fireflymedic

While all the points are good and valid - the best one is that without cerebral monitoring with corresponding video that is prolonged and dealt with by a certified epilepsy specialist I would question the validity of the seizures. Yes eyes are quite indicative of an epileptic vs non epileptic event. In any rate, the most common approach is to treat the patient as you would any other seizure patient, by ensuring they have a patent airway and protect them from injury (with the exception of medications, isn't this essentially what we do anyway?). That is the guidelines set by most neurologists at least in this area for pseudoseizures. Also, the location of where the patient has bitten their tongue (epilepsy is usually the side, pseudo is typically the tip) and other injuries as most pseudoseizure (psychological not organic ) patients do not sustain any type of significant injury. Loss of continence is not always a distiguishing feature. In hospital labs also indicate prolactin levels, but that is something unfortunately that we cannot check. Also, there are types of seizures which can be difficult to detect if they originate deep in the brain, or also frontal lobe seizures are notoriously misdiagnosed as pseudoseizures due to the very short post ictal period -typically a few minutes -(though it varies depending on strength of seizure as well as the individual) and also have bizarre movements which commonly are mistaken for psychological seizures. Also, there are variations on seizures (many different types) such as tonic only, atonic or drop seizures, clonic only, etc. Not all are major motor seizures. Now, with that being said there are a few things that may be mistaken for seizures. One is convulsive syncope (the person just passes out and has some clonic movements afterwards sometimes incontinent, sometimes not). It's commonly mistaken for a seizure. Also certain conditions can cause seizures which are not epilepsy such as drug withdrawl, heart conditions, diabetes, among others. By definition they are pseudoseizures, as they mimick an epileptic seizure. As far as care for the patient - compassion above all else. Many of the patients I've come in contact with this situation are frustrated at how badly it is affecting their lives. They are every bit as disabling as true epilepsy despite their frequently psychological cause. I do believe that the patient should be on some form of anti anxiety medicine as this would likely be quite helpful for her. I do understand the attempt to return the girl to as normal of a routine as possible with school, however, I can also understand how it could be disruptive to other students. That all being said - I think you are out of line to attempt to take over care from the RN who is obviously well aware of the girl's situation as are her parents. Many epileptic patients have individual seizure plans which the schools follow, especially if they frequent status, so I see this situation as no different. As long as supportive care is being given, I see no reason to intervene. For more seizure education, go to www.efa.org and on pseudoseizures written by one of the leading researchers on the subject http://emedicine.medscape.com/article/1184694-overview

Born 4:28 am on Sunday March 22, 2009 - little boy. Thinking about the name Mr. Independence, but if you have any suggestions, let's hear 'em. This guy needs a name by April 1, so let's hear 'em !

Richard, That's probably one of the more thoughtful posts I've seen yet on this thread. It's true - we both do what we do best in our areas. I'm lost urban and didn't enjoy it a bit. Rural is where my heart is - throw you in my territory 2 hours from any real care, and you might have a harder time. It's not about who's better than who, it's about the right one for the situation. Good post !

Hang in there doc - GET BETTER SOON and quit the smokin !

Hey this is where we could finally publish it ! Suicide - doing it right the first time !

Yeah firedoc - that downer is called PROZAC ! I've actually seen my dog do this more than a few times. It's pretty funny.

Personally, I have issues releasing anyone who has had a syncopal episode be it due to PD choking them out, kids playing the choking game, or even an erotic type issue. Yes, I did bring that into play here because occasionally we do receive calls relating to that that have gone too far. If the patient is awake and alert now, yes they have the capability of refusing (depending on your area if in police custody, PD may be required to consent to treatment ) but I would still encourage them to be checked out. I think it is just the smart thing as damage may not be apparent now, but may make itself present later on. That's just my thoughts though. Stay safe out there !

There is actually a loophole within the ADA to protect emergency services if they deem a person unfit to carry on the duties within the profession of police/fire/ems. Depending upon the service and if there are pre established protocols you may or may not be required to maintain the person on the service. General rule of thumb is does it present a potential threat to the person or the patients and does an accomodation place undue stress or hardship on the service. I think in general (especially for paramedics with a basic partner) the elimination of driving is not a major issue provided their doctor is willing to certify they are competent to provide patient care. However, for a basic, the situation may be more difficult. Basics (unless a transfer BLS only) primary job is driving unless partnered with a first responder and/or driver depending upon the service configuration. If it is a short term issue (ie less than 3-6 months) I feel accomodations should be made in general to move to a non care position (ie dispatch, office work, etc) if possible, and if not, the ability to qualify for short term disability. Many people, once they adjust to the medication, have no problem working on it and I think that applies to any medication. As mentioned many times before people work on a variety of medications for a variety of problems. If going through a medication change, yes, bring the person out of a driving/patient care position until they are cleared by a physician then allow them to return on or off medication so long as they can do the job competently. That being said however, I am a strong advocate of NOT having drivers under the influence of narcotic medications and if they are on any sort of medication similar, they should not be driving. In the instance of an accident, not only are they compromising the potential outcome of the patient and their partner, but also the service they work for. In a supervisory position, I wouldn't want to be responsible for dealing with that because the first question was "why did you let someone under the influence drive?" We wouldn't let you drive with alcohol in your system - so why narcotic medications or ones that severely impair you? I dont see the difference here.

