medic001918

It's all relative to where you live, but starting EMT's here in the Hartford, CT area start somewhere around $14/hour and medics around $18/hr. I believe EMT pay tops out somewhere in the $16/hour range at the service I work for and medics top out somewhere around $22/hour. The area you live in is one of the major deciding factors due to cost of living. Shane NREMT-P

You are 100% correct that your protocol needs to be reevaluated. As a paramedic here if I were ever to downgrade a call like that I would be pulled into my medical directors office to have a chat about why I felt that was a BLS call and possibly undergoing further review or possibly having my medical control suspended. Interesting how protocols vary from area to area, but I would find those to be unacceptable and there's no way that I would allow myself to downgrade a call with a presentation like that. On to another part of your post. You say that she "never lost her airway." I don't know what you have been taught, but I have always been taught to assume a patient having a seizure to be hypoxic and to be without an airway. Maybe it's another case of preparing for the worst but I don't think so. Consider the pathophysiology of a grand mal seizure. You have the underlying increase in intracranial pressure and/or ischemia due to the event itself. This can cause lethal dysrythmia as well as respiratory changes. Now throw a seizure on top of this and you lose the ability to control your muscles. Being that we use muscles to assist with our respiration's by causing changes in intrathoracic pressures a seizing patient may not be able to ventilate (remember that ventilation and respiration are two different things) effectively. Now we get into where ALS comes into practice. While this patient may not need an advanced airway such as an ET tube, the patient needs to have their seizure controlled rapidly in order restore their respiratory status back to where it needs to be. So going on the premise that a seizing patient is hypoxic, how can your service (not you) justify letting that call go in BLS? Your patient seizes 5 minutes into a ten minute transport and is now status epilepticus secondary to the increasing intracranial pressure; according to my math that leaves approximately five minutes of having a questionable (at best) airway until you arrive at the ED? Now, that assumes that the patient has a continuous seizure. The patient may have a series of seizures which would still leave the same question? A paramedic can't do anything for the CVA itself. A paramedic can however maintain better control of some of the side effects that can and do occur with a patient experiencing an active CVA. Benanzo, I am not trying to give you a hard time. I'm just curious now as to how your service allows that kind of treatment to occur? It just strikes me as being care that is less than the standard. If you don't have ALS available, that's one thing. I have a hard time understanding how you can downgrade that call. And more so how a BLS provider is okay with that if they understand any part of the possibilities that can occur on this call? Shane NREMT-P

Paramedics don't have the monopoly on doing a thorough physical assessment. You're correct on that statement. However, from an education standpoint based on certification alone a paramedic is going to have a more in depth assessment. Medics have spent the time in school studying A&P, as well as being trained more specifically on disease processes. There are EMT's out there that can do an assessment as well (if not better) than some medics. Those however tend to be the exception rather than the rule and those are people who have made a goal out of seeking out more education. As the programs stand when compared side by side (EMT vs. Paramedic), a paramedic is going to be able to pull more out of an assessment. Now, on to the transport decision. You're correct that this patient does require a rapid transport to the hospital. And that could very well be your closest ALS provider. But would I want to risk simply transporting this patient BLS without asking if a medic was available? Not at all. If something were to happen and you hadn't requested a medic I could see a lawyer having fun in court with this case. If you don't request a medic and the patient does seize or end up with a respiratory compromise (both very real possibilities), you might get picked apart for not knowing where the closest medic is. It would be in your best legal interest, and the patients best health interests to call for a paramedic and at least attempt an intercept. If you miss the intercept and are at the hospital by the time you could make the connection then you've done yourself and the patient a great service. You have gotten them a higher level of care as quickly as possible. At least that way you are covered by having recognized the problem and attempting to request the proper resources. If those resources are unavailable it is not your fault and you transported expeditiously. Transporting BLS on a call you admit to be an ALS call without making the request just strikes me as not being in anyone's best interests. Part of being a paramedic is being ready for what "could happen." In a case like this, we might not have to make any major interventions. But the fact remains that if the patient should deteriorate (which can happen quickly), as an EMT you are limited as to what you can do to control the situation. As a paramedic, we can control the airway more effectively or control a seizure. And as a side note, I would rather put an IV in this patient when they're not having a major compromise so that should they need the intervention I'm not fighting for a point of IV access...it's already there. It's the same reason why seizure patients get IV's while they're postictal. It's safer for them to have the access and easier for me to do then as opposed to when they're seizing. Thinking ahead and anticipation is part of critical thinking. Shane NREMT-P

