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Hello, Location: You are an ALS crew in a small town (population 5000). It is 1000hrs and you are dispatched for an urgent transfer to the local University Hospital. The University Hospital is 125km away. On Arrival: You are greeted by the ED staff and are given a report. Mr. Smith is a 67 year-old male with an extensive and complex medical history. He has had a MI in 1993 (NSTEMI),CABG in 1994 (4 vessels), PSVT, HTN, DM I, Dyslipidemia, Depression, Renal Insufficiency, Esophageal cancer that was managed surgically in 2008 with a Esophagectomy as well as Oropharyngeal Squamous Cell Carcinmona (OSCC)in 2009 that was managed with radiation and surgical interventions. Since 2008 the patient has had dysphagia and numerous aspiration pneumonia. He was made NPO. A PEG was insert in Dec 2009 and the patient was started on bolus feeds. However, he has still had trouble with aspirations. There were plans to advance the PEG in to the small bowel. For the past five days the patient has been feeling unwell. Chills, myalgia, fever, and a hacking cough with some think yellow sputum. His wife was concerned that he had a pneumonia. The patient has been refusing his tube feeds because he feels unwell. The patient did not want to go to the hospital and took some old antibiotics he had around the house. This morning he tried to eat. His wife started his tube feed at 0800hrs. Shortly after feeding began he started coughing and threw up. Gagged for awhile and trued 'blue'. He developed respiratory distress and was driven to the hospital by his wife. On Exam: The patient is sitting up in bed (75 degrees) and looks distressed but is lucid. Numerous old surgical scare are seen on the patients neck and jaw. He seems to have a poor range of motion as well. GCS 15 PEARL 4mm Strong x 4 BP 180é90 HR 120 Temp 38 EKG: Sinus Tachycardia with an old RBBB RR 34 SpO2 88% on 100% FiO2(humidified oxygen wide open) Lungs - course crackles Abd is soft Foley is in situ with 20cc of concentrated urine There are 2 IV. An 20 gauge in the left hand and a 18 gauge in the left arm CXR shows a white out on the right side and cloudy looking left side. Labs are limited. They show: WBC 24 Hgb 84 Na 137 K 2.9 Mg .85 ABG show (100% oxygen): Ph 7.45 CO 32 O2 64 BE 2.2 He has been Dx with Sepsis and aspiration pneumonia on a preexisting community acquired pneumonia. Treatment thus far: 1L NS bolus 40mEq KCL IV NS+20 KCL at 125cc Vancomycin 1gm Pip Taz 4.5 mg Zythromax 500mg Decompressed his gut via the PEG Zantac 150mg IV His medications are: ASA 80mg od Lopressor 50mg bid Lipitor 40mg od Ramipril 5mg od Sliding Scales Insulin tid Tyl prn Advil prn Lansoprazole po od Motilium 10mg po tid Cheers...

what I can't seem to wrap my head around is this: You openly bash firefighters as being 'useless', yet countless numbers of us have heard how you come from a 'pro fire service' family', and you yourself have said on countless occasions how you'd like to become an engineer. You can't have it both ways, and the hypocrisy stops here! Either you're 'pro fire service' or you're 'anti fire service' ... make a stand and quit trying to side with the side that's winning at the moment!

I've worked for a dual-role department and trust me, it's a nightmare. Currently, they have moved away from the police/ems role and have separated the sides within the department (with a director of EMS and a chief of police). Cops should be cops. Medics should be medics. Firemen should be firemen. Firemen and policemen are more than welcome to help on an EMS call. Regarding this; I'm not sure how the laws work in Colorado but being a police office does not discount you from being charged with "interfering with a 911 call" in Texas. Sounds like the Sheriff's department is not dispatching correctly (with prejudiced) and not utilizing resources appropriately (dispatching fire to medical calls which I understand is protocol there).

I should clarify, this sort of job here would be undertaken by a physician or some specalist as even our Intensive Care Paramedics are not trained to take care of somebody this crook. The hospital would send somebody because he is on a lot of meds and things Ambulance Officers have no experience in.

