fireflymedic

People, there is a scope of practice for a reason. If you want to exceed it, go and get the additional training which permits you to do so. Otherwise, if you like your job, and like not being in court, then stick to what you have been trained to do. As one so eloquently stated earlier - how many lives will you save if you lose your license? I think HERO mentality seriously plays a part here. Also, what many of us simply forget is that many times basic procedures which all of us are trained to do WILL get the job done. Now that's not saying there's not a time and place for ALS. There certainly is, or we wouldn't have it. However, when all your ALS toys fail, you better have darn good BLS skills to back 'em up. It's amazing how many medics I've seen that simply seem to forget their BLS if they can't do their IV or get that tube. Their world falls apart. Oh the things we forget. Personally, no I wouldn't exceed my scope of practice. And yes, while it would be hard to sit back and only be able to perform up to what I was trained to do, I understand that training and oversight is there for a reason. How many basics run on an ALS stocked truck? Lots in our area but it functions as a BLS truck unless they intercept. If the rules and oversight weren't there, we may have basics doing all sorts of things that aren't within their scope. Ideally you shouldn't be doing anything until you know the reasoning behind WHY you are doing it. We SHOULDN'T (note I said shouldn't ) be training basics, intermediates, or even medics just procedures. They should understand the reasoning behind why they are doing it. If you don't, I think you are doing your patient a disservice. All that can be summed up in what I've told people many times, "I've worked way too hard to get and keep this license to lose it to stupidity". Exceeding your scope of practice is just that - stupidity. Period, end of story.

Squint - you have varying options for paralysis besides sux - our alternative is Roc which I don't have an issue with except the average down time is 20-30 min. As CB so well stated, I'm not a fan of snowing patients to get the tube. I'd rather do it right and be done with it rather than snowing them, attempt, have them gag, puke, and have to deal with possible aspiration. That's exactly what we are trying to avoid, so why promote a procedure which encourages it? RSS really has no place in EMS - I see it as an all or nothing. If we are going to have RSI, have it, but have the proper training and controls in place or don't have it at all for those idiots that refuse to function at the level required IMHO. In reality though, outside of CCT or services that run high trauma - how many RSI's do you get that you TRULY need? Even within that realm I don't see very many so I'm really not convinced it's something that everybody needs to "run out and get"....just food for thought. And here's another thing we haven't discussed - what if you don't get that tube with RSS? You bump or irritate the chords enough for a spasm, well you're either waiting and praying OR you have to move to a cric. Neither of which is a great option. Definitely things to think about here people and discuss within your services.

CB - my guess is something similar to DAI where you only use sedation in an attempt to knock out respiratory drive and relax 'em enough to tube without the use of paralytics

ER doc- point well taken. No this wasn't the naples crew and I'm in agreement this service needs to have RSI pulled from them as their intubation rate currently sucks already and there are multiple other problems including pitiful medical oversight. I do look for an investigation to occur with this. That's the problem with this area, too many people have RSI that shouldn't 'cause it's the 'new toy' but fortunately the state since under new direction is changing that. As I previously mentioned, I've had the experience of RSI with no sedation and know how unpleasant it is - I'm in agreement that would be a just revenge. Sadly it can't be given though...all well. At least hopefully this will prompt some change as I do intend to follow up with the patient.

Gotta give the drugs time to work - if ya don't then the effect isn't achieved. Average time of onset is 60-90 seconds. Make sure they don't have reflexes anymore before you go shoving crap in. Sirduke - I'm amazed with two broken femurs he wasn't complaining of pain. Must have been running on adrenaline high and not feeling it yet. Agreed with you that certain things in the wrong hands can be a deadly combo. That goes for anyone.

Dust - oh trust me, they got an earful from me later on. As I stated, this was not a pt of mine - it was an intercept pt and once in our hands was nicely sedated courtesy of fentanyl and versed. I'd be interested in talking with this patient later on to see what was remembered and what wasn't just to prove a point !

For those of you that utilize bougies for intubation - how does it improve your intubation success rate overall for pts that may have had to have an alternative airway otherwise (ie king, combi, lma)? I'm specifically looking for information relating to difficult intubations such as bull necked patients or extreme obese as those are the ones commonly encountered. Thanks for the info.

Recently I was quite disturbed when on a scene with another crew who cared for a patient prior to my arrival. I found the pt intubated, paralyzed, but not sedated or any pain meds given. I'm finding this to be a disturbing trend among those who RSI that they are not considering the comfort of their patient. I cannot think of a single reason why one would not do the courtesy of at least mildly sedating a patient who has been paralyzed. The comment made by the other medic was "he's down far enough he won't know". I beg to differ as someone who has experienced RSI without sedation and was a VERY unpleasant experience. It was terrifying to be unable to breathe and feel the intubation attempts, despite fact I knew what was going on - imagine if you didn't have that knowledge... You may think your patient is down far enough, but some may still have some awareness and remember hearing is the last thing to go and I've had more than one patient tell me something I've said as I'm sure many have. I know the topic of RSI has been hashed here extensively, but I thought this reminder important. So please everyone, be a kind medic to your patients. They will thank you for it. I'll get off my soapbox now.