Where I work we have the option of using chemical sedation, but unfortunately your son would not meet the criteria for me to consider sedation for him. The scenario you presented gives paints a picture where we could not rule out a head injury or Multi-system trauma. In the field we can't say for sure that the way he is acting (aggressively) is not the result of a head injury. Unfortunately, physical restraint would be the option most commonly used. With that being said, we could always try to contact medical control and get an order to sedate him if we could obtain his history. If the docs are like the ones in my area, they probably aren't going to approve that order though. Now as for the treatment of him, he would be treated like any other patient. With regard to his mental status and his inability to communicate in a manner in which we can understand (by no fault of his own) I would treat this patient like a young child and base my assessment on what I can see and feel during a thorough exam. I would attempt to talk to him and explain to him what I'm doing in hopes that he might be able to understand at least part of what I'm saying and realize that I'm there to help him and not hurt him. One other thought would be the possibility of a medical alert chain/bracelet to let providers know that he is autistic? That could prove beneficial to us to help understand his actions and how we need to act in order to care for him most appropriately. Shane NREMT-P

With such a vague sceanrio, I'm going to question if it might be testicular torsion? If so, time is critical to get the patient to the hospital for surgical repair. Shane NREMT-P

Good job. Better way of putting it into words than I accomplished tonight. Shane NREMT-P

Don't beat yourself up over it. There were other people there to help you out. That's part of the reason we work in teams. Remember you're fairly new to the field and don't have a great deal of experience. No matter what, you're not going to know what to do in every situation. The more calls you run the more comfortable you become with different scenarios. Talk to your peers that you work with you and your medics to find out what you could have done differently. I'm sure they'll be more than happy to help you out and talk to you. Most of all, instead of beating yourself up; take something from the experience and learn from it. Remember, as a new EMT you only have a small foundation of which you are building upon. After some years of doing this, you'll have a larger foundation and a bigger house of knowledge. Go forth and learn. Shane NREMT-P

CHF is when the heart is not effective as a pump. One side of the heart may still be effective putting more blood back into the other side of the heart than the heart can effictively put out. This inability to pump is what causes the back up. For an example, think of a funnel. Only so much fluid can pass thru the small opening (the damaged side of the heart). So if you put more in, it eventually backs up and overflows the system. When the vasculature becomes overloaded, it will "third space" into the lungs (or systemic depending on the side of the heart). Left sided heart failure will commonly cause the pulmonary edema where right sided heart failure will commonly cause the systemic edema (pedal, etc). So in simple terms, CHF is the inability of heart to pump the vascular volume effectively. Sorry if it's not the clearest picture I'm just really tired at this point. Shane NREMT-P

Really? It's not their choice any more? So you're going to tell an alert and oriented patient what WILL be done against their wishes? That sounds like a less than smart decision if you ask me. An alert and oriented patient has the legal right to refuse any and all medical care...even if it will be life saving. Unfortunatly, unless they are a danger to themselves or someone else, you cannot force an unwanted treatment on this patient (provided they are 18 years of age or older). The mechanism may be there, the injury may be there. But if they don't want the treatment, they are allowed to sign off on it. Documentation is the key here and obtaining the proper signatures. Hopefully you meant this as if the patient said that we as providers could do whatever is needed and it was the decision of the crew to not immobilize to an LSB. If it's the patient's decision, I wouldn't violate their rights. Shane NREMT-P

Lead II is commonly used as a refrence lead since it shows a great deal about what's going on in the heart. Now, with that being said...there's more than just lead II. A complete view of the heart via 12-lead or modified 12-lead (if you have the capability) is in order for any patient you suspect to be having some form of cardiac event. You should try to view as many leads as possible to form a complete picture of the heart. Even if you can't obtain the complete 12-lead, the more information you have the more informed you are about your patients status. Don't just think in terms of one lead. Think of the complete picture. This applies not just to an EKG, but in overall patient care. Shane NREMT-P

