fireflymedic

haha - makes me think of when I worked back in university a few years ago with a brand new CNA in the ER (for some reason she got floated down there was interesting as she hated it). Had a pt pass away and we had to relocate him. Got the stuff together to move him and the cart. He was nicely already packaged to move. Unfortunately, we ended up with the cart that didn't like to lock, so you had to do the foot stop thing which under most circumstances wasn't a big deal. I told I would be nice and take the head and she could take the foot to transfer (we both were short and reaching across was a challenge for both so dead people got moved head to foot). I had my foot down, and did the okay, 1,2,3, move. She picked up feet and had them about halfway on the cart. I had the head and was right between the two beds (she moved a little quicker than I) when that "moan" you get happens. Poor thing turned pale white, dropped the guy and went OH SHEAT ! HE'S ALIVE ! Well, I now had 200+ pounds of dead weight just dropped on me and I couldn't help it and dropped the guy right on the floor. Woops Anyhow, if the fact that the girl ran out, I dropped the dead guy and he is now laying on the trauma room floor wasn't bad enough - tack in the fact that two FF from the local fire/ems were sitting there completing their run report and are now laughing their butts off. Yes, somethings people just never live down (even 3 years late I still haven't). Fortunately they were nice and helped me get the guy off the floor, but not without a few red faces and a good laugh. Yeah, that brought back bad memories there herbie - thanks

When getting students from the local EMT/Medic school does your service financially compensate you ? or give you any compensation ? Nope, no compensation granted here that I am aware of, though I know there are contracts in place between the powers that be and run the program that establish those contracts. There is already a pay grade difference for those that are preceptors and regular crew which is pretty nice. How are the students assigned to preceptors ? Preceptors are predetermined by the department - there are typically at least two per shift (sometimes more depending on the shift day) and may be at any base (there are 7 bases throughout the state all of which do 911 with the exception of one which is solely a CCT base). They are required to have and maintain their instructor and evaluator cards in order to be a preceptor so they know what is expected of the students and guide them properly to not only prepare them for the streets, but also adequately prepare for NR and they can answer questions as well. Two years of service is a requirement before you are allowed to precept. So no matter what days the student picks to ride there will always be a preceptor available, just perhaps not at the location they want. Many of the preceptors if they connect well with a certain student will give them their schedules and the student will try to schedule those days. If they don't like the person, it gives them a wide opportunity to change. They receive a calendar and pick their days from a listing of available dates. The number of students riding that day may not exceed the number of preceptors available. New hires ride with one of three dedicated FTO's (one per shift) so cross scheduling is not an issue. Service turnover is typically very low so rarely an issue (pretty much only turnover is through retirement out). Hope that helps you some !

Well stated Herbie. One day you may be taking care of me or my family. If that is the case, I want to know that you know your stuff. If I don't trust you to do that I'm not going to pass you.

Fantastic story - thanks for sharing with us. I am constantly amazed at the true cold water drownings that people have survived because of the reduced demands on the body. Fascinating - thanks again for sharing - sometimes we all need a "warm fuzzy" like this to remind us why we do this job. Take care and always stay safe.

Herbie, Point well taken, and if I am teaching the class I will bend over backward to help a student that wants to help themselves. However, sadly I've found many that go through a vast majority of the programs around here brag about the fact they never opened a book and still managed to pass because they could halfway listen to lectures and be able to B.S. their way through a test by guessing right. They skated by in clinical time, and then when they arrived at ride time, they didn't have basic knowledge of things they should. I'm patient and if you don't know it, I'll help you try to figure it out - can't remember drugs? I've done flashcards, CD's students can play in their cars, etc to try to help them. Even did jeopardy with meds to help them learn (candy was involved instead of money lol). I try to get students as involved within the classroom as I can, however, if it's not my class, then we have to figure out where the mistake is. If it is because you didn't put the time in prior I don't have sympathy (which is usually the case), however, if you are working hard to learn it, I'll try to help you find a way to get it to sink in. Ultimately it comes down to though, no matter how good you can treat a patient, you'll still have to be able to pass registry and for that you'll need to recall info from your brain. We just have to figure out how to get you to link the two together. Most of the students I referenced in leaving to write drug cards was because they had goofed off in class going through the above mentioned way and thought they could just look at me nice and pass ride time. Sorry kids, it don't work that way.

