SSM, but only time will tell. I just wanted to share this article with you all. PS. We're finally getting induced hypothermia!!!! Our inservice ist next week!!

Prediciting an Emergency I wanted to also point out that our agency is the first north american agency to ultilize both SIREN predict and SIREN Live products. Here's the Companies website: Optima Corp

CTX grow the hell up and stop acting like an arrogant <..........> Your type is the main reason why we're not looked @ as a profession..... cocky, arrogant, and failure to see the big picture. Now, what in the OP suggests this patient is not hypoxic?? Is it just because "she's @ 98% on 4 lpm"? Are you even seriously thinking this through. A normal person would not need supplemental oxygen @ 4lpm to have their O2 saturations @ 98%. The damage the chronic pneumonia has caused to the lungs is already enough to suggest VERY mild hypoxia under normal conditions. Now with her lungs compromised by the infection again and not to mention tachypnic why would she not be hypoxic?? Oh my bad, you don't treat the monitor (aka magic box as you call it). But it sure as hell sounds like it to me. The whole compensatory tachycardia added : "don't touch it", does not apply here. A-fib and a compesatory tachy are two seperate things. Just because she has a high HR with "stable" vital signs (which is what your getting stuck on), does not mean its a compensatory tachy. But when you decide to ignore it and she becomes hypotensive, AMS, cyanotic with circumoral cyanosis, your causing harm that could of been avoided. As ERDOC put it, Good Luck with trying to defend a Tort Law case. Your arse will go through the ringer.

I just happen to work for an agency that allows us to peform pericardialcentisis. It's protocol for a trauma arrest patient with subsequent blunt force trauma to the chest. Bi-lateral chest decompression and pericardialcentisis. No online medical direction needed. Now, to do one in a live patient requires online medical control. The only way to fix the tamponade is to fix the cause. Wether it's infection in the pericardial sac (high dose anti-biotics and a centsis), a hemorragic anurism, or an effusion. Fix them, you fix your tamponade.

I'm gonna have to stand with Mateo on this one. Going wayyyyyyy back to your first ACLS class... What did your instructor tell you?? Anyone? A heart cannot perform at its best when its beating 3x faster then its desgined to. With someone already having a compromised cardiac function, its only a matter of time before (even in sepsis) hypotension and failure will start to set in. I agree it ultimately sounds like the patient's is suffering from ARDS secondary to Pneumonia with a mix of sepsis. However, it all depends on how long the patient's been in that rhythm. But there is always the added patch I could get just to confirm the use of Cardizem or electronic therapy. And what most of all of you don't realize is corticosteriod use in ARDS / Pneumonia / Sepsis patient's actually significantly increase their chance of surviving out of hospital. In fact it's standard treatment for ARDS / Pneumonia including minimal doses of methlypredisnoe, high dose anti-botics. A fluid bolus in this situation is on the fence. Because more of the fluid could rehydrate the patient, however the patient could also end up drowing in the narrow passage ways that are created due to the mucus back up in the bronchioles and aveloi. Myself, I would of gave the cardizem ( I would of probably checked with Medcom just before to make sure I was right in my thinking), and gave the sol-u-medrol and transport with oxygen.

It all really boils down to maturity levels and life experiences that you normally wouldn't encounter. I am like Mateo also 22 yrs of age and the lead paramedic on a truck. I've been employed since 5 months after high school (dual enrolled my senior yr in high school with college and took my EMT- with my agency (4 yrs now), worked as an EMT, then last year went back and finished my AS degree. But the situations that I encountered and went through when I was young (my mom was divorced 3 times and numerous other instances with cancer, cardiac arrest, living homeless). I just chose to learn and not make those same mistakes. I just simply chose to not fit in with the crowd. I just simply chose to learn, interpret, understand, and move on with my life. I think a majority of the maturity if it comes at a young age, like in Mateo's and myself, is self-learned from life experiences that a normal teenager wouldn't encounter. To those that think they can become a medic without learning to adapt and overcome, well you might was well get plenty of lube ready ( I couldn't help it Dust, I was tempted), because after your first malpratice claim, it's all downhill from there.

NEWS FLASH!!!!!!!! Dustdevil IS NEVER HAPPY!!!! Now back you regularly scheduled posting...........

A-fb with flutter

I appreiciate the suggestions. As that's what I was looking for. I guess I should be more open sometimes. -5 for me for being closed minded and not thinking outside the box like I normally do. The only thing about this call was the fact the FD already had her c-collared and backbaorded prior to my arrival. When I got there they told me she was a priority 3 back pain patient for the bandaid clinic. And meet me at the foot of the stairs as they were carrying her down the flight of stairs head down......... yea. And what's worse was there was a Fire-Medic on the rescue truck that supposedly did an "assessment". Good ole Fire based oppression of EMS....

