Just Plain Ruff

I find some problems with this scenario and please do not take this as a personal attack but I'm surprised to say the least. The patient had an accepting physician at the receiving hospital and you talked her into a refusal based on that insurance would not pay? You also talked a pre-eclamptic patient into a refusal based on insurance reasons? I would request that you run this one by your risk management people at your service to see if that was the right thing to do. What is your level of medical education that gives you the ability to say she was not pre-eclamptic? What was her blood pressure? If her pressure was 140/90 then she's pre-eclamptic. Remember that pre-eclampsia can also be diagnosed with the absence of high blood pressure but there is the presence of protein in their urine. Did you see the Urinalysis? If not then you dont' really have all the tools to dispute the diagnosis of pre-eclampsia do you? I am still shocked that you would get a refusal based on insurance reasons. Are you sure her insurance policy would not cover the charge for the extra mileage? I think you should re-think how you handled this case. For your edification here is what can happen to the baby if pre-eclampsia is left untreated How Can Preeclampsia Affect My Baby? Preeclampsia can prevent the placenta from receiving enough blood, which can cause your baby to be born very small. It is also one of the leading causes of premature births and the difficulties that can accompany them, including learning disabilities, epilepsy, cerebral palsy, and hearing and vision problems. (Source http://www.webmd.com/baby/guide/preeclampsia-eclampsia Here is another resource that you can refer to. It's from the Mayo Clinic http://www.mayoclinic.com/health/preeclampsia/DS00583

well let's see, I'm suspecting the big one. Are we sure we have the leads in the right places??? It could happen. What about this scenario WE had a patient one night who when they had chest paiin they showed an MI yet when their chest pain resolved they showed a normal ekg. I was pretty new at the time and I didn't believe it but the cardiologist said at the time(I hope I get this correct) - that the clot was right on where the artery branched and split. When the clot was covering the opening of one of the arteries the MI appeared but when the clot was not on the opening then there was no MI. (Can this even happen? I was skeptical). The patient was given Eminase and the MI symptoms resolved. It sounds like this guy is too far into his MI but I just thought this was pretty hinky, I mean my patient.

For Akroeze An article on syphillis and respiratory illness http://www.aegis.com/conferences/hiv-glasgow/2002/P257.html But CHBARE, wheres the twist? You said there was a twist. I'm leaning towards Pulmonary Edema but there's something else going on here too if you go specificaly with the chest pain with a twist topic title. What is his LOC now? Is it to the point where this guy is so tired that we have no choice but to RSI him and ventillate him? I think that we may be to this point. Or is he becoming so obtunded that he would not fight off attempts to nasally intubate or orally intubate him? Has anyone mentioned Morphine or is his BP too low now? Do we have access to the following: Nesiritide (Natrecor) -- Recombinant DNA form of human B-type natriuretic peptides (hBNP), which dilate veins and arteries. Human BNP binds to particulate guanylate cyclase receptor of vascular smooth muscle and endothelial cells. Binding to receptor causes increase in cyclic GMP, which serves as second messenger to dilate veins and arteries. Reduces pulmonary capillary wedge pressure and improves dyspnea in patients with acutely decompensated congestive heart failure. Here’s a little statistic regarding sub-optimal care in the acute setting • Based on data from 4606 patients hospitalized with CHF between 1992-1993, the total in-hospital mortality rate was 19%, with 30% of deaths occurring from noncardiac causes. These patients, however, were noted to have had suboptimal use of proven efficacious therapy, compared with those who survived hospitalizations, particularly among women and the elderly. Thirty-year data from the Framingham heart study demonstrated a median survival of 3.2 years for males and 5.4 years for females. source http://www.emedicine.com/EMERG/topic108.htm

There is no way to earn a living doing EMS as a volunteer, and finding a paying EMS job elsewhere defeats the purpose of being an EMT in this area. Anybody have any suggestions? 2 things wrong with your statement above. 1. you are correct to say that there is no way to earn a living as a volly which is precisely the point of going paid. 2. The point of getting a paid job out of your area is that your area is too cheap to pay for full time EMS. Your friends or co-workers(with a side of chagrin when I say that) are working outside the area are being paid a living wage, why not you. This exact post is exactly what dust and the others have been saying all along. If you give away your services for free then you get what you pay for. I'm sure the poster is a great guy and a good emt bbbbuuuuuuuutttttttttt this is clouding his judgement. His community doesn't need him, they need EMS. If he didn't volunteer someone else would do it cause we all know that there will be someone to give it away for free. Put away the idea of going to emt-I and go directly to paramedic. You will skip the redundancy. But the question I ask is this, if your service is only emt's right now what makes you think your service can provide ALS. Are you licensed for ALS yet can't provide it due to resources like medics? If so then your service needs to be paid. I'm just waking up so this whole post may not have made sense but I think our original poster is cutting his nose off to spite his face.

