medic001918

The other thing I noticed is that in the second case presented, he feels the nurse was wrong for calling a trauma on an occupant of a vehicle that rolled over. While the patient may not have been injured, you can certainly make a case for a hospital calling a trauma alert for any patient involved in a roll over motor vehicle accident. I also wonder what kind of radio report the hosptial got on this patient. Did they accurately describe the roll over as low speed, self extricated (if that was the case), or was it simply a "roll over MVC?" Our wording when we notify a hospital has a great outcome on what will be ready for us when we come walking through the door. I'm not totally sure that the hospital was at fault for calling a trauma on that one. Quite possibly, the same problem could have contributed to the nurse's decision in the first case as well. Dust, I have to agree with your points about making us look poor to the hospital. While you may have disagreed with the decision the triage nurse made, there was far better ways to handle it. Why not explain why you think the patient needs a trauma room instead of throwing the protocol book in her face? Protocols are really just guidelines. There's not a single thing absolute in the entire book, and that includes trauma criteria. If you think a patient needs a certain level of care, advocate for it through your educated assessment, not by something that was read out of a book. Try to work well with those who work in the hospital. You can learn a great deal from them, and their respect can certainly be earned. I've seen it plenty of times in the hospitals we frequent. Certain people get taken seriously, where others are nothing more than a joke to the ED staff. It all has to do with your rapport with them, and past history. Chest thumping and belittling (such as stuffing a book in someone's face) does nothing and gets you nowhere. An educated conversation about your reason's for why the patient requires a certain level of care will go much further towards advocacy for your patient, and respect to you as a provider from the receiving facility. As far as costing a patient money before they get to the hosptial, guess what? It's not really my concern. That's something he can sort out later in life. I would prefer to see a hospital be more aggressive than needed than not be aggressive enough and miss something. When I'm treating a patient and making decisions, the last thing on my mind is the end cost to the patient. My concern is their care. The hospitals concern is their care. Most facilities don't enjoy misusing resources when they're not needed, but erring on the side of caution is far better than not and having it come back to haunt you (as one of the hosptials in our area learned). Don't fault the hospital for ensuring an adequate assessment and treatment promptly for a questionable trauma. You're not paying the bill in the end anyway. Shane NREMT-P

Shane NREMT-P

The apology has been offered and accpeted, so it's a dropped issue. Hopefully the thread will resume the productive nature that was intended... Shane NREMT-P

I'd still like to see mrmeaners answer to how he justifies what he said. Since it wasn't him that removed the content; an answer to the question or an apology is still owed in my humble opinion. Shane NREMT-P

My personal feelings aside, I have to point this out. You blast him for being insulting and for devaluing the forum, and two sentences later you throw your own insult out there. Way to lead by example. Maybe you're part of the very problem you pointed out? Until you can lead by example, you have no business telling someone else they devalue this forum. Shane NREMT-P

A high voltage QRS complex can indicate ventricular hypertrophy commonly. Shane NREMT-P

20 mg Etomidate. Shane NREMT-P

My thoughts exactly. I've been in a deep sleep and hard to wake up. And sometimes when I get up, I'm a little off balance or don't move that quick due to old injuries and such. Doesn't really sound like he had any problem...other than being tired. I don't think you missed anything. Not every patient that has 911 called for them has a problem. Shane NREMT-P

Oh how nothing could be farther from the truth. One big reason that service's continue to be rendered by volunteer's is because volunteer's continue to give the service's for free. The expression "why pay for the cow when I can get the milk for free" comes to mind. Nobody is in a position to have to pay for services when they're being provided happily at no expense. The people of your community get upset at any kind of tax increase, and so far it's working to keep things status quo. Get rid of the volunteer services and then you'll see them in a position where they have to put into place some form of system. I'll be they don't go long without services. It might last until the first important town member needs them and can't get them quickly. Then things would certainly change. You said it's a small community, so my guess is that there are other small communities in your area facing the very same problem. Rather then having each town figure out to provide for their low call volume town, they group together with other towns and make a regional or county response. This lessons the burden to any one town, while still ensuring a paid response in a timely manner. With proper management, this is possible without question. I'm sure you could all pull your call histories and see where your busy spots are and figure out strategic location of units. This makes the financial burden spead among more tax payers, allowing each to pay less. Also, I'd be curious about what their homeowner's insurance rates would be with paid services. I know that when I bought my house and got the insurance for it, they were very interested in knowing how far I was from the nearest "manned fire station" and the nearest "functional fire hydrant." I was actually given a cheaper rate based on my proximity to both of those. So while their tax payment goes up, their insurance payments could go down helping to offset the cost of the paid services. To get paid services in any area when they are switched from volunteer is a matter of sales. You have to sell the townspeople on why it's a better idea. And that comes from being able to educate others about the benefits of why having a paid department is worth the extra money. When you're looking at insurnace for your property, self, etc; do you not shop to see what the benefits are of different providers? And make your decision not just based on the bottom line per month, but the services avialable to you? The same methodology can apply here. You have to sell the customer on why it's a good idea. It's not an easy task to accomplish, but not impossible. And if you all stopped volunteering, they really would have no option. Shane NREMT-P

