MedicAR

I had this problem with a DOA. I know that sounds ridiculous, but the deceased was the caregiver for an adult functioning at about the level of an 8 year old. My concern was whether he would be able to care for himself without anyone present once the coroner had removed the remains. He was unable to give us information on who to contact, family names, phone numbers or anything. They used a land line phone so raiding the "contacts" wasn't an option. We got law enforcement out which is standard procedure on a DOA and they spoke with him, trying to determine if he was safe being alone. We spent nearly three hours trying to find a solution. From a legal standpoint, none of us can actually declare him incompetent, but we also know better than to just leave him. Adult protective services said that it wasn't an abuse case, so they had no emergency power. PD considered taking him to jail just to be supervised and get meals but there was the question of traumatizing him and the legality of taking him in. Out of sheer luck, a family member called while we were there and agreed to come take care of him. PD remained on scene until they arrived. This seems to be what usually happens on these tricky cases, there is no clear cut resolution, just what works well at the moment.

Auto regulated through a tube in the lower abdomen. They said the pump rarely gives him problems, but it's not out of the question.

I was completely unaware of this. I don't recall it being something that I saw in school and certainly haven't seen in any refreshers since. I will try to learn all I can to pull together a presentation to teach my coworkers. Your description fits better than anything I have been able to find or attribute. It was a short ride to the ER, so I am betting that the release occurred while we were with him, giving me a good CBG when I checked but allowing it to quickly crash after dropping him off. Thank you! I thought I had it in the first post, but apparently that was an earlier draft. No facial droop at any point. Once awake and oriented enough to follow orders, he had no stroke symptoms. He had good grips, clear speech, equal smile, normal arm strength...the works. No signs of a stroke at all. It was the first thought I had when given the history of headache and then unconscious. I have seen a hemiplegic (or complex) migraine in another patient close to his age (mid 20s) that presented as a classic stroke complete with facial droop, word salad, and single sided paralysis. It was only diagnosed after symptoms resolved and she was able to tell us she had migraines. Well, that and the repeated CTs were completely clean. Nothing exciting in his vitals. I didn't make notes, but from memory I would say a heart rate in the 80s, varying respiratory rate, BP of 110/70, and pulse ox at 100%. No big clues there. I have no idea on the insulin. I can say that it isn't refrigerated as it stays in the pump on his belt all day. Administration is auto-regulated for the most part but the patient can make minor adjustments. I'm still learning about the pumps but they seem to be a pretty solid technology at this point.

Honestly, I don't believe the glucometers are ever calibrated.* By the same token they are usually within a point or two of the readings in the ER and the one I used is still on the rig with no other unusual readings. We did a finger stick to get the glucose level while still in the early stages of the assessment because nothing really made sense. No real history other than Type I Diabetes that he generally keeps well controlled. He and his family stated that he rarely has consciousness altering episodes and has even had fewer since getting his insulin pump. They estimated it at once a year or less and that he usually realizes what is happening and corrects it right away with no outside intervention. The family could not specifically remember the last time he had a problem. Otherwise healthy with no recent illness or trauma, not even as simple as bumping his head on a car door. No meds outside the insulin. Diet and daily habits had no recent changes. He was fit and toned without being bulky and said that he worked out frequently, crediting his healthy lifestyle for keeping his diabetes well controlled. He claimed that he didn't use alcohol or illegal drugs and nothing lead me down that path anyway once he was awake. Vitals were normal aside from exhaled CO2 which was low in the mid to lower 20s which could tie to DKA if other symptoms are present. The problem with DKA is the obvious, that it would result from an increase in glucose, not a decrease. He described the headache as a pressure that felt like the right side of his head would explode. He said that he didn't have problems with his vision or nausea with the headache. He said that he didn't feel weak or tired but felt like he should lie down. He said he still had a headache but nothing like he had experienced earlier. There was nothing visible that would lead me to suspect trauma to the head, no bruises, bumps, scabs, bleeding...nothing. ER treated and released with the sole diagnosis being hypoglycemia. No X-ray, no CT, no MRI. It was like the headache was completely ignored. *It sounds weird, but my management seems to take great joy in keeping us grunts in the dark on everything. Their attitude seems to be, "You don't worry about it. Just use what we give you." It's most likely a control trait but who really knows?