We use capnography in my system and I use it often. We have it for intubated and non-intubated patients. I find it to be a far better indicator of ventilation than pulse oximetry. I look for wave forms to aid in seeing how effective my patient is breathing, as well as to determine a greater need for intubation since as the numbers rise, resp failure is immenent. It's great for trending. We're required on all intubated patients to use it as well. I'd like to see it used more frequently than it is though. It's a great tool. Shane NREMT-P

My service does not provide us with the bougie, however it is in our protocol. I managed to get my hands on my own bougie that I carry in my pocket while on duty and wouldn't go on a shift without it. Also, like Rid said, any additional airway class should be taken. I've taken the DAMS (Difficult Airway Management in the Streets) class and felt it was one of the best 16 hours of CME's I had ever taken. It was filled with great discussion, immense hands on skills and all of it was good practical knowledge from experienced providers. Well worth the time and money. Shane NREMT-P

If anyone should consider not taking themselves so seriously, it might be yourself. My guess would be that since you're still a student in EMS, you have MUCH to learn and that the vast majority of people here might have an idea as to what they're talking about. But using the combitube is NOT intubation. Actually, for paramedics the combitube is considered a "rescue" airway to be used when intubation fails. The fact that you can use a combitube but not truely understand how it functions, or the anatomy of the airway from your class is rather discouraging. You are going to be able to perform a skill that you don't really understand. The majority of being a good provider is to have an understanding of what you're doing, how it works and why you're doing it. I have a strong feeling that you lack at least one of those key pieces. Hopefully that will be corrected by the time you're on your own in the field. Shane FFI/NREMT-P

I voted that I typically work my patients in the ambulance. But I also feel the need to clarify and say that I do bring all of my gear into every call with me (bag, O2, monitor). If the patient needs immediate intervention, I'll start working in the house. But if the patient is stable, it's off to the truck where I can work in a more comfortable environment. While I know that you didn't want any "what if's," I felt that the answer needed some qualification since there are times that it's appropriate to work in the house, and other times in the truck. Shane FFI/NREMT-P

My understanding (and I might be wrong) is that at Boston EMS everyone starts a basic and you have to be promoted from within to being a paramedic. I'm not really sure why they do it like that, but it's what I have been told more than once about how they do things. I'm not sure that having your medic license will help you out if you want to get a job with them. The best way to get a 100% correct answer would be to call them and speak to human resources. Shane FFI/NREMT-P

You will never know how you will handle your first loss until it happens. Everyone handles it differently. And even after you've lost more than a few, there may still be the one call that bothers you. Sometimes you don't know why a certain call is bothersome to you. It just is. You'll learn who you can talk to when you don't feel good about something. Just know that you are there to help and that you did the best you could do. You also didn't put them in the situation that they ended up in. One thing that I'm curious about is what kind of prehospital experience you have? You said you're starting paramedic school, but you've never experienced a loss before? Have you ever worked a cardiac arrest? If you're prehospital experience is limited, I suggest spending some time working as a basic EMT. This will teach you how to deal with a lot of aspects of the job and see if it's truely for you. There is a high burnout rate within the field due to the built in stressors that the job has to offer. After working critical calls as a basic where you're not in charge of everything, you'll have a better understanding of what you need to do when you're a paramedic. The best paramedics are great EMT's. Good luck and feel free to ask more questions. Shane FFI/NREMT-P

I would definatly want to see a 12-lead on this patient. With the cheif complaint of SOB and a 12-lead that didn't show an infarct, I would most likely have gone ahead with NTG but ONLY if I had a patent IV in place. I would also want to know if they were orthopneic? Exertional SOB? Febrile? High flow O2, NTG (provided SBP>100mmHg), and lasix. Our protocols state to double the dose of lasix since he has not taken his daily dose. I don't think I would have gone that far, but I would have given whatever his dose would be. Again, this is all dependant on the 12-lead not showing any signs of an infarct and having a line in place. Start with the NTG and see how the BP does before giving lasix. I would have been kind of surprised to see that he was infarcting being an elderly male. It's not impossible for them to have the silent or atypical presentation, but they are the one's who typically present with crushing chest pain, pale/diaph, etc. I'm thinking this patient is in failure, not AMI. Shane