Krysteen

Interesting topic:) Actually had the exact same patient presentation. Bottle of benzos empty. Note written. Pt unresponsive. Gave romazicon per protocol and was later pulled aside by ER doc and was informed that treating benzo overdose with romazicon has changed primarily because had my patient had rebound seizures, which has become increasingly common, I would have had no way of treating them. This was one of three times our service was warned, each a diff medic, in the last six months. So we we have since changeed our protocol for use only as a adjunct to our administration of benzos if reversal is warranted.

I agree,AAA. What caught my eye was that I had a pt that presented exactly the same with lower back/abd pain that radiated to the groin area, hypotensive. This too was an AAA. Pt survived however.

Would gladly=) I have also given rides home, generally to the elderly.

Nice! and true! I have worked under some fantastic rural ER docs. Have no clue how they do it though, I will see them up all hours of the night only to have to work clinic in the morning. I have brought in some pretty nasty stuff and you're right. There is no trauma team, pulmonary team, surg team at their disposal. I also have the privilege to be able to have one as my med director. Always nice to be able to have a close working relationship with your director and receive feedback immediatly on your treatment decisions.

As far as books your class list is best to go off of. However, one book I purchased on my own and still pull out til this day is "Rapid Interpretation of EKG's, 6th Ed., Dale Dubin. I'm more of a cardiac kind of girl. Kudos on deciding to further your education:)

You mean everyone else's calls are 100% perfect everytime? Dwayne, loved hearing about your NTI experience. We use the BAM as well and I really just pictured you waiting oh so patiently for the next whistle on a RR of 6.

No offense taken here on the halfassery comment:) Beat myself up on this call enough. Usa, you said so yourself you have that luxury of RSI. I on the other hand do not. There was talk on RSI and utilizing it. Here were my thoughts and you can do a double take, I know my limitations. For as much as I would love it in situations like these, unless I can guarantee a spot quarterly in the OR keeping up those skills and that I have a Paramedic partner to assist I will pass. Now with that being said I have heard the largest ground EMS agency may be losing that privilege due to misuse. Which isn't good because I could use them as intercept. You never know what you are missing til its not there anymore. Dwayne you are my hero:) I am quite close to your location also. I enjoy reading your posts, learn, and agree with you on many scenerios. The patient exhibited cheyne-stokes. Classic Cushings Triad, not sure if I will ever come across it again. Thank you for saying this call sucked. Here is what happened. Risk of aspiration was already there. Vomit was being expelled through clenched teeth of what may have been beer and pizza for all I knew. I know that versed most likely would not have the effect I wanted on the trismus, but it was worth a shot. Pt was already vomiting when I grabbed it. I was debating nasal intubation, and chose not because of head injury. So I pushed a little versed with no effect obviously. All I could do was roll the board and suction. Pts vitals did not change significantly. I informed them no definitive airway, and that I do not have RSI capability. First thing asked was, "did you administer anything to facilitate intubation". At least I was able to say yes to that. Dwayne, per my medical director review. He said nasal would have been the choice. He would have backed me on that one. Now it depends on which doc you ask. All have different opinions. Now, if I am ever presented with this again I know which route I am heading. This also lead to a Trauma Review with the receiving facility. I was terrified, but in the end the ER also had their struggles. The physician on review did not agree with nasal and not once was cric mentioned. Versed was just a waste as I held back on giving enough to possibly see any effect. The end thought was to request for intercept of the said agency above. I was ready to take an ass chewing, but to my surprise I was commended on what we Paramedics face out in rural country without a controled environment or a trauma team at our disposal. This patients prognosis was poor even before I arrived. On a good note, this patient may have saved lives as their organs were donated.

I didn't realize medicine was so cut and dry. Sounds like the medic refused online orders. Big problem. As far as reporting errors, I'd tell the receiving facility and document. I am not the one to call the family. My pockets have holes in them as it is.

I had a similar case. However, patient was middle aged, awoke in the night to tongue swelling. They complained of tightness to their throat and voice a little hoarse. Only swelling was to the tongue and quite significant. I by no means am aware of ACE inhibitor reactions. Worth researching, however. Patients BP slightly low, PR was within normal limits. No wheezing present. Per protocol, I chose the allergic reaction route. Started fluids, administered diphenhydramine IV and Sub Q epi. Upon arrival at ER, they continued epi as well as another dose of diphenhydramine, prepared for RSI, and patient was air lifted to a larger facility. Based on their reaction I felt I did well. Interesting as I kept thinking what this person could have reacted to as they were asleep. Think the call came in midnight or so. I questioned some sort of bite maybe, new medications. I cannot remember the list of meds they were on and did not hear of the patients outcome.

