HERBIE1

I find it ironic that an astrophysicist- a guy who deals with incredibly complex concepts- can reduce difficult things to a very manageable level. Pretty profound. Reminds me of that Asian physicist on A&E or the History channel who takes science fiction concepts- like teleportation, warp drive, etc- and tries to make them plausible. It's one thing to work with these difficult ideas, but it takes a real gift to be able to break them down to a level consumable by the average person.

Sounds like you have a plan, Bieber, and that's the first step. As you have already realized, the best laid plans... It's good that you are flexible- you never know what curves life can throw at you that try to derail all your best intentions. Roll with those curves and adapt, and if things don't quite work out- time wise or course wise, do not beat yourself up over it. Good luck, and keep your options open. Something may come along that you never even considered before and it may take you in a whole new direction. As long as you are happy and doing what you want(or at least heading in that direction), it's all golden.

Not sure what's up with the website, but I tried to Google info on it and the site would not load. Just FYI...

Funny stuff.. LMAO

Kudos for your longevity in the business and the marriage. Both are amazing feats in this day. 40 years in EMS? Wow, and I thought I was an old timer at 30+... LOL Well, dating a subordinate(temporary as a student, or as a supervisor) is a slippery slope- logistically, ethically, and morally. I'm sure we all know of horror stories as well as good outcomes there. As a preceptor, of all the students I had, I honestly can say there has only been a couple I was ever even remotely attracted to. Problem is, I was already almost old enough to be their fathers, which would have made me a dirty old man anyway... LOL I also agree about this thread, Dwayne- it's quality, not quantity. You don't necessarily need 10 pages of posts to get some great information and perspectives. I've seen some great advice about a very difficult subject.

I think this is a matter of CYA. Nobody likes to be the one left hanging in the breeze for making a judgment call, but as you note, what does someone need to do to ensure their final wishes are respected? I wonder on what grounds this person thought the wishes were not properly documented? If you parse hard enough, I'm sure anyone could dissect a DNR or other Advanced Directive to bring some doubt into the mix. Sounds to me like someone got lawyered up and is making sure the hospital does not incur any liability here.

There is no way that things like this are black and white. Have you ever had a patient who was DNR who presented in full arrest, and suddenly a family member on the scene questions/contests/ignores/impunes the validity of the directives on that DNR? I have had situations where a family member feels the patient was coerced into signing a DNR or ceding control of their care, and now we are put in the middle of a hornet's nest. I am not a lawyer, and that is not the time or place to debate the validity of the order, the true wishes of the patient, or what ulterior motives a family member or care giver may have. "Thankfully" in each case such as this, the patient never responded to our treatment or interventions, so the point was moot. Yes, we subjected the person's body to something they did not wish, but to me, that "person" was already gone and would hopefully forgive our interference in their final moments since our intentions were without malice. I would not feel comfortable simply standing behind a piece of paper- regardless of how "legal" it may be. We are obligated to work the patient(contacting medical control, of course) and let the hospital sort it out when we get there. Rare, maybe, but it happens. Uncomfortable- certainly. I really wish to honor the wishes of the patient, but if there is any question as to the validity of the DNR, we have to work them. More often, it's a case where the family panics at the last moment and questions their or the patient's choice not to be resuscitated, but generally a quick explanation/discussion clears these things up. I understand that Issuing a DNR or any type of Advanced Directive is an abstract concept, and despite preparations by doctors, hospice, or other medical staff, the moment of death is often not pretty-ie the agonal respirations of a loved one are not something most people want to see or are prepared to deal with. Example of a judgment call. Recently we were called for a man in his 60's who had arrested. He was in a hospital bed at home, with a DX of terminal cancer- pancreatic with metastasis to the bone. Palliative care only. He was brought home from the hospital 3 days prior per his wishes to be under hospice care and the hospice folks were scheduled to arrive the next morning. At this point apparently he was completely lucid and competent. The doctors had given him 3 months at best to live. In the last 24 hours he had rapidly deteriorated mentally and physically. I asked about a DNR, and the wife presented me with the original document, completely filled out with explicit details and instructions- except for her or her husband's signatures. She said they simply did not think this would happen so fast and they would have more time. She- and her adult son who was present- asked us to honor the document even though it was unsigned. The patient technically did not meet our criteria for a DOA, but was apneic and asystolic. We honored the wife's wishes and did not resuscitate the patient. Technically wrong? Yep, and I would have a tough time defending this in court should someone opt to challenge this. I would also do the same thing again in a minute- without hesitation. The wife knew her husband was gone and nothing could be done for him, but simply needed someone to confirm her thoughts. (Full disclosure- We actually had a connection to the patient- a coworker used to work with the wife, and we actually knew the son- he was a fire and EMS fan that would occasionally hang around houses throughout the city. They were both grateful for our discretion and even invited us to the funeral and memorial services. )

