EMS2712

I was asked to a lecture on "Lesson Plan Development and Documentation", and I am looking for ideas to incorporate with this lecture. If you have any ideas on what to incorporate, it would be greatly appreciated.

I can full understand the original poster's situation, as I have been in a similar situation when I was first going to Paramedic school. I worked part-time for a County EMS system in Ohio, who won't transition to have some true ALS Paramedic level service in the county. I have seen several EMT-Paramedics that worked their while going to school, only to be run off by the "old guard" of the department. Countywide if you are a Paramedic you have to function as an EMT-Intermediate level. The reason I have been given for not going to paramedic level include the following: We have gone without Paramedics for 25 years why do we need them now? We don't want to alienate the EMT-Intermediates who work here because of your skills. What can Paramedics do that I can't, it won't make a difference. I have learned to bite my tongue on many occasions. Has anybody else dealt with this?

Lone Star I fully agree with your view on this. I was hoping to open discussion on this. I think we have lost our ability to think. In addition, I think that we rely too much on technology on the truck. A new tool is great to have, BUT a tool is only as good as the person operating it. In Ohio, I think there are too many programs in the state, and because of that the quality of product being put out is gone down as well.

Generally, how would you describe the EMT students that are currently entering your programs? Tech-savy? Lazy? In addition, Are you happy with the students we put out, or do you think we basically teach to pass the exam and that is it?

I am in the process of setting up a mentoring program for our new instructors (CE and full EMS-I) within our department. I am looking to pull information from other instructors as to what they feel were the best resources (articles, books, CD's, DVD's) that helped them over the years in their teaching careers. I am hoping to pull this information to do some lectures and training sessions with the new instructors along the way. Any help would be appreciated. Lt. Zachary Wolfe Delaware County EMS

Here are a couple of scenarios we have done recently: School Shooting MCI: Did this training in conjunction with local law enforcement, and turned it into a joint training scenario with them. Mass Electrocution: We have done this in two situations: Pool setting, and packed bleachers at a football game. I like the football scenario as not much moulage to do for it. Hydrofloric Acid explosion in a lab. Our local MRDD program retired a smaller transport bus, and we hired the staff from the DD staff as patients, and did a special needs patient accident. It was a great learning experience for all parties involved. I hope some of those you haven't done yet. Lt. Zachary Wolfe Delaware County EMS

At the time of this incident chemical and soft restraints were unavailable. Chemical restraint is not in the county protocol, and for some reason we don't have soft restraints on the trucks. I am looking at fixing that problem. I did get end stage follow-up and talked to with the medical director. Per OSU Medical Center where the patient was transferred to, CT scans negative, Tox screen negative, cultures negative, CBC and BMP were within WNL. Patient was discharged home to care of his PMD with a psychotic episode of unknown etiology. In talking with the medic director, seratonin syndrome, would be logical, but local facility doesn't have capability to draw it, and apparently OSU didn't draw it. To answer the question the patient wasn't less combative with a particular sex. Thanks for the input on this.

Good Afternoon Ladies and Gentlemen, I apologize for not answering the questions yesterday, as I was under the house working on some pipes that burst. I will try to answer everyones questions the best that I can. Use of Narcan- I can see both sides of the argument that have been posted on this issue. In talking with the medic the reasoning for this was as follows. The patient has an altered LOC of unknown etiology at this point. Yes the airway is patent, and the patient is combative, but is the altered LOC and combativeness a side effect of a narcotic overdose, hypoxia, neurological, or some other underlying cause? With the pinpoint pupils, one could assume narcotic overdose with the altered LOC and combativeness. I am also of the mindset that if I do give Narcan, I like to slowly infuse the Narcan, as not to induce an instant withdrawal from the drug. Unfortunately, I don't know how every patient is going to present after giving Narcan, maybe he would become violent, and maybe not. I agree that is a potential risk though. Updated Blood Sugar of 152 Updated BP 172/104, P 58, R 18 T 99.1 Yes, potential for CO poisoning would be a diff. dx, but we ruled that out pre-hospital with the use of the Rad 57 handheld units showing 1ppm reading. Patient was found lying in the middle of the room with no apparent items that he would have struck his head. No signs of trauma noted on exam. No abnormal chemicals noted in kitchen. The teflon study, could possibly fit, I read that study as well, and to be honest I didn't really look to see what the pan was made of. I noticed to burned eggs still in the shell in the pan. Patient remained combative throughout transport. Upon arrival at the hospital, patient was moved to ER trauma room and report to staff Patient was initially given 5mg Haldol IM with minimal response. Patient was given 5mg IN with no change in status. IV was established, and patient continued to be restrained by PD handcuffs, under the observation of PD unit. ABG's were drawn with SLIGHTLY elevated PCO2. Due to patient continuing to be combative, patient was selectively intubated with the assistance of 25mg Etomidate, and a Propofol drip. Urine tox screen showing positive barbituates and nicotine. With patient sedated CT scan completed, with no bleeds or masses noted. Patient was subsequently paralyzed, and transferred to University Hospital. Follow up with receiving facility showing subsequent CT scans negative and tox screens showing no changes. Receiving hospitals advised the patient had blood cultures drawn and are awaiting results. What are some other thoughts. I haven't heard anything else, but I will let you know.