I had a strange call recently. Called for an unresponsive/syncopal patient. When we roll up, he is awake and looking around but not interactive even to pain. Family said he was completely unconscious when they found him and his eyes were closed. He had no seizure history, oral trauma or incontinence but for all intents and purposes, he appeared postictal. He had a diabetic history (and insulin pump) but CBG was 128. Skin was pink, warm, and dry, and pupils were equal and reactive. He was young (late 20s) and very fit, last seen normal two hours prior when he was complaining of a headache. Family stated that he has never complained of a headache in his life, much less one that he would lie down for. He moved all of his extremities but not to command and even his grunting wasn't related to painful stimuli. Sinus rhythm in the high 80s, normotensive, SpO2 100% and….hyperventilating. I didn't notice it initially but then caught him breathing close to 60 times per minute. By the time he is on capnography, he is back down to 16 breaths per minute. He has some meaningful movement as we roll him onto a sheet to move him, almost assisting with movements. Respiratory rate continues to vary but the changes are sudden, not like Kussmaul's, with the gradual changes in depth and rate. It really was like flipping a switch. We move to the bus and when I am looking for an IV, he is cooperating with his arm movement. I stick him and get no reaction. Within a minute or two, he is awake and oriented with clear speech, initially drowsy but quickly awake and lucid. His breathing sped back up to 40 but slowly decreased with coaching and explaining why he had carpopedal spasms. He was cooperative and lucid. He had no history of anxiety or respiratory issues. He remained awake and oriented all the way to the to the hospital. In talking about his headache prior to all of this, he described it as intense pressure behind his right eye and was easily the worst headache of his life. He remembered walking to the bedroom and then nothing until he awakened in the bus. Now here's the problem. Later, I get a call saying he was hypoglycemic (CBG was 28 when ER checked) and am accused of not treating it. I checked his CBG and found it normal. He improved without intervention and once awake, was well oriented and remained pink, warm, and dry. His skin was also normal prior to arrival and during his time with me. By the time we arrived in the ER, his only complaint was carpopedal spasms. Breathing had slowed to 20 and appeared to be well controlled. Am I missing something? Could it be an insulin pump malfunction? If so, wouldn't the CBG continue to rise or fall until an intervention is made? Why didn't he become cool and clammy? By his own admission, he usually becomes diaphoretic when his CBG drops. Where did the hyperventilation come from? I generally associate that with hyperglycemia, and slowed or even snoring respirations with hypoglycemia, although neither are hard and fast rules.

Not what I was looking for but a great read!

https://www.research.net/s/EMSProviderStressPoll It's a survey. The same link is in this article: http://www.ems1.com/ems-advocacy/articles/2117096-EMS-leaders-studying-suicide-and-mental-health-in-emergency-responders/

I appreciate the support and suggestions but I have been down this road, too. I started with our Employee Assistance Program which was hysterical. While their counselors might do very well for the average office or factory worker, I saw immediately that they were ill prepared for the difficulties I was seeking help for. Let's face facts, a big part of what we do in our job is reading others. Some of us study body language and the science involved while others just do it without fully understanding how it works. It becomes instinctual. I clearly made both of the counselors I tried to work with very uncomfortable. Whether that discomfort was due to the situations I described, the realization that they were in over their heads, or something else entirely, they were of no help. I moved on to an actual psychiatrist and saw some improvement there. Mysteriously, I was declared "well" and cut loose. I wasn't sure, but went with it anyway. I went back briefly but thanks to the changes in insurance and co-pays, continued therapy is now out of financial reach. That is how I wound up looking around online and for groups. I figured they were better than nothing. I found this article this morning and was deeply disappointed to see that the person in charge of finding and helping those that were at risk within our profession in her area succumbed to the very problem she was trying to prevent.

Speaking from experience, there is next to no assistance available for responders. There is a new group called "Sheepdogs" that claims to be specifically set up to help first responders and veterans with PTSD, depression, anxiety or any other problem. They also reach out to perform disaster relief since their members are already trained and ready to go. I tried three times to get help from them with no response at all. I looked for PTSD groups in my area but since I am not a veteran, there are none available. My favorite questions when I am looking for assistance are "what branch did you serve in?" and "what could possibly have been that bad?" Lesson learned. I'm on my own. As for the numbers, there are many things that skew them. I feel certain that the problem in Canada is farther reaching than anyone suspects since suicides are not technically LODDs. I know of two in my area over the last five years, but many more left the business permanently damaged. I know one that disintegrated on a call. I was not present, but those that were said that there didn't seem to be anything special about it. No fatalities, no grisly scene, no kids, just a minor traffic accident. To this day, we don't fully know or understand why a responder that was by all accounts, happy, healthy, and strong just quit mid call. Thankfully, he was a FF, so he got a medical retirement. To this day, he has nothing to do with any of us he worked with for many years. I have known several others that have left in a less dramatic fashion, but simply stated that they couldn't do it anymore. Those that leave, don't count in the suicide numbers since they weren't on the job at the time. This business still has a hero complex, it hides what doesn't fit the image. Personally, I have never felt like a hero. I'm just a shmoe doing a job that was appealing at one time but now I'm too old and under-trained to do anything else, so I stay. Don't take that wrong, I am still committed to being the best that I can, but given the opportunity, I would leave in a heartbeat.