Well doc, I'm glad that the patient was able to reiterate her wishes and hopefully leave no questions as to what she wants in the future. These cases are where the doctors really earn their money, and I'm sure are the cause of a few gray hairs and sleepless nights. These types of ethical situations are where prehospital folks like us turf responsibility to a higher authority, and decisions like this SHOULD be left in the hands of someone who has access to more resources- legal consults, bringing more family into the situation, getting other medical opinions, etc. I know what doc is saying about dealing with headstrong nurses. As anyone who has dealt with old school ER nurses knows, they can be a handful. They may look at situations from a slightly different perspective than a doctor, but in the end, the doctor makes the ultimate decision and has to face the consequences-and although any staff caring for the patient has a stake in this, the doc has the final say. Great case, doc and thanks for making us think.

Looking at this from my scope of practice, and the same circumstances- prehospitally- if this person arrested and the DNR said no mechanical ventilation, then I would use the BVM, CPR, and contact medical control, citing the DNR. I would cite any concerns or suspicions about a possible suicide attempt and/or foul play, and let medical control sort it out. Based on similar ambiguous cases(questionable DNR's), our medical control usually advises to continue BLS resuscitation enroute to the ER. It's a lot easier to discontinue efforts vs waiting for clarification and then starting. I honestly do not know if there are any medical/legal wrinkles with such a death, with a DNR, under suspicious circumstances. I suspect that the DNR may trump everything- regardless of HOW the person ended up pulseless and apneic. I wonder if we have any lawyers here that could answer that.

I am concerned about something doc said here: She required multiple doses of D50 and D10 to maintain her glucose level. Why? Malfunctioning pump or could someone have tampered with it? If she has an insulin pump, then should I assume her pancreas is completely nonfunctional or maybe her pancreas suddenly begin producing excess insulin? In other words, why does her glucose level keep dropping? I sense something wrong here- either she is trying to kill herself- maybe an insulin OD, or the husband(or someone else) has done it to her. Either way, I would be concerned that this is a criminal incident. I'd want some answers ASAP before she coded and I'd have to decide about that DNR. I would definitely want the Risk control/legal/law enforcement folks involved. If this is a criminal manner, what are the obligations in terms of honoring the DNR and finding out if this was a suicide or homicide attempt.

I agree the only "native" Americans are the American Indian tribes. That's fine, but since Ellis Island or INS was not around back when the explorers were carving out their niches here, I'm thinking that "illegal" is an inappropriate term to describe everyone who came after and settled this country. Did we screw the Native Americans- yep, but unless we are willing to cede control of the country to them, I don't know how to address that wrong.

Seems to me the ride alongs aren't nearly as common as they used to be. I believe various specialty courses allow for riding as an option to maintain their certifications. Obviously you would think telemetry nurses would be mandated to ride- but most do not. Is it a good idea? Of course it is. Prehospital folks know far more about what ER nurses do than the other way around. All it takes is a shift or 2 in the ghetto and these nurses have a whole new perspective on what we do. I especially love the nurses who occasionally come from "nicer" areas and have no idea what ghetto life is like. One day I had a couple 20 something cute little nurses from the ER I worked at (busy urban Level 1 Trauma Center) ride with me in the worst area of town. Both were from small towns and although they worked in the ER for awhile, they were still pretty naive. As we were returning from a call, one of the "working girls" stepped up to the rig as we were sitting at a light. We exchanged pleasantries- how's business, nice day, etc, and as the light changed, the "business woman" decided to flip up her shirt and show me her wares. My partner and I laughed. Apparently the riders were looking out the window at the side door and I suddenly heard shrieks from them. "Oh my gawd- why would she do that??" I said it was like the yellow pages- she was doing a little advertising for her business. To this day- 15+ years later- these nurses still talk about that incident. LOL Coming from someone who has done both ER and prehospital-I still really think that to this day, nurses need more exposure to what we do- and vice versa. We get quite comfortable in our own little worlds and forget there are different perspectives on the same thing. I try to explain to new folks what it's like working in an ER. Many nurses flat out admit they do not like being on the rigs- they enjoy the controlled environment(as chaotic as it can be sometimes) of an ER. All the help in the world is just a call away- security, a doctor, lifting help, another nurse, a tech, housekeeping- essentially whatever they need. In the field, we have no such luxuries. They love hearing the stories, but are happy to leave it at that.

