medic001918

It's possible that she pulled muscle or had some other physical ailment from the fact that she was engaged in a physical activity that she is not used to participating in. Ever talk to someone who has just started an excercise program and hit the gym (or other activity) to hard? These people will often complain of chest pain, shortness of breath and other aches and pains. I know when I used to run and I had just started, I'd have pain in the middle of my chest that was sharp and stabbing that had nothing to do with my heart. It is the time of year for people to be getting sick. The additional physical exertion can bring on many manifestations of the common coughs and colds that we generally wouldn't see on a day to day basis. My guess is that this patient was not having a cardiac event occuring, but some other physical condition. While it's not wrong to treat this patient for ACS, I'm thinking from what you've posted that I would have gone the routine ALS route at best. It's always advisable to go on the side of caution, but at the same time you don't always have to find a major cause of an event. Sometimes it's smaller things that look something major. Good luck, Shane NREMT-P

I'm glad we were able to clear that up as well. It's something that we'll most likely not see in the field, it's more an interesting little fact about a drug we carry and a demonstration that we can all always learn something. Good luck, Shane NREMT-P

See, I wasn't totally crazy when I mentioned this today. It's amazing who lurks on the boards. I couldn't remember the proper spelling to look it up today. Here's some information from http://adam.about.com/encyclopedia/001085.htm on paraquat lung: "Severe ingestion of Paraquat can rapidly cause death from respiratory failure due to a form of proliferative alveolitis, or inflammation of the air spaces in the lungs. This impairs oxygen transport to the blood and may lead to acute respiratory distress syndrome (ARDS). Administering oxygen to improve the blood oxygen level may actually increase the damage to the lung in such cases of ARDS. Chronic exposure to Paraquat, may cause pulmonary fibrosis, or a stiffening of the lung tissue." And taken from http://www.ijnephrol.com/aprjune2003/23.htm "As oxygen potentiates paraquat lung toxicity, supplemental oxygen should not be given as an initial measure. Oxygen is recommended only if FIO2 falls below 50 14. Recently there has been some interest in using nitric oxide to treat paraquat-poisoning 15. Paraquat specific IgG antibodies and their Fab fragments are effective but the “window of opportunity” is very short, only a few hours at the most 16. Lung transplantation has been performed in a few patients 17. The mortality of paraquat poisoning remains high. Multi-organ failure with circulatory collapse is associated with 100% mortality, early in the course of disease while late pulmonary fibrosis with respiratory failure also remains an important cause of mortality 7, 10, 18. The survival rate in our study is 41%. On comparing the different variables amongst survivors and non-survivors, the severity of poisoning, late referral to hospital and multi organ system failure showed increased mortality." And taken right out of Idaho's BLS guidelines http://www.healthandwelfare.idaho.gov/_Rai...dult_oxygen.pdf And finally another MD written document at http://www.prn2.usm.my/mainsite/bulletin/sun/1997/sun13.html "Prevention of pulmonary damage Paraquat is known to accumulate selectively in lung tissues and destruction of the tissues is exacerbated by the administration of oxygen. Thus it is suggested that the minimal oxygen is given to the patient to reduce the damage caused by the oxygen." Some reading for you. Enjoy. Shane NREMT-P

I still don't agree with the idea of having a medic performing care regardless of training in the hot zone. You talk about having an airway controlled early in the case of an event, but how well is the airway being controlled when that patient is being extricated from the hot zone? and what's better, delaying extrication to try to perform in the hot zone? Or simply removing the patient and trying to remove the patient from the environment? In my experience it's better to remove the patient then begin treatment. While knowing all of the officers medical history and medications is great, that's not too impossible of an issue to overcome. Each officer carries an information sheet somewhere on their body that the officer in charge can relay the location of that information to any responding units. And if the officer is in that bad of shape, they'll be treated as "unknown meds, history and allergies," just as they would if you respnded to any other call with limited information. I'm still going with the fact that a tactical medic has little to no real benefit in a life fire situation. Should there be medics on stand by? Yes. Should they be in the hot zone trying to perform patient care? Absolutely not. The only thing that's going to lead to is having two patients instead of one since your situational awareness is going to be decreased trying to focus on patient care. You're not going to be looking at this guys airway and still be aware of who's aroud you doing what. The best means of safety for this patient is rapid egress from the hot zone for stabilization. Given your belief that paramedics should be part of a swat entry team so that care can be initiated early in the event of injury, does that mean that a paramedic who's a firefighter should be inside of a burning building or a hazardous environment (again in the hot zone) to initiate care to the sick or injured? Standard practice is to remove the victim from the danger zone and bring them to a safe point prior to initating care. Maybe we could actually take something from that protocol that is widely used and accepted. Shane NREMT-P