There is no team in baseball that needs the help more than the Royals. At least after the first game this year they were undefeated. It went down the crapper from there. At least I can always be assured that there will be plenty of tickets available for the odd day I want to take my son to the game. Usually close to the 1st base or 3rd base and within eyesight of the players grabbing their packages.

ok, now the real fun begins. You need to focus your time on the station you failed since If I remember right you re-test on it and another station. gloss over the ones you passed if you feel so inclined but work work work practice practice practice on the one you failed. Chances are if you are going to fail another station it will be the one you failed to begin with. If I was in your neck of the woods I'd offer to help you prepare but I'm not so GOOD LUCK Does southwest airlines fly from your city to concord? or near it? If they do let me know. I might be able to hook you up with something.

I'm afraid we may have no choice but to tube her but Doc says that we are 10 minutes out or so. I think if we ventillate her via BVM we can stave off intubation until the experts can get to her. Her mortality rate with cerebral edema is about 70 percent and coming out of it with normal mentation and results is pretty slim. Kid's always scare medics and emts and for good reasons. The only reason I've seen the need to tube kids are three fold. 1. The child needed it due to condition or arrest status. 2. We have missed something in our evaluation and exam and that item we missed was allowed to progress to the point of having a child in an obtunded state. And at that point we are behind the 8 ball and getting further and further behind. (this is the one you never ever ever want to have happen to you my friends) 3. We are correcting something that was missed by someone else. There are others but the above are the ones that cause my pucker factor to get significantly worse. This is a prime example of needing advanced education throughout your career. Don't rest on your laurels and think you don't need the education cause we all do. So Doc, how did this turn out?

as I pick myself up off the floor and dust myself off I exclaim Episiotomies inthe field. Holy crapola batman, do you think your medical director will allow you to basically cut the woman? I can't see a single benefit of a medic or (for dust's sake) GOD FORBID an emt doing this procedure. But seriously, I can't imagine even thinking about doing an episiotomy. There is just too much that can go on with a sharp object down there. I don't want that anywhere near my liability insurance.

reading more on cerebral edema this kid sounds like we've given it to her on a silver platter. I think we may not have any choice other than to intubate her. from the same article cited ---- Once severe symptoms occur, the mortality rate is greater than 70 percent How bout some mannitol if we suspect cerebral edema - Same article -- About 10 percent of the patients initially diagnosed with cerebral edema have other intracranial pathology such as subarachnoid hemorrhage.43 Mannitol (Osmitrol) therapy and hyperventilation have been recommended based on limited evidence So if she indeed has cerebral edema, we need to tube her and begin to assist ventillations even to the point of hyperventillation. The mannitol will help reverse the fluid imbalance in her head. Again, I'm going to kick myself after the call due to letting my newbie partner take care of such a critical patient. So my guess is that she already was suffering from the beginning stages of cerebral edema even before we made contact with her. The signs and symptoms are all there. Of course I may be off base and way out of town on this one but I think that we have done more damage to this kid than we think we have.

well first off the starting dose of fluid replacement is 20cc/kg which by my estimation my newbie partner has given her 1.5 times the amount she should originally get. Here is what I found about cerebral edema which apparantly is much more common in kids than adults so we have to be extravigilant in kids. You never did tell me what the pupils were? Cerebral edema is a rare but important complication of DKA. Although it can affect adults, it is more common in young patients, occurring in 0.7 to 1.0 percent of children with DKA.3 Early signs of cerebral edema include headache, confusion, and lethargy. Papilledema, hypertension, hyperpyrexia, and diabetes insipidus also may occur. Patients typically improve mentally with initial treatment of DKA, but then suddenly worsen. Dilated ventricles may be found on CT or magnetic resonance imaging. Treatment of suspected cerebral edema should not be delayed for these tests to be completed. In more severe cases, seizures, pupillary changes, and respiratory arrest with brain-stem herniation may occur. Once severe symptoms occur, the mortality rate is greater than 70 percent, and only about 10 percent of patients recover without sequelae.3 Avoiding overhydration and limiting the rate at which the blood glucose level drops may reduce the chance of cerebral edema.3 However, some patients may present with cerebral edema before treatment is started. About 10 percent of the patients initially diagnosed with cerebral edema have other intracranial pathology such as subarachnoid hemorrhage.43 Mannitol (Osmitrol) therapy and hyperventilation have been recommended based on limited evidence.44,45 Source - http://www.aafp.org/afp/20050501/1705.html