I'm thinking Jesus would have a problem with it. A HUGE problem. I seem to recall a few (10 to be exact) little rules he thought were important. One of them said something about STEALING. When an illegal comes to this country, he/she takes goods and services that are bought and paid for by, as well as designated for- US citizens. Liberals decided to not only ignore the ILLEGAL part, but push for those services for those who broke that rule. While we are at it, I also seem to recall something about coveting thy neighbor's goods, so I'm thinking that could apply to our south of the border neighbors as well. So, my answer is no different than Jesus'. I think that puts me in pretty good company. Why don't you follow what Jesus would do?

Here's the scenario- 50 year old white male, called for chest pain. PMH-Essentially only multiple ortho injuries 4 years ago. He was a LEO who was struck on duty by a truck, broke 38 bones, had shoulder and hip replacement. Extensive rehab. Fire assist company with allegedly ALS capabilities on scene 10 minutes prior to our arrival, began treatment. The report we got from the medic as we arrived- initial vitals 170/110, HR 120, RR 32. pulse ox on room air 97%. Pale, sweaty, Sinus Tach in lead 2(no 12 lead available) with no ectopy. Lungs clear and equal. The rest of his exam was unremarkable. Meds- Analgesics and Lipitor, if memory serves NKA As I approach the PT, I note that his L arm is drawn up to his chest, his is extremely anxious, and confused. I also see that he is hyperventilating, with what appears to be anxiety, but quickly realize he is exhibiting a Cheyne Stokes breathing pattern. The fire medic tells me that he gave 1 NTG for the chest pain, but my partner thought someone else(an EMT on the fire company) said they gave 3 NTG's. I immediately do a quick neuro check, his L grip is indeed profoundly weaker, L leg is also weak, but he also has some residual leg impairment from his prior injuries. I see facial assymetry, and he has some expressive aphagia. Unable to perform the arm drop test- too confused, but no matter. Wife says the patient has been complaining of headaches for several days, but onset of these symptoms was sudden, while watching TV. We perform ALS, and take him to a Stroke Center. The fire medic realizes he completely missed the DX-now he claims that the neuro symptoms "just started". He claims the patient actually pointed to his chest with his left hand. I say "You mean with the arm that's already contracted and resting against the L side of the patient's chest? " I glare at the guy because I know he's full of crap. He later admits to me it never occurred to him this was a CVA in progress but in the same breath swears the neuro symptoms just started as we arrived. The medic says he wants to ride with us to the ER- unusual, but fine with me. The man is clearly sick, but in no immediate danger of coding so the extra hands were not needed. 10 minute transport to ER, essentially unchanged. I am sitting in the captains' chair, finishing the radio report enroute, and pantomime to the fire medic (out of eyesight of the PT) that I think he may have a brain stem infarct going on. His eyes get real big. I find out the PT is good friends with someone at our firehouse, so I ask if he wants us call him. He says yes. The fire medic does an unusually thorough job of completing his patient report- (guilty conscience, CYA) Our coworker arrives at the ER rather quickly, and we find out he and the fire medic work part time at another small department together. I tell him the story, and my coworker becomes irate. Apparently he does not think too highly of this fire medic's skills based on prior incidents at the other job. I can see why. The PT has an episode of transient hypotension in the ER, but stabilizes. They do a quick CT, find no evidence of a bleed, so they proceed with the TPA. The patient regains some movement but not sensation, and the confusion and speech improve. Subsequent CT's and MRI's reveal the patient has 2 areas of ischemia-posterior, and L temporal areas from what I was told. He continues with rehab today, My coworker is livid. He is an EMTB, but is sharp enough to realize this was never a cardiac event, and wonders if the NTG exacerbated the ischemia and caused the hypotensive episode, wondering if the vasodilation of the NTG moved the clot. I explained it's not likely, but no matter.(Trying to defuse the situation since this coworker is known to have a quick trigger temper) He's ready to kill this fire medic for jeopardizing his friend. I try to ease his mind and explain briefly about the effects of NTG, it's half life, etc, but he's still really upset. I find out later that our PT was at a social event 5-6 hours earlier, said he didn't feel well(head ache, nausea, dizzy) and came home, so that the ischemia probably started awhile ago. A few days later, our coworker tells us he confronted the fire medic. He wants to hear his side of the story. Of course the story changes now, but our coworker had already heard what really happened from us. The fire medic still asserts he only gave 1 NTG, and that the neuro symptoms were not initially present. Our coworker said he told the fire medic the hospital is running tests to see what medications could have caused the drop in BP, and/or precipitated the ischemia (total BS, but he wants to scare this kid) He's convinced this fire medic is in someway responsible for what happened. The kicker is that our coworker is a superior officer over that fire medic in their other job, so this could get interesting. He plans on pursuing this fire medic's clearly inadequate skills because he has been reprimanded in the past for medical issues. So- my questions- Why the Cheyne Stokes type breathing? He did not have the classic apnea period, but my partner and I agreed that's what it appeared to be. Could an embolus indeed have initially been in the respiratory center and traveled farther along, causing the 2 other areas of ischemia? The areas of ischemia do not explain that respiratory pattern. Could that NTG have caused the embolus to dislodge and migrate? I honestly think the majority of the damage was already done before we arrived, and the patient's delay in recognizing the early S&S's were the real problem. The ultimate kicker: This fire medic actually told me he no longer wants to be a hose monkey-he's bored. He wants to come back full time to an ambulance. Not if I have anything to say about it. I actually laughed at him- I thought he was kidding.