The problem with your scenario is that if the first officer does go down and there is active shooting, in the hot zone is not the place to begin any kind of treatment. The best treatment that could be provided would be to remove the officer from the situation. That is a scenario that the SWAT team should be trained to deal with, and not one that requires any kind of medical intervention in the hot zone. As for your extended standby situation and keeping the team healthy and alert, this is something that again should be being done outside of the hot zone. There's really a minimal need, if any ever for a medic to be in the hot zone. The injured need extraction prior to treatment, not the other way around. Trying to treat while in the hot zone only adds to the potential for more injured responders. Extract and then begin treatment. That's the safest way to get out of the situation with the minimum number of injured/dead. Keep in mind that these are the opinions of just your normal street medic that works in a busy inner city. I've had the opportunity to do police standby's for situations similar, and not once has it been mentioned or asked that a paramedic enter the hot zone. And this includes responses to the officer down (one of which was killed in the line of duty). Shane NREMT-P

And the lack of professionalism that your posts demonstrate is exactly how others will form opinions of you. If you take the time to construct your posts as you would speak to a colleague in the same profession as yourself, you will find that you are received in a much warmer manner. While you're only "posting" here, you are among your peers and colleagues. Speak (or in this case write) in a manner that reflects your intelligence. This attitude that you've already demonstrated about wanting to do it your "own way" isn't really the best way to start off. Imagine starting with that very same attitude when you're working with a new partner for the first time? Treat us as colleagues. Welcome to the city. Shane NREMT-P

First of all, I'm sorry to hear about your call. That's a really bad call and unfortunately, one that many of us can relate to at least in some form. It's amazing how as hardened as we become to many calls, that there are still those calls which impact us so greatly. Hopefully in time you'll come to terms with that whole call and everything that happened. As for your comment about your authority to practice coming from a medical director, you are 100% right about that. However, if a paramedic is on scene they become responsible for managing patient care. This includes directing the other providers on the scene to accomplish tasks. Your medical director sets forth the protocols for what you are allowed to do, the paramedic on scene (if you're working with one) is responsible for making sure it gets done and when it gets done. There is a difference between the two. When you're working with a basic, you're following their protocols and procedures. When you're working with a paramedic, they follow their protocols and procedures; up to and including managing patient care. All of that being said, if you want to do something within your protocols that goes against what the medic on scene wants; who do you think is going to have the final decision? The final word of what you're allowed to do is decided by your medical director, but when working with a paramedic the final word on what and when things happen is decided by the paramedic on scene. Working paramedic/basic truck is vastly different from working a basic/basic truck. Good luck, Shane NREMT-P

Just for some clarification, not all states have "licensed" EMT's. In Connecticut, paramedics are the only one's that are licensed. An EMT holds nothing more than a certification. The standards to which they are held is vastly different, along with the responsibilities. Should something go wrong on a call, yes it should be a shared responsibility. Unfortunately, the first person they are going to contact and ask questions to is the paramedic (I know this from experience). I have done calls that have required further questioning, and my EMT partner was never even made aware that there was an inquiry into the call. How's that for a shared experience? But either way, you're right, it should be shared. Unfortunately, this is not a perfect world and that's not how it always works. As far as my feelings on the medic/basic relationship, it's one that is sometimes handled delicately and other times not so delicately depending on the situation. I am okay with my partner doing things such as an assessment or skills within their scope of practice. However, one thing that I ask for is the courtesy that you talk to me about wanting to do some of these things (like assessment) before we get to a call. I have no problem letting someone do something if I know you're going to do it. That way I can allow you the courtesy and respect of performing the task. What I don't like is when someone interrupts my assessment trying to ask questions of their own or even worse, something that I've already asked. Chances are that if I'm in the middle of my assessment, I'm going somewhere with it. I won't interrupt your assessment if you don't interupt mine. I had to have words with someone after a call one night after being told that I was "stepping on their toes" because I stepped up and directed things to get done on a BLS call. As a paramedic working with basics, I have an obligation to make sure that things flow smoothly and the job gets done. If noone else is going to get things done, and noone has voiced a desire to take initiative; then guess who's going to do it? That's right, me as a paramedic. I think the biggest breakdown in the paramedic and basic relationship starts with communication. People don't communicate their intentions and desires well enough until their in the middle of a situation, and then only after someone already has taken issue with something. If more people would talk about how calls should be run when working together before getting to a call and seeing how things go, there would be less discontent. As a paramedic, I find myself educating my partners frequently. It's part of my job as a paramedic. It's not just to provide patient care, but to help others further their careers and knowledge levels as well. My full time position is as a paramedic that works with a volunteer service. This requires me to be more "political" (for lack of a better word) in how I handle issues that arise on my shifts so that people still want to ride with the service. It becomes more of a constant state of education rather than discipline or discouragement. On that note, I also take the initative when riding with someone new of talking to them at the start of the shift about what I expect out of them, and what they can expect out of me. It's in these intital conversations that things get outlined. These things can range from when it's okay to question something about a call to my willingness to cover any kind of material that they request (I'm currently reviewing A&P with one of the members currently in paramedic school at his request and it seems like it could turn into a regular review with more of the membership). By opening the communications early, they are not afraid to talk to me about calls, ask questions or perform their required skills. The biggest breakdown is communications. Once we all work on that issue (from the medic and basic side), many services would find a better working relationship between levels. My partner is there to perform a job, and to assist me in my job expectations; just as I am there to assist them. Let's all work with each other so that we can all benefit. Shane NREMT-P