Alright before you guys go jumping off the bridge..... relax, take a deep breath. She had c/o of moderate back pain that was caused by the fall. Hence the c-spine with LSB and C-collar. The board was also @ about a 20 degree angle forming that "triangle", with the lip of it resting in the cradle at the end of the stretcher. And if you can READ correctly, she was given the atropine (I had a free hand), while my partner was putting the pads / pacer on and starting to obtain capture, as I had another medic with me in the back of the truck. Crotchitymedic, BTW, I asked for an opinion, not a verbal thrashing. And I'm not an idiot. I would hope and assume that the hypotension and junctional rhythm she was in would of caused the LOC instead of a stroke. And in my eyes I did what was needed for the patient. And to be honest, there was nothing else I could do besides intubate her, she was so full of fluid to begin with. The use of CPAP was contraindicated becuase of the hypotension. And even if it wasn't I bet you 5 bucks and a wooden nickle the CPAP wouldn't of been enough. The pacing controlled the rate, but the Dopamine didn't even touch the hypotension, even after 20 min after I offloaded and was leaving and the pressure @ best was 74/42

Mid 80 yr old Female, HX of HTN, CAD, COPD, right hip sx, and osteoporosis. It appeared that she was walking from her chair in the living room to her front door and fell onto the tile floor right in front of the door. Small lac to the right orbit and skin tears to bi-lat forearms. Found in prone position. + LOC.

Is it better to C-spine someone who fell and is also symptomatically bradycardic with rales, hypotension and severe respiratory distress (which will lead to you intubating the patient. Or better to not c-spine, place the patient in high fowlers and treat accordingly? I ran this call the other day, I've never ever had someone like this before. I went with the first choice, C-spine, High flow O2 NRB, IV, 12 lead (negative for STEMI), .5 mg of Atropine, placed pads and turned on pacer and started Dopamine ( pressure was 60/24). And I intubated the patient about 2 minutes later. Which one would you all of chosen?

Dammit I was gonna say hyperkalemic too!!!

I think there was an article in JEMS recently on how EMS continually does not effectively use pain management or just "play it off". Somewhat of an eye opener. But at the same time, each person responds to pain differently. Much as noted in EMStudent's post. I just try to think outside the box and do what's BEST for my patient. Not what's BEST for me. I say 10 being the worst pain you have ever felt 1 being no pain.

No demerol..... MS, Fentanyl. Versed, and Ativan

For all of you I fully appriciated everyone's post. Here is some answers to you'alls questions. Why didnt I bolus and then NTG and MS??? Perhaps if you read it correctly I put the word PERSISTENT HYPOTENSION in there. My fluid bolus did not change it in fact had gone down a few points by the time i got to the ED. There was no way I was going to give someone NTG with a B/P not responding to fluids. I gave the Fentanyl for pain management and agitation. Fentanyl treats both of that. The patient was literally try to get up and walk around the back of my truck. Here's the other factor. One week ago, the pt's RCA was 95% blocked. A stent was placed but after discharge they never took their prescribed medications. I knew this after interviewing my patient and that's why I chose not to try anything further then ultra diesel and some fentanyl. On scene time was 7 minutes, transport was 13 minutes, Time from STEMI called on scene to balloon deploy: 56 minutes. Thank You guys for all your support, opinions and answers....... I personally hate doing "by the book" because you will never have a BTB patient. So Y treat them that way?

I ran a call the other day and got a rash of mess for it by the MD. Let me bounce this off ya'all to see if I was a little off with my thinking. mid 40's female chest tightness and pressure lasting approx 40 min 7/10 radiates to left arm bradycardic 54 bpm pulse ox 95% RMA b/p 98/62 + Cardiac Family and patient specific Hx. 12 Lead is STEMI in II,III,AvF with reciprocal changes in V2,V3, and V4. During transport: Repeated 12 leads including Right sided 12 leads which revelaed right sided involvement. Bi-lat AC 18g IV's, Pressure infused NS total admin : 600 cc's, ASA 324 mg PO, 4 lpm NC, 100 mcg of Fentanyl, and some ultra low sulfur diesel for a min 10 min trip. The MD in the ED pulled me aside asked me what our STEMI protocols was on NTG and proceeded to chew me a new one because I gave Fentanyl to an MI patient instead of MS and NTG. He told me to explain myself and when I did, he said that I must be stupid or ignorant because Fentanyl is just as much of as a vasodilator as Morphine is. Every article I can find says the exact opposite, when given slowly it does not effect the circulatory system. I gave the Fentanyl for pain management and pt anxiety. He told me if I was giving that then I should of given the NTG bc that would of helped in the long run. But, if my right sided 12 lead showed depression in V3R and V4R, isn't the use of all pre-load reducing drug contra-indicated?? Not only that but as things progressed her perfusion was lacking with cap refil around 2-4 seconds. Sorry but I'm not giving someone with hypoperfusion NTG. Was I just balantly wrong and not see it or what?? BTW our protocol contraindicates NTG for anyone with a systolic lower then around 100, B/p upon arrival was 88/56. Pain went from a 7/10 to a 5/10.

