ERDoc

Just to play a little devil's advocate here, I do not wear gloves on every pt contact. It would be impractical to do so. HOWEVER, in any case where there is a real possibility of fluid contact, I do wear them. Before anyone asks, my exposure was not due to not wearing gloves when I should have been.

"when the reality is that what patients need are more paramedics and more ambulances to appropriately facilitate appropriate response in a timely fashion" and I think that is the most important part of the whole issue. Who cares if a FF can give someone oxygen? It's useless without being able to transfer the pt to the hospital. The FFs even state what the problem is when they argue about this, "We can get there before the ambulance." That is where their logic falls apart. If the problem is that there is not enough ambulances on the road then the solution is NOT to add more FFs who cannot transport or PROPERLY treat the pt. The solution is to add more ambulances which can properly treat and transport the pt (you know, those silly little things that the pt actually needs). EDIT: Did anyone pick up the hero complex by a FF in the comments about how they gallantly run into burning buildings with their long, blonde hair flowing behind them (think Fabio) while the fat ass, lazy paramedics sit on the street smoking pot and drinking whiskey (yeah, I over dramatized it but that seems to be the way you are supposed to argue these things)?

Don't forget that when you are dealing with Joe Q. Public, they are programmed to have unrealistic expectations. Our standard of care is set by Turd Watch, Rescue Me and the other such shows. I've had colleagues who have had families complain to hospital admin that no one was exciting or yelling while their family member was coded. They just don't get it. Just ignore what those who do not understand medicine and those who were not there have to say. I know that it is easier said than done. It sounds like you were put into a crappy situation by a partner who freaked but you stepped up and did what you could. Try to set it aside and focus on the pts to come, the ones that you can do something for.

Report it and let the infection control officer tell you what to do. As Mari said very eloquently, your risk of HIV is almost 0, but Hepatitis can be a concern. Be more careful. I can tell you from experience that taking post-exposure prophylaxis is no fun.

Normally, once a pt is intubated, I would not paralyze. There is really no reason to as long as they are properly sedated but if the pt is shivering, I'd consider paralysis. However, are we sure the pt is truly shivering and not seizing? So we have a depressed pt with hypernatremia, hypokalemia, hypomagnesemia and hypophosphatemia. If you don't carry anything with potassium, have the hospital hang some fluids with 40 of K+ if they are not already doing so. A few grams of mag would be good also.

I would recommend finding someone (relative, friend, someone from this site) to talk to that does not live in the area and has no knowledge of the call. It sounds like you need an unbiased shoulder to cry on and ear to listen. Feel free to PM me if you want.

Not to beat a dead horse, but look at this bunch of "girls" http://forums.studentdoctor.net/showthread.php?t=154841

I can agree on those points. This is a case where you won't find any studies or textbooks to support or refute your treatment. If whatever you do works, you will look like a hero. If whatever you do makes the pt worse, people will criticize you. Another thing to consider is that this stent may have involved the junction of the mainstem bronchi and placing a tube will do nothing. Maybe we need to think about putting it in the right mainstem, beyond where the stent might have been. Granted we are shutting off one lung but again, it is an option.

If we are worried about a perforated trachea, do you think PPV is the best idea? He's already pushing air out of the respiratory tree. I'm a big fan of RSI but I would agree, not in this case. I also think blind nasotracheal intubation would be a bad idea. You have no idea what the airway looks like and may just push the tube through the defect in the trachea. I know you can't do it in the field but in the ER this is someone I would want to use a bronchoscope to intubate. I also agree with 2 large bore IVs, central line once in the ER. I'd be hesitant to cric this person also. Again, we don't know what the airway looks like so we may do more damage than good, although of all options in the field it might be the best idea.

Can the mother tell you anything else about the stent? What kind, where it was placed, etc? Does she have a card for the device or a way of getting in touch with the surgeon? In the meantime we still need to manage this guy and I don't think we've made it past the A in ABC. He has an unstable airway that is going to be a potential disaster to manage. Who wants to RSI him? Who wants to do something else?

So, back to the OP. How do you manage this guy at the BLS and ALS level when you have more than a 30 second ride to the hospital?

Welcome to the City!

It's interesting how we are saying the same thing to him that others on that other website said to him a year ago when he got his EMT card: "I am beginning to think this is a troll...and maybe I shouldn't feed it. FDNY isn't even the best EMS provider in the City, so lets bring that noise down a notch. Your FDNY provided training will in no way make you an experienced provider. Unless I'm not aware, there isn't a huge difference between how FDNY THEORETICALLY does EMS and any other agency does. The medicine is all the same. This kind of attitude will not endear you to other providers in the City, hospital staff, ect, some of which you will have to deal with and are very good. It also may aggravate your co-workers" It's funny how they mentioned this website in there. Oh wait, maybe they meant New York City. EDIT: He also referred to pts as "just packages" and pretty much got the same response he did here.