Something to ponder within this topic - it's a good read and really breaks down the pain med options and their durations, actions, etc (thanks Dr. Bledsoe) http://www.bryanbledsoe.com/data/pdf/mags/Analgesia.pdf

I am very proactive in controlling patients pain and I'm sorry if that ticks off the docs a bit, but I'm going to within my ability to do so and providing the patient is stable enough to allow it. Every patient is different so that would influence how far out I gave pain meds (within the 5 minute category). I think to withold pain medication is not only cruel but compromises patient care - pain increases heart rate, anxiety, among other things. If you can reduce that don't you see positive effects from it? As to the being close to the ER, well, I'm going to go ahead and give meds if the patient warrants it because our ER's around here are almost always overcrowded and it takes the docs a bit to get around to see a patient sometimes. Sometimes it's even a bit before someone comes in to assess them (the nurses sign paperwork, ask for vitals, and leave). If they already have some pain control on board then it helps them wait out those long minutes. From a patient perspective, I can say I've appreciated the few times I've received pain meds due to a few significant injuries I've had. It was one of the kindest things they could do. It at least took it from being almost unbearable to just discomfort which I could more than live with. Old people I've found are some of the most reluctant to take pain meds as most have been raised with the "suck it up" mentality, and younger people the most willing. That's solely an observation and much of it depends on the patient's prior experience with pain. If the worst thing they've had is a stubbed toe, then obviously a broken arm is going to be unbearable and if the opposite is true, then they will have a greater pain tolerance (which varies from person to person as well). I hardly think you are overstepping appropriate patient care Spenac - you have put your patients care and comfort first, and I'm sure they thank you for it. You already knew your answer as others stated and I give you for your treatment of your patients. If a nurse fusses at you again, just calmly ask - if you were in this position wouldn't you want some analgesia? I'm pretty sure their answer would be yes. It's not cruel and it got alot of people in our area to change their mind set. Most don't want to give to due lack of convenience, it's one more thing they have to give, one more thing to chart. But when you flip the coin and get them to thinking about it being them, most will soften. Continue your compassionate care (wait did I just say that to spenac?) and always stay safe.

Etomidate is commonly used in the ER's here, but is not currently on the trucks. It seems that they are not wanting to make additions to the current approved medication list (though if your medical director applies for a waiver for your service you can get additional medications added along with certain procedures). I am aware though several surrounding states have Etomidate within their protocols with Sux and it seems they prefer Versed/Fentanyl with Roc. Using Vec as a paralytic and Ketamine as a sedative are not common within this area. Analgesia again is a pertinent factor as having a tube down your throat is less than comfortable so anything to lessen that discomfort is good. Ch - I was trying to stay within the confines of meds he would have available within his service. I think we can all agree there are better alternatives, but you still have to work within what you have. Also curious as to your choice of diazepam over midazolam for continued sedation - any reason or simply personal preference? Thanks for getting a good topic started mobey !

Welcome and I'm sorry you are stuck with Dwayne in bad weather. (you know we love ya Dwayne) Must be a drastic change from sunny Florida ! Take care, stay safe, and welcome !

Sorry for the confusion there. I was actually referring initially to students (thus the drug card comment) as the students I typically see are from a certain program and I know they have not only completed a full pharmacology class as a prerequisite to beginning paramedic class (in addition to cardiology), and then had the medications reviewed yet again as they are going through class within the pharmacology chapter of a larger book, and then again in the separate sections relating to what the medication is commonly used for. By that time they should have a very strong handle on what the drug is expected to do, side effects, and dosage. I keep to a list of about 30 drugs that are common on every ambulance throughout the state. As I stated, I don't go with the added drugs we use, specific to our service. If they know about them, great, if not, I understand not having the knowledge. I'm willing to teach what you want to know and if I don't know, I'll find someone that does ! I know how this program works as it is the same I went through so I am aware what is a reasonable expectation of the students. Occasionally I see outside students, but the majority are from there. They should at least be able to tell what I ask on the common drugs. And to note, this is a program that will not allow ride time until all didactic and clinicals are done so they should have a reasonable knowledge base. For those that come from a different program then adjustments can be made. And no, I don't think I'm being to hard on the typical student from that program - it's how it was done to me (not that I think everything about is was right, and no I don't have the well I survived it you should be able to suck it up too mentality) and I really learned. Instead of focusing on how little I knew about medications, cardiac strips, etc I could focus on learning how to properly treat my patient. As far as new hires, yes there is still a learning curve and that's cool, but I expect a little more out of you than a students. But as you state, that's for another area. Take care, stay safe.