Stupid 911 calls clog system, put safety at risk Originally posted on: Wednesday, November 05, 2008 by Kara Kenney Last updated on: 11/5/2008 6:32:19 PM LEE COUNTY: For 3 months, NBC2 Investigators have been working with emergency services collecting calls and riding with paramedics. We discovered a large number of calls coming into 911 are for anything but an emergency, which puts your safety at risk. 911 operator: What is the address of your emergency? Caller: We are at the corner of Edison and Cleveland-- 3 car accident at least with injuries It's Friday night and multiple calls are coming into the 911. But this story isn't about people who call 911 for a real emergency. This story is about the 40 percent of calls that aren't for an emergency at all. Some examples: 911: What's your emergency? Caller: Um, yes I locked my two keys in the car. Caller: I'm depressed because [expletive deleted] Obama's going to get the thing 911: What's going to happen? Obama's going to get what? Caller: He's going to get elected. Caller: She needs to go to the hospital because she has a toothache Caller: Yeah I ran out of gas. Caller: I'm at the Chik Fil A on Colonial and I'm trying to get an ambulance to move and they won't move. I'm parked here in the heat, I'm about to need an ambulance myself. 911: So, you are not having a real medical emergency right now? Caller: It will be if I sit here in this heat any longer! The four days we rode along with EMS, only 2 cases were truly life threatening emergencies. "Typically 911 is the first thing people think of, and it's the easiest thing because it's guaranteed," said Paramedic Robert Bertulli. When people call 911 unnecessarily, it puts a strain on the system and puts your safety at risk. "It happens all the time," said Bertulli. When crews are tied up on a call for a stubbed toe or nosebleed, EMS must shuffle ambulances and your ambulance could be coming from farther away. "Inevitably someone's going to suffer as a result of calls made that are unnecessary," said Bertulli. Only 20-percent of the calls that come into 911 are truly life threatening emergencies - like heart attacks. Forty-percent of calls are emergencies – not life threatening, but serious enough you shouldn't be driving to a hospital. The remaining 40-percent of calls are not emergencies at all. "We still handle it as we regularly would because it's protocol," said Angelina Ursitti, a 911 call taker. EMS is obligated to go on all the calls to 911. "If you call we're going to send you an ambulance," said Lieutenant Janet Quinn of Lee County Public Safety. Despite the obvious drain on resources, NBC2 uncovered there's little that can be done to stop 911 abuse. Lee County says the solution isn't arresting people, it's educating them. The more time and resources emergency crews have to save lives, means they have a better chance at saving yours. "Please don't abuse it-- because someday you're really going to have an emergency and you're going to need it," said Denise Griffin, 911 call taker. Public safety workers want to emphasize that calling 911 doesn't mean you're going to get into a hospital sooner. Chances are you will end up in triage with everyone else. One other note, Lee County is also developing a new priority medical dispatch system to better determine which resources to send. They hope it will eliminate unnecessary time and equipment. If you have an emergency you should absolutely- call 911. There are other options, though, if you need assistance and it's not an emergency. You can call 211 if you need social services like a meal or someone to talk to, 511 for traffic information and 411 for directory assistance. If you need medical help but it's not urgent, consider seeing your regular doctor or going to an urgent care facility. A very nicely put video is also on the website: http://www.nbc-2.com/articles/readarticle....=22828&z=14

I've only seen Cardizem slow the rates down, never actually "converting" them.

Transport.....transport.....transport......... how do you know that all he needs is to "sleep it off" can you say your 100% certain of that...... No?? Don't "assume" it's a mistake that can cost you your job. And in the state of Florida if I let someone who's that drunk sign off stating they didnt want to go to the hospital..... I'd be breaking the law somethin fierce and liable for anything that happens to him/her. U know what the say about assuming..... It's the mother of all f***-ups