I'm well aware of the levels in NYC and have worked with many EMTs and Medics on LI who also worked in NYC. Again, you failed to answer the question. Do you work for FDNY, a hospital based service or one of the privates? You know exactly what I mean when I say cowboy. Should I use the term buff? I know you understand that. I also know full well that EMTs and medics are not doctors. I did EMS in NY, not NYC, for 10 years and know the systems from Staten Island to Montauk pretty well. When we say scared, you know we do not mean it literally. However, the fact that you cannot do anything more and cannot properly provide the care the pt needs because of the standards in NYS and the fact that you are an EMT should literally scare you. People are dying because of the dismal state of EMS in NY but that is for another thread. So what are you going to do when this guy goes unconscious because his SBP is 70 and you can't bag him and your ALS backup is tied up on another call and you have to take care of the pt. You are right, there is nothing you can do but watch him die. The fact that that doesn't bother you makes you a piss poor provider in any system.

Mari, unfortunately in NYS, yes that is all EMTs can do. I guess we shouldn't be too hard on him since again, he really doesn't have the knowledge to appreciate how sick this person really is. In NYC with the closest hospital being a block away in most cases there isn't much need to learn to manage sick pts, just apply diesel. Please don't base your opinion of all FDNY EMTs and medics on this one newbie. Most are good people that don't want to see people die and do care about their pts and would know that this person is a disaster waiting to happen. With a whole year of experience under his belt he still has the cowboy mentality. Time and experience will hopefully change that or weed him out. EDIT: Miscusi, who exactly do you work for? In this thread you imply, though never state, that you are with FDNY but in the thread about transporting dead people. I would think if you were FDNY you would know the answer to the question of transporting dead people.

Sorry to go off topic since medicgirl is looking for help, but I'm sensing a troll. Check out these girls:

I think our young padawan is suffering from a case of "the not knowing what you don't know". This guy should scare the hell out of anyone that has a clue. He's septic with airway issues and has the potential to have a nightmare airway

Just because something seems to make sense doesn't mean it is the right thing to do (MAST pants, spinal immobilization). Read Dwayne's post and do some research on your own through the current literature and it might make more sense to you.

If you are not affected by the crap we see in this field then you are either burnt out and need help or you have no conscience and should not be in the field. We all have those pts that affect us. With experience we learn to shut it off in a part of our mind while we care for the pt and continue with the shift. Once you are safely away from pt care, you MUST open that box and deal with it. If you don't, you will fall apart. We all have different ways of dealing with it. Find a healthy way and do it (drinking doesn't count unless it is a single, therapeutic drink with a caring friend). Talk to someone who can understand what you are going through, talk to someone who can't understand what you are going through but will listen and support you anyway. Take up kick boxing or weight lifting, go for a run. Do something but don't keep it boxed off in your head.

Eh, it's no biggie. That's the problem with the internet and scenarios. We all get a picture of what we think the pt looks like and incorporate things that may or may not have been there.

When trying to control afib/tachy/htn I like to stick with what the pt is already on, especially if they missed their dose. I'd give some extra beta-blocker, consider an esmolol drip. You can get a "withdrawal" tachycardia from missing doses of beta-blockers. As for the ABG, the doc or a nurse can draw it. You don't need to have RT. Someone mentioned a d-dimer. It would not be useful in this situation. Although it has been stated it was negative, I would place money on it being positive. It is a very nonspecific test that will be elevated for thousands of reasons. It is only useful to r/o PE when your pre-test probability is low, which with this pt's history it is not low (see PIOPED study and Wells Criteria). As for airway control, I'd try to stabilize the HR/BP first to see if the mental status improves but have everything ready to drop the tube.

Any pain, trouble breathing, fevers or difficulty with secretions? What was the surgery and why?

Why would anyone even think of working someone with rigor? Don't waste anyone's time, including the family by getting their hopes up. Be professional and explain that their loved one has been dead for at least 6 hours and at that point there is nothing that can be done. There is no letting the family know that everything has been done. There is nothing to be done other than supporting the family. Needles, your partner is an ass.

I'm going to assume that since we can't get a head CT we also can get a chest, as someone mentioned a PE. Cxr is not helpful in diagnosing PEs (yeah you can see Westermark Sign or a Hampton Hump but those are usually only visible on the retrospectroscope). As cxr will tell us if there is heart failure, pneumonia, pneumothorax, an enlarged heart (possible pericardial effusion), or aortic aneurysm. Is is safe to assume we don't have a bedside US either? I'd like to get some labs going NOW. CBC, CMP, Trop, ABG, coags to start.

Hey Ruff, this is from the 14th, the same time he posted the other ones.