Seems reasonable! Sounds like the Fire Service hung around long enough to make a turd of themselves and get told to leave or be canned I appreciate what he is saying, but when he doesn't listen to being asked to leave doesn't that seem to register with this guy? He also says it in the typical pro-fire way that the Fire Service seems to be good at; I don't hear the Ambulance Service out there going on about "thier oath to protect the community". This is all very publicity, bright lights and making things look good for the Fire Service, the IAFF would be proud! I agree! Sticking your beek in where it does not belong!! I don't see how oxygen and taking a blood pressure would help? It doesn't sound like this patient was critically sick Why, because they poked thier nose in where it did not belong and got it bit? Oh FFS what a lot of bullshit. Good to see the local IAFF man had to step in and make the fire service look like the victim. No, but he is legally able to arrest those who do not comply with his requests! Sounds like they should look in thier own backyard before condemming others! It seems to be local protocol to send Firefighers as "first response". The Deputy decided that he did not think the firefighters were needed which may have been for any of the following or other reaosns unbeknown to us (we aren't the cop) 1) the transport ambulance was either there or coming, and the firefighters could not transport, 2) the patient was not critically sick, 3) three firefighters on scene in addition to the two ambulance officers who were already there, or coming, would be execssive, 4) the ambulance officers may have been able to provide a higher level of care than the BLS firefighters, Then it seems the Firefighters hung around long enough to create a bad smell despite being asked to leave that the cop said he would arrest them, the Fire Captain in his "last stand" mentality said he did not want to leave a medical scene, where at that time he was not needed. Does it not register with this guy that (at the particular time he was told, future circumstances notwithstanding) if he was not needed why would you hang around somewhere you weren't needed to the point that you were told to leave or be arrested? Why on earth would you stay somewhere you weren't needed?

Sounds kind of screwey, you leave a scence where you aren't needed and get threatened with jail WTF? I think the cop had it right to tell the Fire Department they were not required as the ambulance crew was already treating the patient A bunch of more emergency personnel standing round doing nothing wouldn't help the situation any.

From the article:

Actually, COPD patients often do require high flow modalities. Remember, high FiO2 and high flow are profoundly different concepts. Additionally, a NRM at 15 LPM is NOT a high flow modality. Simply stated, a high flow modality must meet or exceed the patient's flow requirements. A simplified way to view it is the following; Say I have a Vt of 500 and I am having some respiratory distress and am breathing at say 34 times a minute. That gives me a minute ventilation of 17 litres. Will a NRM at 15 LPM meet my inspiratory flow requirement? That is not even throwing in other concepts that can alter the flow requirement. In addition, a loop diuretic is not a cure all for every patient with CHF. We need to be very careful about giving loop diuretics in the pre-hospital environment. In addition, other modalities should be considered. Take care, chbare. EDIT: added an '.

Kiwi- how farking IGNORANT can you get? Just because you can't treat him doesn't mean you shouldn't try to figure out what's all going on and how it would be treated... what are you going to do if he develops complications during your transport? Say "Oh well, we just figured we were the taxi ride?" I thought you were against having to rely on physicians for everything. Get your story straight!! I'll puzzle through this and get back to you, have to get to my A&P lab... Wendy CO EMT-B

I do not get it nor do I know your brother. Guess I'm plumb out of luck

Now to get a little more specific. Albuterol is the cure all for everything or so it would seem. If you don't know what is going on in the chest, they get an Albuterol neb in hopes of sorting out the sounds left or that appear after the treatment. Atrovent (Ipatropium Bromide) is generally more effective in COPD patients. However, since asthma can also fall into the broad category of COPD and the lung remodeling that occurs, Atrovent may also be a good med to use with the Albuterol. For PNA, it depends on the history, type and site of the PNA as to whether Albuterol can be effective. Sometimes patients may have a bronchospasm present with the PNA and sometimes not. However, if a neb is given that is powered by O2 from a tank, the patient will probably rave about how good they feel just because of the extra O2. The extra flow may also enhance the intrinsic PEEP effect that may splint some of the airways. This is one of several reasons why I prefer a mouthpiece neb over the mask. CHF is also controversial. If the patient has an underlying PNA or pre-existing lung disease which could also have been an initiating factor for the CHF, Albuterol or Albuturol/Atrovent may help but I would not delay initiating other therapy such as CPAP. For pulmonary edema post operatively following lung surgery and early stages of ARDS, we have been conducting studies for Albuterol (Salbutamol studies in Canada). We have noticed some improvement with the Albuterol and not as much with the Atrovent (Ipatropium Bromide). But, there are many factors to consider with each patient.