While this is bad no doubt (and yes I've done my share of stupid things on duty - using old stretcher mattress for a sled at one point early in my career) I have seen people do spin outs etc for training - however I have a hard time believing this. Do you recall the famous video from several years ago involving AMR attaching an inner tube to the back of a marked ambulance and pulling employees down a snow covered street. As I recall there was little outcry over that stunt which was obvious stupidity. I was never able to find out the disposition of those employees, but I hope they were fired/disciplined as well and don't recall what state it was in. If someone can find the video, and post here so there's a reference, feel free to. I'm sure it's somewhere on you tube. Bottom line - don't do anything that would jepordize your certs - not unless you'd like to have them stripped and face possible criminal action for misuse of a state vehicle if you are a county/city based department. THINK people !

Found out my horse finally won his first race - we sold him some time ago and will be getting him back in just a bit because he was flunking out and now he decides to give us a win ! FANTASTIC ! For those that want to see here ya go ! He's number 4 - Too Tuff For The Devil !

This reminds me all too tragically of an incident here a few years ago involving a former partner of mine. In my state it is a felony to assault/kill any peace officer be it fire/pd/ems. Hope it becomes a nationwide thing soon because too many of us are getting hurt or dying. Stay safe out there people and keep your eyes open. Not all is as it seems.

When I did a paid department with volly supplement both were held to the same standard. If you were convicted of anything or had any type of charges pending, you were put on unpaid suspension until all charges were cleared including any possible ramifications of licensure. If you had negative action, you were dismissed. No questions asked. The departments I'm currently with follow a very similar protocol. For past DUI - more than 5 years - so long as reported to EMS board and doesnt interfere with licensure or driving you are eligible for hire. Same applies for most other things depending upon the nature of it. Now as far as what to do with you if something happens or you have to be on medication whatever where you can't drive. There are a couple options. If possible, and cleared to do patient care, you'll be restricted to a patient care role. If you cannot do patient care, you'll be on alternative duty if available and if not, short term disability for 6 months or until cleared. I think it's a fair system and gives people who may have made a mistake in their past and straightened out a second chance. Just how we do things here.

With us, we typically get service related gifts. If something comes addressed to a particular person, then our director tends to address that depending on the nature of it. In general, I dont have issues with the gift thing unless it is something that is rather expensive, but most times it is something simple (in general like gift baskets etc) and something that can be shared with whole crew. So thats our policy.

The abandonment issue is bad enough that he left without getting a signature (which leads me to believe he didn't do a proper transfer of care). But to FORGE a signature - that is unacceptable. I certainly hope the state permanently strips him of his license and he never sees the light of an EMS truck again. No one we get no recognition as a profession with actions such as these.

Sasha and others, While yes, one should evaluate the performance of one's duties and ability to do the job there are valid considerations to some things. 1. Within the fire department I know of several larger firefighters that are restricted from doing interior operations due to the fact that they are so large that if they went down in a fire, it would be impossible to get them out. It is this way for their coworkers as well as their own safety. I think one should be able to do all aspects of the position if paid and it is their career - volunteer I take a different stance, but if paid you should be able to go wherever needed at any time. This is without concern to the fact of can someone get you out or not. Also, if something happens and your exit is blocked - would you be able to fit out a window etc? Something to seriously consider. 2. Within EMS - if you are larger, that automatically puts you at a greater risk of injury due to the inability to use proper body mechanics in lifting if you have a large middle. I've worked with some partners that were excellent skill wise, but their weight put them at serious disadvantage and created some concerns for more than a few reasons. We frequently did extrications out of rural areas or national park areas. It commonly required us to walk back long distances sometimes as much as three to five miles carrying a patient over horrible terrain which was completely unsuitable to use even an ATV type vehicle to get the patient to an area where we could land a helicopter or meet an ambulance. My larger partners (and some smaller ones to be fair) had a difficult time walking it and carrying the patient and assisting with extrication. Also, larger EMS workers have difficulty on some scenes such as confined spaces be it a tiny bathroom, collapse, or MVC whatever. If you are heavy or even quite tall you may have a really hard time getting in to treat the patient. These are valid concerns, especially if you are the only medic in a given area. Also, as others have stated, it is more difficult to intubate a patient. I'm not going to dance around here and be politically correct. If you cant meet the requirements of the job, you need to get out or do something about it period. I've known several employers to provide gym memberships or even put a gym in the station which does nothing but sit and collect dust while the crew sits in their cozy recliners and eat or watch movies. There is a very valid point to this discussion, and I feel we need to take note.