1) Per the neighbors, he is acting abnormal. He normally is talkative and coherent 2) Neighbors say this isn't normal for him 3) No medications were found at the residence. Bystanders were not helpful in obtaining this information 4) Vitals P 60 R 18 BP 172/100 5)CO readings are in parts per million. Normal is 0.5-5ppm. When you hit 25-30, you have to go to a hyperbaric chamber for treatment

Mobey, I don't disagree with your thinking, however we don't have prehospital RSI as of yet. 1) On fire and EMS arrival, it was a pan of eggs that appear to have been being hardboiled with all of the water evaporated directly catching the eggs on fire. 2) Patient #1 is coughing, but states he feels better outside, and doesn't want to be evaluated by EMS 3) Patient #2 is non-verbal at this point, and taking swings at the EMS crews. Patient is fighting as crew is securing him to the cot. PD physically restrains him to cot with handcuffs x2 4) No Gas monitor available to FD 5) Patient placed on NRB at 15lpm. Sp02 of 100% prior to Oxygen admin. EtCO2 n/a, CO detector showing 1, monitor showing NSR with a VR of 68 in Lead II without ST changes. IV attempted x2 with patient pulling both of them. Protocol doesn't allow for initiating sedation. 6) Patient was recently discharged from area psych unit with bi-polar disorder 7) EMS Crew administer 2mg Narcan via IN x2 doses for a total of 4mg en route to hospital with no response. Pupils remain pinpoint 8) House was also checked by law enforcement as well as the EMS Captain for any drug equipment or pills with none being found.

On March 30, 2009 you are dispatched to a report "Out Fire" with possibly 2 smoke inhalation victims. Upon arrival FD advises fire is out, and the occupants of the structure are out side. Patient number 1 is a late 50's male patient who advised he smelled smoke from his upstairs apartment and came downstairs to find patient number 2 lying on floor lethargic. Patient number 1 advises that there is a burning pan on the stove, and evacuates patient number 2. Upon arrival of EMS patient number 1 refuses care. Patient 2 is standing upright still appears to be lethargic to surroundings. Bystanders advise patient number 2 has significant psych history. Upon making contact with patient, he becomes combative. Initial Ax A-patent, B-normal at rate of 18, C-skin ashen warm and dry with positive radial pulses at a rate of 68. Patient has pinpoint pupils at 2-3mm. Patient becomes combative as you move him to cot, and PD is on site with securing of the patient. Where do you go from here? What is your differential diagnoses? Ask any questions you ask, and I will see what I can tell you because I am not sure what to think is going on with this patient.

VentMedic, I hope you are not taking what I have stated as bashing Hospice. I may have differences with SOME of the policies that Hospice follows, but I do think they do good work as witnessed with my grandmother. I QA the report, and some of the questions I posted were those that were brought to me from the crew on the run. I will also admit that I am not an expert on Hospice care which is part of the reason I brought it up for discussion today.

I agree with what you are saying, and actually having some members of my family under hospice care, I do agree with the choice to die at home comfortably with their family in their home. I have no doubt that this wasn't done on a whim, and a lot of thought went into the decision as this has the potential to be a very emotional time. I still be believe the patient should still have some control in their care. If the patient (or family in this case) makes the decision, and it appears to be a prudent and reasonable decision, does that mean that should forfeit all rights to hospice because you disagree with the hospice decision? As I said, I wasn't on this run, and to get a full view of what was going on, I only have the report to review, and further conversations with the crew on scene. I am putting this up for discussion, and I think we have a lot of valid points on both sides.

I agree with the statement that DNR doesn't mean do not treat. In Ohio, they have made it more confusing by adding the different classifications such as DNR-CC and DNR-CC Arrest.

This is why I posted this for discussion. I wasn't directly on the run, but as it as explained to me after the run because I QA our runs. To answer the questions that I was asked. Patient was an 86 y/o male on end stage heart failure with a cardiac output of less than 25%. This was dispatched as a public assist, and subsequently our crew was asked to evaluate his condition. I was advised by my crews that he was lethargic. Family has Medical POA. In addition, the family was advised by hospice for them to maintain hospice care, they have to notify hospice if something goes wrong and they will decide whether the patient will go to the hospital. I wasn't aware of this, but upon further consultation with a couple of Dr's and Training Coordinators, in some Hospice systems you give up your rights to determine care because a lot of times the families will make decisions with emotions instead of following the patient's wishes. This also includes in whether 911 is called. I wasn't aware of this. I don't agree with this though. Please don't get me wrong, but I feel that the family(and the patient for that matter) still has a right to say in their care. Hospice does a lot of good work, but I don't think it is appropriate in this case. The crew was told that he was put on hospice because of the end stage heart condition, but they (hospice) is also giving him 25mg Morphine daily. What are your thoughts? I think this could be a good debate.