Dwayne, You are correct, and no I am not offended. The first one went well (First Aid) I knew that I was doing that and was able to prepare for a week or more and borrowed some props. It went great. The second got sprung on me with about 3 days notice. I did not have the time to do a good presentation and worked with what little I had. Yes it could have been better and yes I have wondered if "I" failed them... As the old saying goes, If you are not a part of the solution then you are part of the problem. I totally believe it. I know a little more about the subject and if need be with a little more notice I can get the necessary props to do the class. The general attitude of the kids was more of what I was commenting on. Unfortunately some of them have no interest in putting forth the effort to achieve anything. They believe it should just be handed to them. Some of the requirements like the 5 mile hike we try to make a little more intersting. We include other requirements like identifying wildlife and trees and stop along the way to do this as well as just talking to the kids about what is going on with school and family and life in general. Anything to get there mind off the fact that it is 5 miles. It is inevitable that about 1/2 way into the hike or whatever I hear the complaining about stopping and just saying that we did it. I guess my observation is more from a lack of integrity, honor, or commitment. But we will keep plugging away and working with them. We can't give up on them. We have to keep working with them and trying to teach the values or we have failed. If we give up on them, then they have no positive reinforcement and will give up on themselves. Failure is not an option. Thanks for the feed back. I am always open to criticism and new ideas. Trust me I do not have all the answers.

For clarification – Dixie and Dr Early were married – not on the show, but in real life. Emergency was a completely different genre than Trauma. Emergency was a public service announcement worked into a 1 hour television show. Trauma is just nighttime soap opera with no basis in reality. Emergency touched on topics of “drinking and driving is bad,” “drugs are bad,” and the politics of hospital and EMS/Fire. Emergency was based a lot on James O Page, one of the pioneers of EMS, and who the Johnny Gage character was supposedly patterned after. It was also based on actual events of the time, including touching how medics were trained, the legislation in California which allowed the paramedic program to be developed and implemented, and the hurdles they faced. In comparison, Emergency and Trauma are two completely different creatures.

I see what you're saying and I partially agree . . . That said, the biggest difference in the two shows I see is Johnny, Roy, and the rest of the gang seemed genuinely caring and always did the best they could. And they were no where near as angst ridden as the characters on Trauma. But some of that can be chalked up to changing times. Dixie's humongous pointy rack was there for a reason, but it still seemed in line with the morays of the day. And Blondie's behavior, in some circles, will also be acceptable, except it isn't to us. All the EMS woman posters, and many men too, are deriding the depiction of females on Trauma while no one at the time ever called Dixie slutty. On the subject of Chet. I actually found his character a distraction on Emergency. I felt like they were going for a cross between Lumpy and Eddie, from Leave it to Beaver, and they hit neither. The bottom line difference, and again only to us, is Emergency was a positive look at EMS (medical inaccuracies aside) while Trauma is a negative look at EMS and the medical inaccuracies just seem like a further slap in the face. And while Johnny and Roy weren't above a small giggle when they encountered something out of the ordinary (the poor schmuck trapped in his folding bed/couch comes to mind) in the serious extraordinary cases they' huddle up and calmly figure out what to do. In Trauma, and on scene, most of the characters seem to be in panic mode. I think the very first lesson I learned in the field, and just from watching other providers, is no matter the gravity of the situation just act like you've been there before. But the real truth of the difference between the shows is today Randolph Mantooth can sit behind a folding table at an EMS convention and be adored. If Wabbit tried the same thing, today or twenty years from today, I'd fear for his safety . . .

It has always been my understanding that stepping out of the truck with a patient on board, leaving the room before patient care has been PROPERLY transferred to the recieving facility and in general leaving your patient unattended after making initial contact (without proper transfer of care to someone of equal or higher licensure) constitutes abandonment. The medic in the back of the truck should have NEVER left the patient compartment, regardless of what transpired between the driver and the troopers! Thats how I've always viewed the abandonment criteria, Ruff. Dust, you of all people know that there are different rules and circumstances between people in the field and those in the hospital! How can you even compare the duties of a floor nurse to the field medics? You're comparing apples to tomatoes....-15 for you!

Seizures isn't a medical call? Since when? Your paramedic sounds like a weirdo. You're either old enough to work all patients, or you're old enough to work no patients. This picking and choosing crap is nonsense and gives me little faith in your organisation. You're either a member of the team or you are not.

Dixie was as sexy as 70's television would allow.

I have absolutey no idea, I am going to put him on the stretcher and take him to the hospital; oh wait, he's already at the hospital mm ..... did I mention I have absolutely no idea? This is a transfer, so, if they want him treated then send a physician with the patient!

Finally somebody who understands a bunch of Firefighters standing around in thier getup doing nothing are not any use! Sounds like something out of Mother, Jugs and Speed ..... oh no you didn't

Additional fail, they said heart attack and not cardiac arrest! Additional additional fail, "heart attack" should read "cardiac arrest"

If you have a sufficent number of Ambulance Officers treating the patient, what use can a bunch of Firefighters standing around doing nothing be??? Firefighters are good for holding bags of fluid, but so are cops and members of the public! Infact, Firefighters are better at at holding bags of fluid than the public, they always want to squeeze the darn bag.