paramatt_

Just a bit of insight / opinion from one of those non-US degree requiring countries.. I just spent that last 25minutes trying to articulate the merits of having a degree in EMS, however, both my rationale and frustration cannot be summarised in a single online post so I'll just agree with what Mike already said. One quick point to consider...when you look at some of the better known services in the US (medic one, wake co, Boston, etc), what are these services doing that have people are standing in line for jobs and what type of people are willing to put in the effort vs an easy employment mom and pop provider or even a well paid fire/medic job?

Sounds like pretty poor planning / insight from the ED to not have a plan for additional analgeisa but is also something you should have considered and addressed prior to the transfer. Anyways, if I was in your situation I would have considered calling back the doc, putting them on speaker phone so they can explain to the pt their rationale for withholding additional analgesia and allowing the pt to remain in significant pain

To follow on Mike's post, a lot of the issues with community based care is system based. ie a for profit system isint going to benefit from such novel ideas..again, a $$ thing. Working as part of a government funded service, it's a different story and all about value for money and keeping those out of hospital who can be treated in the comunity and trying to save ambulance resources for 'real emergencies'. We are doing this both in a call diversion program (only in its infant stages) where callers can be directed to local services and a paramedic run extended care program to deal with minor wound care / burns, epistaxis, catheter problems, some home rx for migrane, gastro, etc. The major success is that everyone benefits. And yes, major baseline education differences. And spending that extra few minutes preparing some food or having a cup of tea with a pt isn't just about doing a 'good deed' IMO, but is as much about being able to assess the daily living capacity of that person. Spending that extra 10 minutes chatting with someone and looking through the fridge can raise all sorts of red flags that might otherwise go unnoticed.

The easy, but maybe not so pratical advice I can give is to get out of southern California. Very archaic EMS. I don't live in the area these days but I've heard good things about Kern (and to a lesser extent Ventura, Santa Baraba, and SLO counties) if you're looking to stay in the immediate area. Maybe talk to services outside LA for your ambulance rotation. I'd recommend moving interstate if you're seriously considering a career in EMS. Good luck

Didn't finish that post ^ needing replacement, it worked great. Nothing like the more expensive models, but well worth the cost. If youre thinking about paramedic school or further educating definitely worth investing on something half decent. Also, I wouldn't recommend wearing your stethoscope on public transport

I had a Littman Classic SE II which is basically the lite/basic model for a good 10 years. Aside from a the occasional spare earpiece

Maybe petition for higher (?or minimum) education standards first? I'm going go out on a limb and say those services that have higher standards and better governance are likely going to have better outcomes no matter what you're measuring.

Not just the obese. I recall attending a pt, elderly, frail, and quite small that awkwardly fell and landed with most of one thigh basically under her squashed against the ground in what would have been quite an impressive accomplishment if she was doing yoga...unfortunately she wasn't and was found some 8-10 hours later with marked visible discolouration (of what could be seen) to said limb. She had multiple co-morbidities including renal failure. Anyways, we treated her as per crush injury though she ended up having a cardiac arrest after being moved. ps. can we start calling you Plain? And for the OP. there was quite a good topic some time ago on suspension trauma, if you have a chance its probably worth a look.

Ok ill get things started How's she positioned - sitting/laying/slumped/ etc? Skin colour? Consc state - just AVPU Pupils? Also can we confirm that BP...manual if the first was NIBP and the pulse ox pleth

A bit late, but just a couple things to add.. Id also be heading to the nearest facility with neuro. Btw; have we had a good look at his head..ie any recent trauma/falls/head strike? Probably not going to change our management but the reviewing facility would want to know potential med vs trauma aetiology. Il. As air vs ground, unless he's going to get RSI'd, he poses too much of a risk of dropping his bundle mid flight. Would definitely want an extra pair of hands in the back during the transport

Your department is definitely not the first to have issues like this and working in a rural area with volunteers who are giving up their own time makes things even more frustrating. The service that I work for dose not have any general refusal protocols but like most services we have had problems with frequent non-emergent patients who call wanting transport for a number of reasons, many of which just appear bored or have nothing better to do. In a few cases, there have been specific / targeted procedures put in place in dealing with these people between a supervisor, medical co-ordinatior, and the pt's GP, case worker/social worker, and I think the police in the case of one individual. If you're having issues with a specific person document document document, and perhaps if you have enough evidence that you're being manipulated or used as a taxi on a regular occurance you might be able to formalise a plan with some external help to deal with the specific person. Its also important to note many of these people do have legitimate medical problems and you don't want to dissuade them from calling an ambulance when they actually need it.

Perhaps the thought process was to increase venous return / "prime" the LV to subsequently increase stroke volume which can then be titrated with the fusemide to reduce the excess fluid. Definitely requires a careful balencing act. I've done similar with hypotensive inf STEMI pt's with a bit of failure (minus the fruse) with the aim of increasing preload. That's quite different to this pt though. To the OP: what treatment was done at the hospital and dId you stick around to see the outcome?

Just out of curiosity, how many services out there carry dobutamine? Anyways, if the pt was for active treatment, I'd be going for a low dose adrenaline infusion..likely starting quite low..maybe 2mcg/min and titrating to maintain a sufficient MAP and no more. Excess catacholamines = no bueno with a history like that. Maybe if it was extended transport I'd consider lasix balancing act, but would be very vety weary in doing so. I'd also avoid CPAP with a BP like that. I suppose a ddx like dig toxicity should be considered. Wouldn't change anything in the short term but it might mean he'd be going home

"If your heart stops would you like to be resuscitated?"

Welcome & good topic. Cases in Pre-hospital and Retreival Medicine, Ellis & Hooper Written in relation to commonwealth ambulance services, however, still relavent to north American models. Depending on your background and knowledge base, some parts might be a bit over your head, but lots of good cases to help consolodate and better approach scene control / management, differential diagnoses, and treatment goals. Lots and lots of little clinical pearls scattered throughout.