Here is an interesting article I just found. Seems like you can get a 15 second ct scan done to rule out cardiac causes of chest pain. Good or bad? Discuss http://www.americanheart.org/presenter.jht...ntifier=3043217

thats why I originally stated we wanted to get her to definitive treatment and some insulin. I hesitated to give bicarb but one of the guys threw in Acidosis. So I started down the route of bicarb but after discussing with my mentors here I find that bicarb is a bad thing and there is a reason it's been a very very long time since I've given it for really anything. I still stand by my original post of definitive treatment at a hospital for labs and more advanced treatment than we can give her in the ambulance. WE are pretty limited in this situation as to what we can give. Too bad we don't have access to labs. They will tell us almost everything we need to know. But with the limited amount of diagnostic and medical equipment we carry on board for this type of patient, supportive care, fluid bolus's of 20ml/kg and rapid but smooth transport of this really really sick little girl is about the best we can do. Hey Doc, how far are we away from the hospital now?

Wow not seeing the forest for the trees on this one. Let's give her some bicarb and let's see what develops. but I still stand by the fact that insulin is the treatment of choice but being stuck in the ambulance for an hour then the next best thing is to treat with bicarb in the big yellow/puke greenish box.

what are her pupils like? so I guess the original hospital is the place to go. the helicopter will get her to the hospital about the same time you can get her there so it's ground transport. So what are the roads like between us and the receiving facility?/ are they closed due to some tractor trailer cow transport crash or something like that? I think we need to look at the amount of fluid we are pushing in to this girl. What are her lungs sounding like with that liter of fluid? Let's get on the horn to the hospital and discuss this case with them. Or are the phones out in the area? AS for her pupils - these are key for cerebral edema How much does she weigh? We need a 20ml/kg bolus of fluid to start with. Then we can back that off as needed. But in all the research and info I'm seeing is that the definitive treatment for this little girl is insulin.

I still think its a modified version of Marburg but probably not. soooooooooooooo I'm gonna work her like any good medic should and begin assessment all over again since I handed over care to the newbie which after the shift I'm gonna kick myself in the ass and say, never never never again, YOU KNEW BETTER But after I reassess her with the following Vitals blood sugar again cardiac monitor pulse ox loc? IV RUnning OK? is she on oxygen? I'm going to assume that her sugar has skyrocketed and a diversion to a hospital with some insulin might be a step in the right direction. If I can't get a local yokel hospital to take her then I'm going to determine if a helicopter can get her to the peds facility faster than I can but I honestly think this kid needs some insulin and fast. I'm also going to start thinking about intubation if needed. And my guess for the underlying problem is she has a tumor on her adrenal glands that have started to go haywire and causing this problem. Either or, she needs defnitive treatment at a local hospital who can get her stabilized and she doesn't need a ramrod drive to a hospital over an hour away.

ok that makes it a little more clear but this school sounds like it's a flustercluck from the get go. By the way, if I can get a student loan you can. My credit score during school was dismal and as long as you have not defaulted on a previous student loan then you are pretty much guaranteed the loan. Is this school accredited? If so then you are entitled to student loans. Go to your bank and talk to them. They can point you in the right direction or better yet go here http://www.finaid.org/loans/educationlenders.phtml or here http://www.estudentloan.com/ If your school accepts government financial aid then your school will accept student loans from Citibank and Wachovia and ACS. If they don't accept those loans then get the loan yourself and then pay the school. If my credit score can get a student loan then your's can too. You just have to do your homework. Most student loans are not based on grade point average. You have to specify the loan is for education and not a personal loan which I suspect might have happened. As for your little prima donna girl in your class. If she indeed said that then I agree with you I'd have dropped her like a hot potato. Sounds like this girl is from the school of "coddle me to graduation". She probably has been told that she can be anything she wants if she just puts her mind to it. Thats a load of bullcrap. I like the statement you say about the instructors being mean to the students by quizzing them all the time therefore making them drop out. That's classic. If they didn't like the quizzes then they definately would not like the classes I used to teach. There was a quiz every night in class as well as pop quizzes throughout the week. I guess I would be considered mean. Good luck to you my friend, it sounds like with this program you might need it.