DNR does NOT mean do not treat as so many seem to have the impression of. If you can do non invasive measures to make him comfortable, go for it, if not, then don't pursue it. Think of it this way and pose this question to hospice- The patient has a relatively minor infection, but requires treatment with IV antibiotics. They take him to the ER because he is running a high fever where he gets diagnosed. He could easily be treated with the antibiotics and live comfortably for several more months. Don't you think the patient might want that? If the patient is capable of saying what he wants - ASK HIM ! It's his life and despite what his family says and the concerns of hospice, if the patient wants to be treated and possibly extend his life, then you MUST under a legal and moral duty honor those wishes despite what you think just as if he says no you must. Just things to turn over in your mind. One other thing, many families of patients on hospice care panic when things start going downhill - they get scared because the reality that their loved one is going to die is finally sinking in. The best thing you can do (especially if family has POA) is to be as supportive as possible, contact your med director, and also contact hospice for assistance. Ultimately though, it is about patient care AND dignity which is what hospice is supposed to be all about. Remember your license is on the line, so that's why I do say involve your med director and it never hurts - and document, document, document !

That was good - thanks chris !

Good article to give us thought ! With all the nasty bugs out there, we really need to be vigilant about keeping ourselves and our patients and safe and healthy as possible and not spreading the little critters around. I mean truthfully, how long does it take to wipe down the scope after each patient? Not long, I know many of us (myself included) are an every shift person. However, the one thing I've found that keeps the gunk down in addition to wiping it down is to cut the finger off the tip of a glove (nitrile remember for those latex allergy patients or unknowns) and cover the bell of it. Then just simply remove and throw away after each patient. Also - think about those cool looking stethoscope covers. The cloth can't be cleaned between patients, so just a thought to think about. They may harbor little critters as well. Just thoughts going through my head - best bet avoid latex and buy the good stuff and cover those bells and let's wipe 'em down between patients ! It's all good ! Great find mobey !

There are actually several programs (mostly college based) that use this approach and frankly I don't find much wrong with it. I find a student needs a good understanding behind how the drugs we give work and the disease processes they are treating before they are cut loose to (I'm gonna break it out here) practice cookbook medicine. The other classes are meant to develop critical thinking skills in addition to teaching you how to study and yes, weed out the ones that aren't willing to put forth the effort to learn. If they are slacking about this stuff, then frankly they don't need to be in class. Period. End of story. Yes, it's tough stuff and you feel overwhelmed, however if you're willing to put forth the effort, you get much in return. As far as course set up - the program I went through required separate anatomy and physiology (2 semesters) with lab each, pharmacology, medical ethics, psychology, and cardiology along with basic college algebra. A score of a minimum of a B was required in each in order to progress to the other portion of class when you began the main medic portion. Then once in medic class, you were required to score a minimum of an 80 on all tests or else you were dropped from the program with only one test retested. The class had a very high success rate for passing NR for all that exhausted all their testing options. I don't find much fault with the idea and frankly that is how the ideal course would be set up.

As others have said, this is not so much an issue of missed tubes, it's an issue of failure of services to maintain the skill at an adequate level. It seems only flight and critical care crews (in general there are some exceptions) are feeling the need to maintain the skills they are lacking in. If you work in a slow service and maybe have one tube a month, then obviously if you have a difficult (or even moderately difficult intubation) you are going to have a higher failure rate than someone who has intubations more frequently. That's just how it is. Either you use it, or you lose it. No arguement there. With respect to Dr. Bledsoe, as we have discussed many times, his focus is in urban settings, and what works there is fantastic, however, he must not forget those of us who are in rural areas with high transport times where bagging a patient for 30-45 minutes may not be feasible. Is his proposal to take away ETI and be reduced solely to adjunct airways such as King LT or CombiTube? Those are great back ups if ETI fails, but don't completely secure the airways especially in situations such as a devastating gunshot wound etc. Those are your patients that need a definitive airway. However, I am for saying quarterly intubation check offs and yearly clinical time. You may not like it, but it's in the best interest of the patient. Perhaps that is why flight crews have high success rates for intubation. Ever wonder? I think EMS is on a path to self destruction. There have been strides made to improve patient care, however, we have refused to raise our training standards and continuing education past a few hours every two years. It's just not adequate ! Changes have got to be made or else we will be reduced to nothing more than ambulance drivers with a few bandages. It's time to step up to the plate and get to be professionals, and if you refuse, well then now is the time to get out.

I saw that the other day - cracked me up !

Food in patient compartment is a direct OSHA violation. I would NOT want to be caught like that. Plus possible contamination issue with IV fluids yeah, I'd say if the state found out you would have some major issues.

Shoot - was too big so couldn't load - was a plane with a cat's face on the front

I think this may not be a bad idea

ahem, slight correction. First KFC (as it was known by colonel sanders) was in corbin, ky. Then there was the claudia sanders dinner house in shelbyville, ky. Sorry ! And yes, there is that much gold in Ft Knox