I have spent the better part of the afternoon trying to find an article that I am certain that I read online at one of the EMS journals. It was reporting the results of a study on deaths of providers after leaving EMS. The authors of the study had been researching another topic when they came to the realization that a large number of EMS providers die within three years of leaving EMS. It didn't matter if they retired, resigned, were forced out, or whatever, a large number passed within three years of leaving the business. The article itself appeared definitely within the last six months, I think three months is more realistic. Does anyone else recall it? If so, can you provide a link? I am starting to think I dreamed the whole thing up.

Really? ASK for a discount? If you pull that crap while riding with me, you will go sit i the truck for the time being and then I'll make sure you never get to go into any eating establishment while on duty again. Why, exactly, does the world owe you anything?

My service ignores it. Christmas bonuses are gone. No raises for about 3 years. Employee of the month discontinued. Christmas dinner is a potluck, we have to use our uniform allowance for boots and can only do so every three years (the allowance doesn't cover a pair of proper boots), no compensation for training or recertification, no way to promote, cramped trucks (front and back), air conditioning in the trucks that works about 50% of the time, the list is almost endless. We changed from a bizarre mix of 24 and 12 hour schedules to 12 hours for most crews and 24s in the lower volume areas. This was a fantastic boost in morale but came about because the fatigue was simply out of control and it was becoming clear that someone was going to get hurt. It's not perfect but it is light years ahead of where we were. This worked splendidly for more than three years. We still kept hearing that "there is just no money for raises" but given the state of the economy, we just took it on the chin. Then, the brass got brand new vehicles. A suburban and a really nice truck, both fully loaded. I've always considered myself to be pretty good at gauging and anticipating reactions, but this was as demoralizing as anything I've ever seen and it came out of the blue. Even the most ardent "company men" were outraged. Not upset, not disappointed, but outraged. Morale wasn't damaged, it was completely destroyed. The solution was a small raise, not quite as much as all of the other agencies around us have gotten in the last year or so, but a little. Since many employees make only slightly more than minimum wage, it's enough to stabilize things for the majority. I think that as employees, we essentially want three things. The first is more money. It's a no brainer, everybody wants it. The problem is that when compared to the agencies within a 100-200 mile radius, we're a minimum of 10% behind in pay with some studies saying as high as 25%. We also make more responses than all of those agencies. So we're doing the most work for the least pay, which is a recipe for low morale alone. The second thing we want is honesty. We catch our leadership in falsehoods again and again. The favorite to pick on right now is "no one, including the brass, has gotten raises for years." Technically true, but tax records show that they were awarded annual bonuses that kept climbing each year. Another is that no one can cool the back of an ambulance more than 10 degrees below the outdoor temperature. So, by that rationale, crews in Phoenix can't get a truck below 90 degrees for more than 1/3 of the year, anyone from Phoenix? Can you confirm this? The third is be recognition. I was recently told by my compliance officer that I don't get commendations is because I perform at such a high level all the time that they would spend all their time doing commendations. So my file has only my precious few mis-steps, not a single achievement. How does that look over my 14 year career, based solely on my file? As the boots on the ground, we can't find a way to fix these things and I am open to any ideas. Moving into management is out, no one moves up, it's not possible and when a slot opens, it is given to the most easily controlled/beaten down so that there is no dissent at the top. Unions don't take off and after the problems in the midwest over the last year and being an "at will" state leaves a bad taste in the general public's mouth, we don't want to upset the people we serve. On top of that, new hires are scared to commit to a union for fear of retaliation in the set up stages, so we never make it very far. We just feel that our hands are tied at every turn. I'm too old to move on, I can't start over and make what I am making now, and I'm not alone. We're trapped in a job we love if that makes any sense.

We were told it was mandatory and that the schedule for the classes had been arranged to fit into our work schedule, creating the long stretch of days that was at issue for me. So it was implied that we had to take the class through them but it would be a standard PHTLS class.

That's what started the whole subject. We were told that PHTLS would be required by the company ahead of state mandates that might go into place in the next few years. Once I questioned the pay, they backed off and said that the training was suggested. You've got to know, I'm not opposed to more training, it's always a good thing. This particular class was going to put me working 9 consecutive days. It was just too much time away from home at the time it was slotted. Another subject opened by all of this was why paramedics are generally instructors for CPR, ACLS, PALS and such. The reason is simple, it's not worth it to a nurse to spend a day teaching for $200-400 while medics will jump at it.

I always believed that training to maintain the certifications necessary to perform our duties were required to be paid whether regular time (under 40 hours) or as overtime in addition to our regular hours worked. I know that nurses are compensated for their time in courses they are required to take (CPR, ACLS, etc.) but my employer tells me that while nursing may do it, it is not required as we need the training to perform our jobs. I've searched this site and the internet at large with no luck. I know that training required by the employer is compensable but that training required by the state may or may not be. Any ideas on where to find this information?