That was a great story. I met the boss of one of the ambulance services I used to work for. Her name was Mary and she was pretty nice. We spent quite a few late nights shooting the breeze over coffee and doughnuts. It was the only privately owned ambulance service I worked for that really cared about it's employees. Bonus's at christmas, christmas and company parties and the like. A good ole Mom and Pop service until the big guys came to town and screwed it all up.

That was an excellent point and post CMK I never thought of doing that though. My line of thinking is that it has to be a valid a truly valid reason to refuse initial parmedic A's services and not just the fact that he didn't provide the narc's or whatever on their last encounter.

good answer spenac, I've worked in both service styles. One service we were the only ambulance that was serving the county at the time they called so they are stuck. the other service style is one that had 11 ambulances running and sometimes there were 5 or more available. They still didn't send another ambulance but sometimes they would send the supervisor or if there was a medic at HQ the supervisor would drive that medic to the scene to transport the patient. I don't know of a amicable solution to this but you would hope that this doesn't happen very often.

I can see you haven't lost your dislike of me since our last volley of messages and PM's. It's good to know you have a long memory. Actually we already discussed your responses to my answers in a pm a long time ago. You criticised many of my answers and said they were google based answers so no I'm not going to answer your questions because you have nothing but criticism and negative disdain for them. No matter if I answer them right you will find one or two little things wrong with them and focus on those things. so no I'm not going to get into a pissing match with you, I'm more of an adult than that and it serves no purpose. No matter what I write you will find fault in it. Nice try so let the flaming and personal attack from Fire begin. Plus I can tell you off the top of my head that I don't completely know the answer to your question as it has so many variables that the question needs to be better posed but I'm still not falling for your ploy but to answer part of the question, I rarely treat the monitor before treating the patient. Patient condition and presentation count more than the monitor. If the patient condition, my evaluation of the patient and them monitor coincide then I'll trust the monitor a little bit more but there are many times when the monitor is doing one thing but the patient is doing another. Do you treat the monitor first or do you evaluate the patient with the monitor as an adjunct?

I can understand the not being able to accomodate the patient in situations where you are the only medic out there but what about the larger services who have at times 4 or more units on the street. If the patient has a bonafide medical issue and is refusing to go with a particular paramedic due to an issue in the past isn't there any way in your service that another ambulance can be sent. We have an obligation to care for the patient and when we refuse to budge and not send a unit then could that person not have a case against the service saying that there were units available and care was refused. I know that you can come back and say we provided the service they did not take part in it but I think that's a cop out. The patient obviously has a problem with paramedic A and refuses to go with them. We then say, your options are this paramedic or you sign a refusal. Isn't that kin to forcing a refusal. I have had the situation where the patient was very unhappy with me for not giving them the medications they wanted and when they got me as the responder they said they weren't going. I told the patient that it's either me or no-one, they went to the hospital with me. We ended up doing a lot of talking on the way and in the end we came to a sort of truce and the call wasn't so bad. I'm getting off track here but my real question is I guess, if you have the units available would your service send a 2nd ambulance if the patient refused to go with the first? The second question would be is if your service refused to send another ambulance and the patient refused to go to the hospital could that not be considered a EMS Forced refusal in all reality. Since the patient wanted to go to the hospital but not with that particular medic. One other example - female patient, transported by Carlos the sex addict. She is touched inappropriately by carlos. Investigation ensues and no wrong doing by carlos is found but the patient continues to believe he touched her inappropriately. She falls down and breaks her arm. Carlos is the responding paramedic. She refulses to go to the hospital with Carlos but obviously needs to go for treatment. Ambulance service refuses to call 2nd ambulance and she is told it's Carlos or no-transport. Could that not be considered a EMS forced-refusal? And would she have a claim in court?

ok fire, so go back to what you were doing, rolling hoses or spraying water on trash fires. Leave the EMS to those of us here who take the time to give coherent posts instead of venom.

Fire when did you get back? You vanished for a while until this thread came up. It's amazing that you demanded from many of us on this forum to prove our certification or knowledge base yet when asked the same question you have been unable to come up with the same. You also get bent out of shape when people call you on the carpet but you have no problem doing the same in return. I think that until you give us the answer to the question we have asked over and over again that we should no longer respond you your posts. But wait, we would become the spiteful brats that you have proven over and over that you are. Come clean, are you really a medic or are you a medic student overstating your credentials like Somedic was.

I believe that he requested that you cite the article with a webpage. Anyone can write down a stat, you need to show the actual webpage so we can all go and look at it.