I just read through this topic. While the pay could certainly improve, I think most people want to make more money regardless of their occupation. The key for us improving comes with education and responsibility with regard to our profession. The profession needs to continue to move forward, not remain stagnant or even taking steps backwards. I'm able to make a decent living as a medic. My base salary is somewhere around $50,000-$55,000 a year plus benefits. I work a 36 hour work week one week, and a 48 hour week the next (all 12 hour tours). It allows me time off. Or it allows me the chance to pad my income more by pulling an extra tour every now and then if I want. As for StickEm...your loss for leaving bro. But that's on you. You should do some research on ACLS. If you think that course prepares you for patient care, you're sadly mistaken. Someone already explained it. It's a review of knowledge you should already have obtained prior to taking the class. It's not really a class that teaches you anything. And it certainly doesn't "certify" you to perform any skills or interventions. I question why your service would offer a $5,000 a year pay increase for the course. It's a great deal for the employee's to take advantage of, but does nothing for your patients. You can't analyze rythems or use a cardiac monitor without having that card is what you said. That's great, EMT-B's and I's shouldn't be analyzing or using a cardiac monitor unless it's an AED. And for that, you certainly don't need ACLS. If they're going to require ACLS, do they require PALS for kids? Seems like a lop-sided system to offer incentive for one and not the other. As far as chest pain and shortness of breath calls, the only way an EMT-B or I should be on those calls is if they're there with a paramedic. And if they have a medic there, the certification cards they carry don't really amount to much. If you want the incentive's, go to paramedic school. My guess is that the more you learn, and the more you realize you don't know...your views might change on what level's of providers are doing what. Shane NREMT-P

Definatly some sound advice there. If the hospital is your goal, then go get the proper education to do a hospital job such as being an RN. Most hospital's limit what a medic can do in the ER anyway. You're a tech who can start an IV. Your skills can often times be "lost" while working in an ER. You will stay current on knowledge, and might pick up a few other skills along the way. But paramedics focus on prehospital, nurses focus in hospital. Two different jobs. As to which one, if you have a financial responsibility the one with less expenses that pays more is where it's at. That's not even a question. As far as getting more calls, or better calls at the other service, the calls will generally be the same (with some exceptions)...it's the same dynamic that generally calls 911. It's just the frequency that it's called. A slower system tends to run fewer trucks than a higher volume system. Maybe take a look at calls per truck that's online? You might be surprised to find that you could do more calls working for a slower system depending on system status management. Shane NREMT-P Shane

Happens all the time. Just like you have an obligation to cover your bases, so does the hospital. If it sounded to them like it was a trauma activation, then let them activate it. It also depends on local protocol. We have a trauma guideline in our regional protocols. Just like EMS can request an activation from the hospital, the hospital can activate one on their own if they feel the mechanism warrants it. I know I've had some less than impressive calls get activated, and some really impressive one's not end up activated. It depends on the hospital, and who's on. It's not my place to get involved with hospital policy. My job is treatment and transport to a higher level of care. What they do from that point is on them. Obviously, if the patient really should end up in a trauma room and doesn't...I have to speak up and request that things happen. Also, being that they are only a Level III trauma center, they may activate more questionable MOI's to evaluate the need for a higher level of care. Not all prehospital providers are great at determining appropriate facilities. In fact, most aren't. The hospital is covering their liability. There shouldn't be a trauma activation charge as you describe. The patient should be charged for actual treatment's only. In many trauma's that I've done, the same treatment's end up being done that would be done anyway; they just happen faster. A needless charge is patient's that get flown when they shouldn't. But that's a separate issue. Flying a patient is based on presentation, mechanism of injury and proximity to an appropriate receiving facility. Nothing else. It's NOT based on what the local hospital is going to charge the patient for a service. If they need a level I trauma center, they get one. It doesn't matter if it's by air or ground. Cost to the patient doesn't come into play in my decisions. Appropriate treatment does. If the patient gets charged too much for something or charged for something they didn't need then it's up to them to get it straightened out. Shane NREMT-P

Many others have answered your questions already. But I hope this is either a typo, or the first thing you corrected on scene? A mask at 6 LPM is not acceptable and can cause other problems. And what is "1/10=2/3" Is that a 1-3 on a ten scale? Just trying to get a complete picture of this call. Shane