OMG, after having worked in a university ER level one trauma I can truly say that on a friday or saturday night I am totally feelin it !

Well fire doc, I just got myself dated the other day in class and that was strange 'cause I've been in 8 years. Just wait until they are calling me a dinosaur along with all the others that remember the days of stacked shocks....ahhh that will be interesting 10 years from now lol. As far as age - I was a year old then so hehe old fart ! Oh and don't knock the blanket/towel rolls I've still got 'em on my truck 'cause I hate those plastic pieces of crap that slide all over when you go to tape 'em. At least the rolls stay put ! Amazing what a little duct tape will do !

First off bravo for opening yourself up to a group of peers like this ! It takes guts to do that, and I applaud anyone willing to bring difficult issues to light. Now, as far as mental illness, depression, the like within EMS workers it's something that I think the profession needs to take a HARD look at. How many alcoholic medics do you know? I know many. Several that are just burnt out and it's lead to problems with their personal and professional lives. We sit here and claim all day long that EMS and fire are a family, however depression within our community is the "family secret". One is expected to just suck it up and not ask for help when they are having problems for fear of losing their job. Instead we should be offering options (bravo to the companies with the employee assistance plans that are confidential - but they are few and far between) for employees to get confidential help that is truly that - CONFIDENTIAL. Where they can speak freely and not have to worry about losing their job or whatever. I think we've all hit a low at one point in time and that assistance would have been appreciated no matter how tough we make ourselves out to be. Now that being said, I do feel that if an employee is severely impaired, they should be moved from the patient care setting at least temporarily. I fully agree if an employee is actively having mental issues or severely depressed, they cannot adequately care for their patients, the same as with an employee experiencing any other physical malady. You wouldn't expect a person with an actively healing fracture to be on the truck, well the same goes for psychological issues. But I think we should view them as equal and not condemn an EMS/fire worker for having problems. You wouldn't fire them for breaking their arm, why find a way to fire them for experiencing depression. I think we become more proactive in treatment, we'd see more content workers and also better coping skills. I've noticed personally that some of the services which have the lowest turn over may not have the best pay or benefits, but they treat their employees fairly and they are appreciated. I know I've stayed places that weren't as good because I felt treated well rather than that they didn't care. Just food for thought. It's all illness. Psychological or physical and it all needs treated appropriately and with compassion from our end and the other. Even if it is "just for attention", the person is needing help for something and we should sit up and listen. It's our job as healthcare providers to deal with it with compassion and help where we can. We may not fix the problem, but for that moment we can help.

Just went through this process not long ago ! Anyhow, you have to have someone able to check off your skills that they are adequate for practical (ie your training officer, med director, etc) but is most easily accomplished through the 48 hour refresher - just have them sign off for ya. Then you have the option of either completing a formal 48 hour refresher, OR continuing ed within the hours needed. I'm not for sure, but with your certs you may be able to cover all your hours. Then just go and sit for your test. Pretty simple and painless actually.

dust - I said they may not agree with it, but it IS a humane form of death. Alot of people don't believe the way we euthanize dogs and cats and various other animals is humane (which I believe the majority of forms are short of the gas chambers which is a horrible way for anything to die). The convicts are just wanting to buy time - they don't have a legitimate arguement. Claiming that more than three IV sticks is cruel and unusual - that's the usual number for me if I have to go to ER for anything 'cause I have no veins...all well.

Having watched several people literally go into a meaningless existance when their family members sit there and say "they would never have wanted to live like this" having people change their diapers daily, not able to function, exist, communicate, understand yes I can see where euthanasia would be preferable. However, I do agree it is something that should be decided on early in life and not a matter of family or caregiver convenience. If it is me in those shoes though, if I can't be who I am please let go peacefully, swifty, and quietly without struggle, fear, and pain. I've seen numerous animals euthanized, and well we euthanize prisoners here in the US and I have yet to hear anyone say that it was not a humane form of death. They may not agree with it, but it IS humane.

check e medicine - it can give some great insight on ususual presentations. I've gone back and looked at it a few times after some patient's I've gone hmmm about more than once after finding out what was wrong with them. This did sound more like PE to me perhaps because I had an unusual presentation PE patient no long ago myself. I have seen mental status changes due to hypoxia due to massive PE (a single one usually doesn't cause this) the hypoxia also causing bradycardai and seizures. Though to the contrary I've also seen people maintain a respectable o2 sat around 95 or so with PE - it can be a tricky one. Good call.

I'm going to venture this gentleman is painted green for st. patty's day - may I venture that he is possibly having a reaction to something in the body paint? Can I have some vitals, hx, etc for this gentleman please mateo? Gotta give me somethin to play with here.