Strong writing. It's nice to reflect back on your experiences while in ride time for medic school. You seem to have a good grasp of many medical concepts. From what I've read here, it seems better than many medic students that I've had ride with me. Should you have any questions, feel free to contact me or talk to me at one of the hospitals you see me at. Shane NREMT-P

Absolutely continue to post and educate doc. Your threads are often insightful and accurate. We can all learn something from each other. Shane NREMT-P

Here we go again with BLS providers being able to perform intubation and other ALS interventions. Hasn't this topic been beat to death enough on these forums? Services that want to provide ALS interventions should employ ALS providers. No short cuts. Shane NREMT-P

An exceptional EMT is one that has a decent working knowledge of anatomy and physiology so that they can actually understand what their assessment is telling them. Unfortunately, the EMT-B program lacks in this area significantly so what people are coming out of the class with is not sufficient to meet the demands. My advice to those that want to be a great EMT is to go take an anatomy and physiology course at your local college. When you can talk anatomy and physiology, you can talk the universal language of medicine. Shane NREMT-P

Our protocol for handling a patient that has been tased is that the probes are not to be removed by EMS and are to be treated as impaled objects. Also any patient that gets tased, is automatically an ALS patient. One service I work for has had two patient code after being tased. These situations are not overly common and often related to a predisposed heart condition. As far as the issues of knowing of a patients heart conditions before being tased by the police, it beats the alternative which often times could be the use of the officer's firearm. The tasers that the PD's carry in my service areas can be activated as long as the probes are connected. They don't delived a stepped down voltage or anything similar. Shane NREMT-P

It sounds from the end of your post (where you refer to walking away or waiting) that you already feel that your relationship is doomed. You didn't put a positive part into your statement such as that things could actually work out. While maintaining a relationship and a career in EMS may be difficult, it's not impossible. Depending on what shifts your service offers, it's possible to lead a rather normal lifestyle. If you tend to bring the emotions from work home with you, that's another issue to be addressed seperately. It's up to both of you if you can commit to the relationship and make it work. While it will be difficult, it is not impossible. Any job, no matter what is, will bring any kind of stress to a relationship. There's no job that comes without stress on a personal life. Noone but you and your girlfriend can answer if you should continue with your relationship or walk away. Those are decisions that can only be made by yourselves, and should only be made by yourselves. Shane NREMT-P

That's not entirely true. You simply have to show that the money you are making is being put back into the service. One of the city services I work for is considered a not for profit LLC and they certainly bill for every transport that we do. This billing is what has allowed us obtain new trucks, equipment and building renovations. There is a limit that you can have in the bank after all of your expenses (money returned to the service, operation expenses, salary, etc). The concept of a not for profit business is that they are not trying to line an owner (or board member's) pockets with money; not that they are not allowed to make money to cover expenses. Check your local laws for the details and guidelines of a not for profit organization. Shane NREMT-P

Given the sceanrio you posed, I wouldn't have gone to the drug bag to fix this problem. The medications he has taken have Beta one and two effects driving the heart rate up. A fluid challenge wouldn't be wrong, but doesn't really treat the underlying issue. Supportive care in this case is exactly how I would have handled the call. Shane NREMT-P