Pull the tube. Ventilate and reintubate. My first thought was that the patient may have been distended from when they were most likely bagging the patient upon arrival. But the end tidal reading can be a false positive if the patient has had anything to drink that's carbonated (such as soda or beer). For a patient that was in v-fib, I would have expected the end tidal value to be higher. I'm also curious as to why the fire medic waited to initiate capnography. An NG tube is definatly in order for this patient to try to relieve some of the distention in the abdomen as well. That will help to gain better compliance when a tube is inserted correctly. Shane NREMT-P

Actually, you're wrong. Once you're dispatched to any call, regardless of priority you are committed to that call until rerouted by dispatch. If you don't continue to the call, you have abandoned your patient...even though it may be a low priority patient. Shane NREMT-P

I have to agree with you Ruff. There is no defense for driving a blood tube with lights and sirens. It doesn't matter if it's to get out onto the road, or all the way to the hospital. There is nothing that critical about that blood tube making it to the testing location that additional risk needs to be brought onto the crew and the general public. I'd be willing to bet that while the state said "ok" to this practice, they would not be willing to back that up in court. The difference between your ambulance (especially with lights and sirens) and a courier is that a courier is not going to be running lights and sirens, so there is not that contributing factor to the crash. It becomes a simple traffic accident at that point that the police can investigate. Just as an FYI, more often than not when running lights and sirens and involved in a collision, the emergency vehicle is automatically considered to be "at fault" until proven otherwise. It's that whole "due regard" clause in the wording of the law in many states. If I recall correctly, there's a 70% greater chance of being involved in an accident while using lights and sirens as well. Is it worth delaying the transport of a blood tube by the time of a collision to run lights and sirens? I'm thinking not. A casual ride to the facility would do just fine. You mentioned organ transplant teams, while they certainly should not be driving out of control their task is much more time critical than a blood tube for testing. They are often working within a specified window of opportunity that they have to meet. It's a bit more appropriate for them to use those lights and sirens. Now having worked urban EMS for a while, I can tell you that quite often lights and sirens don't save a great deal of time when transporting. This goes for transporting patients or objects. It's merely a courtesy. At least with someone in the back of your ambulance, you'll have an easier time justifying their use. Earlier you said that a needlestick is considered a "life threatening injury." May I ask why it's considered such? There's no immediate life threat from it. They can start the medications and wait for results of the testing. If a needle stick were "life threatening" (and enough of a threat to warrant lights and sirens), all hospitals would more than likely be required to have the rapid testing on site. And a final question, does the hospital request emergent transport for a patient's critical tests? Or is it simply in the place of an employee of your service getting stuck? Shane NREMT-P

Well stated. Couldn't agree more. And Kat, be thankful that they test for Hep in the blood work. Your vaccination covers only one (commonly the Hep B vaccine) type of Hep. I've gotten the Hep A & B vaccine's. But there are still multiple other strains of Hepatitis. They don't have vaccine's for every type of Hep there is. Be thankful they test for it. They just go about handling it in the wrong manner. Shane

And guess what, in this case your boss was right!!! You have a patient in the back of your ambulance that you're transporting. It doesn't matter if you're going to dialysis or the ED. You have a patient, you're not in service at the time. You're committed to your assigned call. You should have gotten chewed for stopping. You also said that another service had been dispatched, was this call in your primary service area? All things to consider. As much as it sucks driving by someone with injuries, you have an obligation to complete the call you're on before getting involved in another one. So now you would have been willing to transport this child the ED if I'm reading correctly? What do you do with your dialysis patient while completing the transfer of care and paperwork for the patient you decided to transport while already transporting one to a completely different facility? The patient that you were initially commited to, along with the receiving facility have to bear the burden of your decision to stop to help another patient. There are schedules that dialysis centers try to adhere to as best they can. Having a patient showing up late by the time it takes to complete a call is not needed. Any dispatcher should be managing resources to keep a unit available for a call. Someone else earlier in the thread mentioned that everyone can wait their time for an ambulance to respond. I don't disagree. Once you have a patient in your ambulance that you're transporting, you're commited. This is different from a scene with multiple patients that you are dispatched to and arrive to. You've already determined the resources for your patient, and you need to complete your call. Shane NREMT-P

Thanks for addressing the question about your experience and the comments about your blind accusations about other people's experience on this forum. You've attacked our experience (or percieved lack of it) and have not outlined anything with regard to yours other than to say you don't have experience with an active shooter scene. While you might not have a lot of experience with shooting scene's, there are those people here who do have experience with them. These guy's did nothing to "secure the scene." They went to cover and retreated to safety. Congratulations to them...for doing their job. They still endangered a pediatric patient and their family needlessly. So I'll say that takes away their congratulations and makes them square with the house at best. I'd say even negative for needlessly endangering a patient...first by stopping, second by exposing the patient to an unknown situation that happened to turn violent. Exiting the bus and finding better coverage, absolutely. Having to worry about my patient from another call, absolutely not. They would have gotten another ambulance dispatched to the scene. My obligation still lies to my patient that I'm already transporting. Shane NREMT-P

