ERDoc

I don't know if it is so much getting off on seeing the helicopter as it is a comfort level with even slightly sick pts.

I decided to reread some books that I had read back in my EMS days, when I was still a premed. I thought it would be interesting to read the books, having a different perspective. I read them first as a young, whackerish, full-of-hope undergrad and wanted to see what they would look like to an experienced, grumpy, old attending. It is definitely interesting to see how things have changed, both in my perception of the events and just in the medicine itself. I'm reading EMT:Beyond the Lights and Sirens by Pat Ivy right now. She's a little too touchy-feely for me but I enjoy reading it. It's funny hearing about things such as terbutaline, bretylium and MAST pants. It makes me feel read old but I realized that she was on the ambulance before many of today's providers were either born or out of diapers. I had a reminiscing talk with an old friend of mine from my VAC a few days ago. In NYS, your EMT number is a six digit number and they are assigned consecutively. When I got my first card back in 1992, my numbers were 1713XX. I hear they are up to around 410000. Talk about feeling old, lol.

Yeah, but, that is when they had the good filling. The filling they've had for the last 10+ years sucks.

Hardly. I am just lucky and paranoid. If I were a god, I would have a theme song.

That is the scary part about medicine. Not everyone follows the textbook. I had a guy this past summer who was a roofer and was roofing in 90+ degree, humid weather. He developed a heachache that got progressively worse and was feeling nauseous. No h/o migraine or other headaches. Gave him fluids and meds with some improvement. Decided to CT him since he still had a headache. CT was normal. Gave some more pain meds. Decided to bite the bullet and LP him. Can back with a large amount of blood. Dude ended up with a sentinel bleed some a small aneurysm. This guy could easily have been sent home.

Hard to say. I sure would not have jumped on this kid and done the LP. Maybe some blood work and a period of observation to see if something changes.

My initial thought was, "What a dumbass." Then I thought a little more. What exactly do they mean by a wall? Was it one of those 2-3' walls that surrounds a garden and the provider was just stepping over it and tripped? I enjoy some of the what if's we develop around here but I don't think there is enough info in this case to really come up with anything valuable.

Pretty much what she said. There is nothing here that would make me LP this kid. Are there a few concerning things, sure, especially when we use the retrospectroscope. The photophobia concerns me. The hiding under the blanket could just be because she sees Kiwi entering her room and is scared shitless. Meningitis will present in many different ways, depending on the bug. Pneumococcal meningitis will present with vague symptoms until the pt rapidly deteriorates. Someone once said that if you see the rash it is too late. This is not true but is pretty close.

I'm going to need bigger buttons.

That's a great idea. I think I might have to have some printed up for our residents.

I don't think so, at least not for the volleys. Some of the privates could get pretty skimpy on supplies. They would also only check state certified ambulances which meant that you met the minimum requirements to be called state certified. Most volleys were state certified and got stickers that look like this:

In NYS the DOH will stop you at random at the hospital once you have dropped off your pt or if one of the privates are parked there doing nothing.

In NYS you were required to have what is on the checklist otherwise if you got stopped by the DOH and inspected and you were short, it was big fines. You didn't have to do a checklist, but every company made you so that you knew you had the required equipment. Towards the end of my EMS years we started doing the tags so that it wasn't a problem. The locked cabinets would have the required equipment to meet the 800 check and then we'd have jumps bags with extra stuff that we would use first. If you broke a seal and went below the required minimum you were technically out of service and had to restock.

I'm not sure if the OP is coming back since he had some answers on another board. It sounds like he is looking for checklists for daily vehicle and equipment checks. I'm not sure if he is looking for a program to make a checklist or if he is looking to develop a checklist for his service. If it is the second, any service in NYS should be able to help. NYS Part 800 regulations pretty much set out a comprehensive set of what should be minimum on an ambulance. Most services have a checklist form of those requirements that should be pretty easy to reproduce. Oh, looky what I found. Here is a checklist from the DOH (sorry for the excitement, the google search set off some nostalgia). http://www.health.ny.gov/professionals/ems/pdf/9814.pdf

1. The DDx is so general at this point. It could be infections, poisoning, endocrine, etc. 2. The photophobia and respiratory rate are concerning. The BGL is a little towards the low side. This is 911, you call we haul. 3. Nothing to say this pt needs to be made a highest priority pt. 4. Rectal temp and more info from the mother

Now that the story has been out, there are quite a few interesting comments, including some from the pt. I do like the comment that said, "If they can remember the flight, they probably didn't need it."