There's some good advice on how to interact with the staff where you're working. And noone says that you should have to buy lunch or do "extra" chores. But as a guest of our service, there's no reason why a motivated student shouldn't be involved in whatever we're doing as a group. As a guest in the "house" for the day, the student can help us maintain the place. It's respectful and curteous. Shane NREMT-P

From no BP to a BP of 78 and there was another post that stated the patients mentation had improved as well. Well the thinking of a beta blocker overdose isn't bad, and the treatment for such is correct by using glucagon I'm not sure that it would be the best choice for this sceanrio. Think of simple interventions working your way towards more advanced. You have something that's working in this case. I would stick with it as the patient is climbing his way out of the immediate danger zone. Shane NREMT-P

Are you sure you want to do that when the patient's responding rather well to a fluid challenge? His BP has increased and his mentation has improved. There's nothing to confirm that this is a beta blocker overdose. I wouldn't rush into trying to give a medication to counteract any kind of overdose after we've found a treatmen modality that is creating a positive effect for the patient. Shane NREMT-P

I think the patient has a combination of things that could be going on with them. A medication interaction is one like has been already stated (including the alcohol use), a volume depletion for some reason (any recent sickness or poor intake?) But the reason that I stuck with treating the hypotension with fluids rather than the rate is that a rate in the high 40's isn't excessively low for a patient on a beta blocker. Most patients that I come across on beta blockers have a rate of 50-60 that can often mask any signs or symptoms of dehydration or volume depletion due to the medication not allowing for the body to compensate. Also, I prefer to start least invasive and continue to more advanced interventions after others have failed unless an immediate need exists. We need to establish an IV on this patient anyway, so why not start with a fluid bolus? Since the patients blood pressure improved along with his mentation and general appearance, the intervention is working. Continue with a fluid bolus to 500cc and then KVO the line, continuing supportive care and reassessment to the hospital. I would also start to question the patient more about the event since maybe he'll offer you some piece of information that the family wouldn't. I would be curious to see what this patients orthostatic v/s would have been if we could have performed the test on scene. That's an often telling indicator of what could be going on with your patient. And becksdad, you're welcome to play in the ALS forum any time. We're all working in the same field and if you can pull some useful information out of the ALS forum, by all means do so. You did a fine job with this scenario. Shane NREMT-P

I have to agree with Rid here. The patient certainly has the right to refuse care as long as he is aware and able to understand the consequences of those actions, including death. This is a call that I would like to see medical control assist in trying to convince the patient to go to the hospital, and one that would need every attention paid to details in the refusal (not that we don't already do that anyway, right?). I'm agreeing with becksdad as well, that these delayed s/sx are highly indicative of a head injury and are concerning. I'm going with subdural hemmorage for this patient since the signs and symptoms are delayed. Shane NREMT-P

If we can now obtain a BP, things are improving. Has his rate changed at all? As long as lungs are still clear, let's continue with fluid replacement. Shane NREMT-P

I'd treat this patient with supportive care (IV, O2, Monitor) and prompt transport to the hospital. We already know the 12 lead is unremarkable. Let's not forget that his beta blockers may be holding his rate down and causing the inability for the nervous system to compensate for any kind of fluid/cardiac deficity with a rate correction. Although a rate of 48 is a little lower than what is commonly seen with beta blockers, I can't say that I'd jump right into treating the rate. For a benchmark, I'm 27 and my last EKG (done this summer) was sinus brady at 48; and I have no cardiac history. It doesn't mean that it's not a rate issue, but I'm guessing that's not the major issue with this patient. Fluid replacement would be first up followed by possibly an attempt at pacing. Is it possible that he got his meds confused and has taken too much of his beta blockers as well? At which point Glucagon IV would be indicated. There are a number of possible causes for the change in mental status. Shane NREMT-P

I use them at one of the services I work for and we're working on getting them at the other one. I have used it with success and feel that it's a great tool to have prehospitally. Like any other intervention, we have to become educated on not just when to do something, but when not to do it as well. Not every patient that you can't obtain IV access on requires an IO. Once you get people to understand that and be aware of it in their decision making, the tool should be on the trucks. Shane NREMT-P

An MCI falls under an entirely different set of circumstances than the routine 911 call. So the rules don't apply. I wouldn't work the shift. I'm trained as a paramedic and employed as one, that makes me expected to perform as one. Shane NREMT-P