You don't think many of us know what it's like to operate in an urban EMS service? I think you're greatly mistaken there. While we don't openly post our resume's for review, there are many urban and suburban providers on this forum. There are professional's that do this for a career, and there are volunteer's. But, just for the record I do work for a rather busy city service (city=urban) and I have experience working for another large city (city again=urban). FDNY is not the ultimate in EMS care. There will always be a better service somewhere, no matter how good your service is. Who's life was saved? The shooter died, and from the article noone else involved was transported. What did happen, is that the nine month old and their family that was being transported as well got delayed care and placed into an immediately dangerous situation. So dangerous that they were required to retreat to a deli for safety. A pediatric patient that has had a seizure is not a "stable" patient and is deserving of medical care without delay. There's no way that care was not delayed when they had to run for cover. While noone could have known the driver of the vehicle was going to pull a gun, any call we respond to is an unknown and no patient should be placed into that unknown while they are experiencing a medical emergency. Be careful making false accusations regarding the experience of members of this forum. There's a vast wealth of knowledge here. If you sit back and read, you just might get an idea of the experience of many reguarly contributing members. Just out of curosity since you've weighed in an opinion, what is your level of training and experience? Maybe you don't have the experience to comment either. Shane NREMT-P

On the surface, it sounds like pneumonia to me as well. In that case, the combivent is not the best choice of nebulized meds that we can give to these patients due to the anticholinergic effect of atrovent. From the picture you presented, I'm not sure that CPAP would have been the ideal treatment either, but I wasn't there to see just what kind of distress she was in. The best thing for pneumonia patient's (and in the case of COPD it's not detrimental) is fluids. A simple albuterol neb will sometime's cause them cough hard enough to actually bring up the phlegm and let you see what's going on. I don't think you did anything wrong. The only thing that you did that I'm not totally sure that I would have done was the solumedrol. But this also depends too on if the patient has a fever. That's a telling sign quite often of another etiology. Shane NREMT-P

The exacty policy at the services that I work for is the same at both, and this has already been discussed in this topic previously. Once you're dispatched to a call, you're duty to act has been activated. You are committed to that call until it's conclusion regardless of what else is going on. The only way you can get pulled off of a call is if it's before patient contact. Dispatch can reassign you to another call. However, once patient contact has been initiated you are now 100% committed. If you come across another incident, you call it in and proceed to the hospital. You do NOT stop. That is negligent of your existing patient and opens you up to much litigation. The family would have no problem winning that one in court if you stopped while en route to the hospital. Especially in a scenario such as this one where the ambulance was fired upon after stopping, placing the crew, patient and family in unneeded danger. If you come across an incident while transporting and you don't at least call it in. You are being negligent. Once you call it in and requested additional resources you have fulfilled your duty to act to the patient involved in that scene. You have done what you can do, and should do. More resources will be coming along, and your patient that you already have is still receiving care in a time effective manner. As to needing more information on this scenario, we really don't need any more information. The article clearly states that they had a nine month old seizure patient in the back of the truck when they stopped. They had to evacuate themselves, the family and the patient from the truck after stopping. Had they not stopped and proceeded to the hosptial, this never would have had to occur. Stopping is not the best option in this case. And that is a policy based answer at my current service's that I work for, as well as for any other service I have ever worked for. Shane NREMT-P

This entire thread sums exactly why you shouldn't be stopping. No need to rehash what's already been explained repeatedly. There are many people who have explained their rationale for feeling this way on the call. Shane NREMT-P

I think that sums it up. You shouldn't be stopping. Regardless of weather someone stays with the patient you're transporting, you're now committed to that scene you stopped at since you've started to render care. You've delayed transport to definitive care. And you've provided less than the acceptable standard for a transporting ambulance since you have only one set of hands available and a patient already in the back of your ambulance from another call. Again, the right answer is not to stop. You're committed to a call from the time you're dispatched until the conclusion. You cannot get yourself involved in another call while you're on one. That's abandonment and negligence. You would have zero legal defense if you were to do this. Notify dispatch and continue to the destination hospital. There really isn't another answer that works. Shane NREMT-P

You are kidding right? There really are no other facts needed in this case. You have a patient in the back of your ambulance that is being transported to the hospital. You are committed to that call. The best thing you can do is to call for another unit and continue transport. I don't think anyone is disputing that there was a patient being transported and that's really the only pertinent fact to this case. As much as this scenario sucks, I would notify dispatch and request additional support. Notify a supervisor of the incident. However, stopping is not a viable option due to the duty to act incurred by having a patient in the back of my ambulance that's being transported. However, by requesting resources I have fulfilled my duty to the struck patient. It's a difficult thing to do, but stopping is NOT the right answer. Shane NREMT-P