Had the "classic" alternative presentation the other day with a 50 year old female- general fatigue, mild nausea- no pain. Had a massive STEMI going on. When I had my MI, my only symptom was mild heartburn. Drank some water, went away. Came back worse a few minutes later, then I realized it was not heartburn.

I actually laughed out loud. A lot. My wife thought I was crazy when I told her what I was laughing at.

All good advice so far. It seems there is some type of cardiac issue going on. Could be the primary problem, or secondary to something else. I would not rule out a AAA yet either. Pulsating masses are a late sign, and not always present when a person first starts to dissect. You noted fine crackles in the bases, so barring a pneumonia, I would say this person may also be in failure. This person has clotting issues so that complicates everything- whether it be a AAA, a bleed, or an infarct. Tough call, but I agree that dropping a NTG and ASA is not going to harm the person or really exacerbate whatever their problem is. The downside/risk is negligible, IMHO. I would be curious to see what the DX ends up being. My guess is there will be multiple things going on with this PT. Good H&P- sounds like you covered all your bases.

Here's the rub. This is exactly what we are always supposed to do, according to protocols. Call in every patient contact- BLS or ALS. Call in EVERYTHING. Some time ago, there was a huge push from the powers that be for this here, and it lasted a couple days. The hospitals cried uncle- they were simply overwhelmed. There is no dedicated telemetry nurse at any hospital, and so they spent all day answering the radio instead of providing patient care. It literally paralyzed the system. They finally agreed that the protocols would be tweaked and that only ALS contacts, refusals, DOA's, or special cases need telemetry contact. Even so, the system was still overwhelmed, so they then instituted abbreviated reports for routine calls to free up the radio. To this day, it is still sometimes difficult to have anyone answer the radio and we end up having dispatch call ahead to an ER. Not exactly the best or most accurate method, but it beats dropping in to an ER with a critical patient, unannounced. There is the official way, and then there is reality. I will ALWAYS cover my butt- I am known for my detailed documentation. The bottom line is, that in the end, it's up to US to CYA. As anyone who has dealt with a resident or a new RN on the radio, their authority means nothing if they are giving you incorrect information, or they are unfamiliar with our protocols. If something goes wrong, it's our responsibility to and the care for the patient that matters- regardless of the "authority" of medical control. If you are given an order that you know is wrong, it is your responsibility to KNOW it's wrong- meaning just because someone on the other end of the radio tells you something, you cannot simply obey what they tell you if it's detrimental to your patient, or outside your scope of practice. That's why we have standing medical orders- to be able to operate quasi-independently if necessary, and it's those orders that are our gold standard. My point is that gray areas exist. Experience, training, and common sense are sometimes our best tools.

As long as we're throwing out non sequitors... If I was born a woman, I'd know what gender discrimination feels like, or if I was born in the jungles of the Amazon rain forest I'd probably never know what it's like to wear shoes. Do you have a point to make?