It is not just you. It is a profession wide weakness that unfortunately I don't see improving unless drastic steps which may hurt some are made. As far as the students - I'm wondering how they managed to successfully complete their ride time if they cannot complete basic functions of patient care. I've been left wondering the same thing a few times. I remember very well when I started and felt like I knew nothing. Everyone has a learning curve and as long as they are willing to listen and learn GREAT ! If not, please keep walking. If you are employed and ride with me, you are expected to know routine treatment for certain conditions, your common protocols, and also be familiar with your common medications you will be using. I will quiz you on the information and yes, I have been known to leave a student at the station writing drug cards during a run and told them come back when they know their drugs (granted I only go with what is on the approved list, not every drug they could possibly see - I'm not that hateful). As a student, you are expected to at least know the basics, and you certainly should by the time you are being precepted as an employee.

try doing divided doses. Yes it takes a bit longer, but giving like 4 at a time and seeing how he responds may have helped. I've seen some patients be able to adjust with smaller divided doses given than with a large bolus and you still get the effect of sedation. You certainly don't want to have a patient tank out because of a large bolus and then have to work to get it back up. Just something to consider Mobey.

Beautifully stated Nick. HEMS is not the glory area that many perceive it to be. Much of it is being a very expensive IFT (think rural metro with rotors at times). Yes there is over triage and not every patient is acutely dying. I had one impression and found it to be something entirely different. That was even with significant exposure to it and speaking at length with several already in the field. Truthfully depending on the structure of your service, your breakdown may be as little as 20% scene flights. At best I would say is 40% scene. It's different when you go in and you are excited they already have a line because you are trying to figure out what to do with the carousel of drips. Most in the field will tell you the same thing. Also, understand that when helicopters crash they tend to do so with significant speed and injuries are typically bad, if not fatal. Pushing weather and safety minimums only contribute to this. The recent crashes make this an all to common reality lately. She may think she looks cool in that flight suit, but if she goes into things blindly if she ever does make it to a flight service, she needs to be certain it is with a safe one otherwise she'll need to be asking herself how cool do I look in that casket ? Not trying to be harsh, but people need a reality check about it and realize it's not the glamour job people portray it out to be. Pay isn't as great as many think it is. In fact, many take a pay cut in order to fly. Yeah, it's fun, I wouldn't deny that, but there's more to things than that. Always stay safe.

As far as versed's utilization for RSI I've actually had pretty decent luck with it. It is really patient dependent as you said and obviously if they have any type of benzo tolerance they are going to require higher doses. I have found though in combo with fentanyl that you do well with the sedation. I don't even go with paralytics until I am certain the patient is adequately sedated. I certainly don't want them remembering anything. Everything has to be titrated as you said taking into account their hemodynamic status and adequate maintenance of it. Point well taken though CH - sadly we call it RSI, however there isn't much rapid about it if done right unless you do it as a crash airway.

Bartender? One question how long have you been in active full time 911 EMS and at what level? I'm just asking because if you function as a volunteer that shows up occasionally to calls (and no guys I'm not knocking good volunteers - I'm knocking the ones that show up to just the "cool" calls or once a month or so just long enough to say they are still on the dept)I hardly think you have enough scope of the profession to form a qualifying opinion, nor to understand why those of us that do the job for a living are a bit disturbed with what is portrayed.

As far as intubation, if you are going to administer paralytics, you must administer sedation along with it. That is without question. Having said that standard "induction" doses to sedate a patient is betwee 4-6 mg versed though I have seen some patients require a bit more and 100mcg fentanyl. Etomidate is also an option with typical dosing being around 20mg (however remember etomidate does not have analgesic qualities). This typically will do well, however you should titrate doses to patient's respone and vital signs. For maintenance infusion of versed which is preferable in the transport environment to propofol with common dosage for sedation being between 2-5 mg/hr. I have struggled on many transports as due to all the stimulation in the transport environment with propofol and found you have to continuously adjust it to maintain the level of sedation that's adequate for the patient. It's preferable to midazolam or other sedatives in that it is quick on / quick off so evaluation of neuro status at receiving facility is easier than the extended time it takes for versed or others to wear off which is a positive in their eyes. However, the longer maintained sedation is preferable in the transport environment so I am partial to versed. However, propofol is quite popular in hospital and seems to do well within that realm. I've not seen a versed drip used in hospital, but have used it several times in transport. I'm sorry but I do not have any experience with Ketamine and cannot help you. Perhaps one of the people from down under can assist you better as it seems to be used more frequently there.