Harold - the practice which you describe is totally and completely unethical. Alcohol SPECIFICALLY states not for internal ingestion for a reason - if you squirt something up a patient's nose some of it is bound to end up down their throat. If you don't believe me, give versed IN and notice what happens. Alcohol is EXTREMELY irritating to the mucosal lining in the nose, throat, esophagus and stomach. If you have a patient which may have a problem such as varices or whatever and you irritate that you have just broken rule number one - you have caused harm ! As far as being a "good" idea - well look at it this way. If a patient ever came against with that statement, I guarantee you would experience problems not only from the medical community but also the courts. Our actions are judged against what a person of similar experience would do based on established protocols and treatments. I don't know of ANY service or medical director that would support that. You are asking for a lawsuit. On the topic of possible causing injury to patients when attempting to determine level of consciousness I have faced a dilemna of sorts with students. Many out there are still advocating the use of the sternal rub. I admit that's what I was taught when going through class some time ago. However, I have since deviated to other methods as especially with trauma patients, there may be damage to the sternum (ie fracture etc) or underlying structures and if rubbed vigorously could produce injury. How many out there are in the same boat and do you teach your students sternal rubs or do you move away from that?

How long ago did he get home? I'm highly suspicious of a migrated DVT in this guy - is the calf warm? Also, there's the possibility of abcess and infection there which could cause the seizures, pvc's, etc - is he febrile by any chance? I admit though, I'm thinking pretty strongly that it's a DVT that migrated from the calf as most PE's are initially asymptomatic and many die within the first hour. I'd say he does feel like crap after seizing - I'm suprised he could talk to you at all though. Any difficulty breathing? Does he feel like he can't catch his breath? Can I have some vitals please? Sounds like a fun run - can I come and play?

hey I was trying to give one that even newer basics could play along ! I CAN be nice sometimes ! Not all my patients are weird ones !

well just go ahead and ruin the party ! PE it is

You are called out to a 41 year old male for chief complaint of hiccups. On arrival, the man informs you that he has had intractable hiccups for the last four hours and can't get them to stop. He also says his chest hurts rating the pain a 5 out of 10 with inspiration. You take vitals and this is what you get : pupils : PEARL BP : 88/62 pulse : 108, thready resp : 22, shallow Meds : plavix, claritin, daily asprin 81 mg, nitro Allergies : NKDA PMHX : angina Guy is a frequent business traveler and states he just got back from a trip today with the problems starting on his way home. Says he took 2 nitro bringing pain down from 7 to 5, but still experiencing pain. what do you think is this guy's problem and what else would you like to know?

tim - check your PM

National Registry is simply designed to pass the minimum competency levels. It is up to each individual person how much they learn outside of that. My base class (in class time) was 140 hours with an open lab staffed 8 hours on weekdays and 4 hours on weekends to come practice skills or go through scenarios. Then on top of that, you took a supplementary 9 week anatomy and 9 week physiology class separate, 9 weeks of pharmacology, and 9 weeks of basic cardiology. Top that all off with 150 hours of ride time with 25% of patient contacts done in a BLS only service - we have two which we contract with - with you being the lead basic (much as a medic student would do) the remainder may be done in any type of AMBULANCE service. This gave me a really understanding of why I was doing what I was doing and the injuries behind it as a basic. We also had to write full PCR's for the patients, just minus their name. I passed NR first try with 98%. That speaks alot for the program I went through. However, I know other programs that did the bare minimum of 120 with 10 hours of ER or ride time with any service and passed because as I said previously, NR is simply a test of the base knowledge. I think basic courses should be more indepth and require more of the students. EMS in general needs an overhaul - but you can't help those that won't help themselves. With all that was offered in my program, there were some students that didn't take advantage, and failed. Not the instructor's problems, they were there if needed, they just weren't utilized. Can't help those that won't help themselves.

Okay DA is going to prevent proper blood flow and oxygenation throughout the heart producing murmurs and central cyanosis which we seem to be seeing. If severe enough, can also cause oliguria. This is most likely a result of a congenital defect is my guess. I also can't help though but wonder if this fluid overload isn't now causing some kidney issues making the baby reluctant to feed? See where that takes me. One point to ponder though is - aren't we wanting to close the DA to create a proper pathway through heart as is the case with preemies/neonates? NSAIDS are used for that purpose. So just a thought to ponder....

Just out of curiousity, since it seems to be my turn to chime in here - mom have gestational diabetes? We mention pre natal care was lacking, and that's a normal heads up during prenatal care, so I'm heading that direction. If that's the case, may have mentioned effects on baby. I'm slightly tired here tongiht, been overworked, but that's my starting point. Cardiac malformations are also in my list, but I'm not going to delve into those just yet tonight. Let me sleep and get back to you in the morning.