I agree that the mannequins are fine for set up and technique and getting a rough idea what the anatomy looks like, but it only goes so far. Yeah, intubation in the OR is great, but it still doesn't really prepare you for the real deal in the field. Nobody is ever NPO, nobody's secretions have been dried up, and they have not been paralyzed. You do the best you can until you get your shot. Be as prepared as possible. It's a skill that takes time to master and be comfortable with.

LMAO Why are you so surprised?

P instructor is right. Documentation is crucial to CYA. I don't know the particulars of your service, but is your partner solely responsible for completing the run sheet or can you do it? If so, then do it yourself. If your partner needs to do the documentation, then say something like "I know you don't want to or think we need to, but I'm going to do a quick assessment and document what I find". Offer to do everything and maybe you'll guilt them into helping. If not, then do it yourself. It's a touchy area since our fire companies get called for invalid assists. They show up, put the person back in bed, whatever- and they go home. If the fire crew is a first responder level, the only paperwork they file is a NFIR- which is a general form for any fire call. No further documentation or refusals needed. Now if an ambo is called and finds the same scenario, then our credo is if there is patient contact, then you must do an exam, obtain vitals, document that contact, obtain a signature, and call it in to medical control as a refusal. Obviously common sense may dictate other actions. Example- the other day we were called at 1AM for someone allegedly unconscious for unknown reasons. We arrived and found a guy who was having trouble working his home BP machine. He said it would not give him a reading. No complaints, he was just taking his vitals before bedtime to document them for his doctor. We checked the machine- it worked fine, it gave a nice normal reading within his normal range, and that was it. He would never admit that he used a BS complaint to get help, but it was obvious that's what happened. Did I document a patient encounter, obtain a signature, do an exam? No, I simply stated the facts on the run sheet. If I get called on the carpet for that, then so be it, but I've been doing this for 30 years and that has yet to happen. (Knock on wood. LOL) Technically, did I break protocol? Yep, and I would have no real defense of my actions, but then again, if the person actually had a complaint- other than an equipment problem or a bed ridden patient that needed help reaching their box of cookies because their caretaker in another room would not wake up- true story- then I do the whole routine.

I was looking at this from a management perspective, Ruff. If there is a piece of equipment on a rig and my employee uses it without proper training, what if they screw up? As an employer, I am liable for the consequences since I knew this crew was never trained in 12 lead EKG interpretation, yet they used it and began treating someone with a PE for an MI.(maybe a bad example, but you get my point.) Obviously the crew is in big trouble as well. That 12 lead module on the LP should be disabled- if not removed- if your system protocols do not allow you to obtain and treat someone based on a 12 lead EKG. Now if you are talking about a failure of training, that's a different story. If the provider is working in a system, they need to be familiar with and proficient on every procedure, medication, and tool. If you are transferring in from another system, with different protocols, that person usually needs to take a system entry test and get up to date on any new procedures or tools they will encounter. It's up to the employer to ensure it's providers are adequately trained. If the person WAS trained and for some reason still does not understand how to do something, then it's still up to the employer and the system medical director to ensure that their employees are proficient and up to date with their skills.

Well, maybe I'm stupid, but how can you have a piece of equipment on your rig if you cannot use it, nor have you been trained on it? For years, our state statutes said we must carry a roll of aluminum foil to wrap newborns after an emergency delivery. Well, as long as I have been doing this, we ALWAYS had OB kits for such purposes, yet that mandate continued for that foil anyway. I agree, sometimes the need for drama outweighs any discomfort a person may go through. You'll always get the girls who try to "end it all" by taking 4 Motrin, but you can also have the 20 something girl who took a bunch of Tylenol, because she "knew" they wouldn't really hurt her because they were OTC meds.. She called us hours later- after she was not feeling well. Last I heard about her was that she was in critical condition in the ICU and not expected to make it because her liver had shut down.

My how things have changed. The days of grabbing an Ewald tune(aka the garden hose) and the charcoal are distant memories from my days in the ER. I always said that if folks knew what was waiting for them in an ER after their OD, they would have either chosen another method as a suicide gesture, or simply given up on the idea completely. Gowns, gloves, face shields, masks, shoe and head covers- yuck, and working those monster sized syringes.... That damned charcoal got into everything, too. LOL. As for NG insertions, I've dropped many, but never on the streets- not part of our protocol, nor do we carry them. Obviously there is a benefit- especially with prolonged lay CPR or improper BVM use, but as I've said many times, our system is also not very progressive. BTW- Thanks for the info, doc.