I'm pretty much in the same boat as Mike Our EMR has a link with the insurance companies to collect scripts that the company has paid for (I have a feeling we use the same disaster, er, I mean vendor). It misses the cash payments. Our state registry has started putting in scripts paid for with cash. I love the look when they think they are getting one over on us only to be stopped. I give people several chances to be honest with me, because we all forget about the 120 pills we picked up the day before. It's like the lion circling the zebra before the kill. There is usually some bargaining but once you show them the reports they really can't say much.

I've been pushing to get one of these. It reduces loss due to send meds home that we don't get reimbursed for. There is no bargaining for narcotics. "But doc, the pharmacy closes in 6 hours and I can't get there in time." The few hospitals that have it out here have good things to say about them. The only issue I have heard of is that sometimes a nurse gets tied up trying to help the pt put the insurance stuff in.

Narcs are one thing that the great state of Michigan will not allow us to eprescribe. Apparently they think it is safer to hand the pt a paper script than taking the pt out of the entire equation. I'd like to see the reasoning on that. It also comes from current movements in regulations. We have made pain the 5th vital sign and various regulatory/credentialing bodies force it upon us. Soon, our pay will be linked to pt satisfaction which will be linked to the amount of pain meds they get. For independent groups like mine, our contract and therefore our survival depends on meeting the hospital's definition of happy pts. The ones with the least amount of say in this is the people that actually see the pts and prescribe the meds. I could go into several stories where docs have been bullied into giving narcs but I won't delay this thread for that.

Wow. Let's start by saying that there is a lot missing in this story. First, why was she restrained to begin with? Second, why are you calling a helicopter for someone with a seizure? Third, informed consent was mentioned, however, if the pt's mental status changes you MUST reassess her. Just because she did not have the capacity to make her own decisions when you got there, doesn't mean she cannot regain that capacity prior to dispo. This sounds like a huge fail on the part of the EMS crew and I hope they are treated appropriately. At least they dropped the bill. It's crazy that the 20 minute helicopter ride cost almost 2.5 times what the overnight hospital stay costs. EDIT: The company mentions, "We follow state and federal laws and regulations on how and when we transport people,” I didn't know there were federal laws on how and when to transport people. Maybe someone from AZ can tell us if there are state laws.

But come on, how often does that actually happen? Oh wait, it's the most common complaint in the ER and accounts for about 5% of all ER complaints. That almost makes my head hurt to think about. With the ePCR, maybe you could have the pt fill out their demographics, if their condition allows. You could try saying something like, "I hate to do this, but it is required that I ask you, are you genetically male or female?"

I agree with that. In NY, I hardly ever took care of someone who was on chronic narcs. I moved here and I am more surprised when someone over the age of 8 ISN'T on narcs.

OK, Mr. Scenario maker. Why do you think I want her to look at her bellybutton? And the Hooters was on 28th St.

It amazes me the doses of morphine that are given in some places. I think there is a large cultural influence on pain perception by pts. When I was in NY, we would give 4-5mg of morphine with complete pain relief. Here in MI, it is usually multiple doses with minimal relief (this excludes those with drug seeking behavior). Most people just get dilaudid and require multiple doses. In my 3 year residency, I used dilaudid twice after morphine didn't work. It would be interesting to see a study comparing the required amount of pain medicine needed for certain diagnoses and comparing them across different regions.

Agreed with Island. A NR cert means nothing to employers in NYS (especially if you are in NYC or on LI). Unless you are looking for a job in another state, it is pretty useless. If you want to take it for personal reasons that's a different story.