Current orientation is roughly 6 weeks (depending on the type of service the person is coming from and their familiarity with aggressive protocols) and verification of all skills as required. Knowledge of protocols and appropriate transport destinations, etc are covered within that time. Then release is by the actual medical director and satisfaction with him of knowledge and skills. Previous service I worked for operated in a different fashion. It was roughly two months of orientation with the home base which runs a few dual medic trucks. After which you proved competency to be released, you operated in a medic/emt transport rig for six months doing routine ALS transports. Following that, you progressed to a 911 truck within the base county which had additional paramedics to back you up if needed for another 6 months. If all went well, then you may be placed into another county if you wanted which was solely 911 and often ran 1 medic truck per shift (it was dual medic). However, you were prevented from performing RSI (which was allowed at that sevice due to a state waiver) for two years and until you completed the class and were approved by the medical director. You then were eligible to apply for a critical care class to move into that aspect if there was an opening. Understand turnover was quite rare within the service, but I would have no problem trusting any of the medics treating myself or my family. I know the process seems a bit drawn out but it produced knowledgeable, competent medics that functioned in primarily very rural bases throughout the state. PT medics rarely functioned on the 911 setting in the rural counties unless they were already employees that dropped to PT status. They usually floated a medic from the home base which had several to the rural county and the PT medic went to the main base. That's how it functioned.

We were told unless it is one of the few major disasters (ie the pump has entirely quit working, disection of the tubes, etc) that transport time for a ground up to 4 hours tends to be the max that is acceptable through Jewish protocol. They are the local referral center, though there are two other facilities which may do the procedure, though by far they are the largest implanters immediately surrounding. Over 4 hours there is issues with the transportable battery (rather than the large one the patient uses as night). Also has anyone dealt with a BIVAD patient? We were given brief informatino on them a well. One other thing - were you trained on the handpumps for those that the LVAD entirely quit working or has significantly low output and have such terrible function on the right ? We were but just curious if anyone has had to use them yet.

Are you looking to provide EMS related education or something entirely different? That is the dependent factor on whether I can be of help or not. If you are looking to move into a different career, nursing, etc there are also a couple options. Please be more specific so we can help you.

I'm suprised the hospital didn't notify you. In this area, we are given a list of patients within the county and surrounding counties that have them which is updated yearly by the hospital (unless one passes away or receives transplant). I find it extremely useful as they are flagged within the dispatch system along with the others that we have info on that have unusual medical conditions and may require physician contact to treat appropriately. Perhaps bring this up to the local hospital that does this. We even get notification from the hospital if the patient has gone out of state for treatment. I would find it unusual they don't !

The Heartmate is also what tends to be the most common around here as most are on transplant lists. However, Jewish tends to take the mentality of if the patient is doing well and has a good quality of life and is happy, they may no longer recommend transplant. There are a few in the area that have had the devices for a while and are so pleased with their quality of life that they have chosen to remain on it. When I saw the difference in the size of what was formerly implanted and what is now, I was amazed. In addition to all the things the patients can do on it. Very much a normal life. I guess most suprising to me was that the doctor informed us that the vast majority can (and should) go by ground if possible as flight places additional stresses on the equipment unless the patient is an unreasonable distance away as most problems have already been discussed with the patient. We have a whole troubleshoot guide that we keep on file and also have the contact numbers as previously stated. I am curious though - has anyone experienced a patient that had a disection of one of the tubes? I am wondering if that is of concern for patients with airbags in crashes regardless of impact, I know some cars trigger airbags quickly. If so, let me know ! Thanks. Great topic again ! I've not seen those but I would definitely be interested in seeing them. Here we have to contact the people if patient is unable to tell us (though most of our patients are quite educated and teach us much better than anyone could !). If you have a link to a place which carries them, I'd like to see them. Thanks again.

Christ? Well Advocate I guess it is now? I'm not there now, but used to live up that direction. Didn't know if they were a big heart place or what. They had just built the pedi hospital when I left. Anyhow - we got similar education and contacts as you did, and yep, I did the same thing - those numbers are easily accessible !

Wonder if you were at the same thing I was at...got quite the education that's for sure and a ton of take home stuff to study further and the guy that does the implants for university gave us his card and contact number that he or someone affiliated with their LVAD program could always be reached at with questions. Really awesome and learned alot. I'm still learning, cardiac stuff fascinates me without question as does neuro stuff so right now I'm digging into some of the things that have perked my interest lately, especially a couple things that I've seen in patients.