Very relaxed protocols on pain management. I start with fentanyl for faster onset and will usually continue with morphine. Also we have abdominal pain management protocols. The old treatment of absolutely no pain control has been done away with here for quite some time. I refuse to let my patients suffer.

HLPP, could you present a similar situation where you have had to weigh risk/benefit in airway management. With all do respect I have read your posts and am under the assumption you are a non-emergency transport service. Sure the risk is there for a potential non-emergent situation to turn emergent. I have scenerio I will present and please others weigh in on this one cause it still haunts me. MVC ejection. Both your air medicals tied up. Trauma center 45 min out. No obvious external injuries. Pt gcs of 5, unequal pupils (one blown), patient showing Cushings Triad symptoms. Airway suction needed. No vomitus (yet), pt has clenched jaw. Your attempts at sunctioning are minimal, you are able to pass the catheter through an approximately 2-3cm opening, this opening could allow you to pass a laryngoscope, but would in no way allow you to visualize the cord. How would you manage this airway? You do not RSI. Your prayers to meet up with medivac go unanswered. Patient begins to vomit large amounts of chunkyness.

Dwayne, absolutely I would agree on transport time. If arrival at hospital is ten minutes I will assist with BVM, but for me if I am 40 minutes out I will consider intubation. We do not RSI but I might have used versed as an adjunct in the way this patient presented.

I mentioned that I also transport multiple patients on the patient advocate thread. As a matter of fact, when some others said absolutely never I paused, but then again I am in Rural EMS, what else am I to do? I have two ambulances, that is if anyone responds for the backup. Two Paramedics staff the primary rig 24/7. We ask that our EMTs answer for backup if they are able. So at most we could transport 4. I did work in an ambulance where the possibility to "hang" a patient was there but never used it, seemed a little unstable. We cover 240sq miles, but have zones where we have non-transport units that are dispatched because our on scene time could be up to 25 minutes. Nearest trauma center is around 40-60 miles depending on incident location. We have access to two air medicals. Last two potential scene flights I had, I really really wanted them to come but both were unable. We have the option to transport by ground to the most definitive care, Paramedic discretion. Otherwise, there are 5 other small hospitals they could be diverted to. There are other ambulance services, response times probably 25-40 minutes, who may come for mutual but generally if we man both our ambulances we will not request aid unless we have more then 4 patients. I will also add that the "other" ambulance services are three very small volunteer services who have limited resources, and one paid full-time service which staffs only one ambulance each shift.

Essentially, for me it begins at scene safety. I never enter a scene where law hasn't cleared it first, such as an assault call. If at anytime I have felt in danger, I have left to a safe distance until law arrives. Even if that means leaving your patient. One instance I had a family member becoming aggressive towards me. It was one of those I allowed the person to block my only exit, he was not complying with my requests to wait outside, and once he came toward me, began threatening me, I made my escape and called law for backup. We can do no harm to our patients. Even our restraints are padded as to not hurt them. In my experience, my next step is applying soft restraints, that is if law has not cuffed them first. It depends on your protocol, ours is pretty liberal. Now in my protocol, the way I find most these patients they also end up backboarded as I can't rule anything out. Another backup to restraining, works well, but even they can wiggle loose from that. Just have to really monitor their airway. I can easily say I have applied more restraints then say given ASA for chest pain. That's just our common problem in my area. Pretty sad. Then there is also chemically restraining them, when and if you decide to become medic:) Boy would I love to have some other means of defending myself like a taser! But unfortunately, that will never happen. Like I said, for the most part I have been doing this for 8 yrs, this has worked pretty well so far. In this case, I was taking c-spine on a patient. I was in the direct path of the "slime". I immediately backed up cause to me saliva can be just as deadly. LE intervened. Pt restrained, and I had to go on as if nothing happened. Sucks but that's the way it is. You HAVE to keep your cool in this field. Not only applying to instances like these but everything you encounter. To me that is probably the most important quality an EMT must have. Everyone is looking for you to calm the situation, and if I look "freaked" I have just made a bad situation worse. Inside, yes, I feel all the emotions. I just keep a lid on them. HERBIE, I think your right for my area. That is pretty much what I was told verbatim.

Hey thanks for all the replies. I think I really needed to vent a little. In the meantime, as I would love to update, the plot has thickened. When I'm able to share more of my experience and outcome I will.