HERBIE1

Bad. Not many details here- as in how the patient presented, what the call was for, initial vitals, respiratory rate, etc. For the sake of argument, let's say the patient did not present with agonal respirations, but maybe an altered mental status, lethargic, etc. You administer the Narcan, they become fully alert and oriented. Fine. So- how much of the opiate does the patient have on board? Are these legal drugs or something like heroin? How much was ingested? How many pills? What else did the patient consume? Was the heroin laced with anything- ie Fentanyl? What was the purity/strength of the drug? Is there alcohol present or other illicit substances? How much Narcan was given? In other words, you have no idea how much of the drug may still be in the patient's system. The Narcan may have reversed just enough of the OD to improve mental status and respirations, but there is still plenty of opiates still in the patient's system, which means that once the Narcan wears off, the action of the drug returns. I've seen it happens many times- we restore a person's respiratory drive- only to have it knocked out again when the Narcan wears off. Bottom line- these people are NOT competent to refuse transport. They need to be monitored for awhile at the ER until it can be determined the are no longer under the influence.

Don't know an official response, but intuitivly it should make no difference. The air bladder in the cuff is what this is all about, so as long as it is functioning properly, I see no reason why it would matter which direction it's facing. I would be curious to see comparisons between both methods- especially with an "objective" automatic measurement of the BP.

LMAO I know this thread is old but it does bring up an one of my pet peeves. I cannot speak for someone else, but of all the urban providers I know, nearly every single one I know is guilty of using these terms- status hispanicus, "aye" tach, or making some other stereotypical/off color, generalizing comment at one time or another. And that would include folks who are part of those various groups. I've worked with Jewish doctors(and even an Orthodox one) who was guilty of making stereotypical comments about his own religion and people. Does this make them a bad person? No. Does it mean they are racist, a bigot, or xenophobe? Nope. It means they are HUMAN. That said-if someone says they do not engage in such humor or make such references, good for them. Clearly they are a more evolved human being than most of the people I know and have worked with in my 30+ years in EMS. I have found that the few people who I have met that do get bent out of shape at such comments/phrases/comparisons, they fall into one of 2 catagories. Either they have limited or no exposure to such groups or environments(new to the business or very limited history (limited call volume), or they are promoting an image or attitude that is not actually indicative of their true beliefs but still want everyone to think their behavior and attitudes are above reproach. Whatever. I have used such phrases, made similar comments and observations, and yet I would put my patient care and customer satisfaction up against anyone. I realize EMS is constantly striving to be a professional group, but here's a little secret- doctors, nurses, cops, lawyers, judges, and every other profession have similar off color/unPC/stereotypical humor or comments they enagage in every single day. Does that make them less of a professional, or somehow unqualified to practice their profession? Not in my book. Sorry, I just hate the holier-than-thou crap. end rant.

Check your inbox, bud.

I am not an RT or Critical Care medic, just someone who has been around the block for more years than I care to admit. One of my closely held truisms is the KISS principle- Keep it simple, stupid. When it all goes to hell, as a couple people have mentioned, the first thing you do is take a deep breath and go back to the basics- ABC's. Since I have no clue about vent settings or troubleshooting vent issues, my first thought was about a mucous plug- based on the patient's PMH. Horrible things- especially if you cannot get at them. Suction is certainly a good idea at this point. They can completely occlude an airway, may be too deep to remove quickly, and they can easily prevent you from using a BVM. That said- what other choice do you have? The issues here had nothing to do with ALS skills. Yes, the person was on a piece of equipment you were not familiar with, but you know what a pulse ox is and what it means. You do have the knowledge to address the problem. Once those alarms begin, and you cannot figure out what they are, what they mean, or how to correct them, remove the vent and try to manually ventilate the patient. Clearly the person is decompensating and it's time to earn your money. Better to pop a bleb or push a plug distally then have a patient become anoxic. Anyway- this medic sounds like he has no business doing critical care transports. He screwed the pooch on this one. Next time if your medic isn't willing to step up, you need to be your patient's advocate. After the call you can discuss what went wrong. I'll echo the statements about you having big nuts for putting yourself out there like this. On the plus side, I promise you will learn more from this incident than you would listening to a lecture from a doc from the Mayo Clinic. These are the calls we never forget, and always vow to never repeat.

Awesome. New jobs are scary and exciting. Enjoy- now is when all the hard work and studying pays off.

Welcome to the city. I find it fascinating all the different paths that folks take to end up in our business. Yes, some people seem destined to be in EMS since they were a fetus, but others take a more circuitous route, such as you. Good luck in your studies and don't be afraid to jump right in. We don't bite- much.

In many instances around here, each attending MD (with admitting priveleges to the hospital) of a patient has a different set of requirements/standing orders for their patients. Some require a consult from the ER only when one of their patients is admitted to the hospital, some want notification on every one of their patients who are brought to the ER. In the case of nursing homes, some attendings literally may have a hundred or more nursing home patients(that is their entire practice) and have very specific rules about what to do when their patients present to the ER. This of course is for comprehensive ER's, and some of the smaller hospitals have a different set of rules, or none at all.

Congrats, good luck, and remember, even the old salty dogs had a "first day" too. You will do fine.

I'm going to assume that the ER doc spoke with the patient's attending before discharging the patient, found out about a baseline, PMH, ,mentation, etc- maybe she's normally hypertensive, as noted by others here, and maybe she is a DNR. Sounds like the patient was worked up appropriately to me- in my humble, non medical school backed opinion.

Agree about the shift issue, but if you have a bunch of folks who rotate through that ambo duty, then it won't be the same people getting the crap beat out of them every single day. One day on an engine, one day on a truck, one day on an ambo, etc. That way you split up the workload. It also depends on the number of days off between shifts- 24, 48, or 72. Traditionally, the fire service works 24 on, 48 off for a period of time, and then they have a Kelly day or something where they get 5 days in a row off to reduce the number of hours worked. Part of the problem with EMS working a similar shift is the issue of FSLA and OT. The laws vary, but police and fire are generally exempt from mandatory OT after a 40 hour work week- meaning they do not get OT after 40 hours in a normal work schedule. EMS is not considered to be exempt, so in many places, shift schedules needed to be adjusted to take that into account. Believe me, I know 24 hour shifts are brutal- I've done them for nearly 30 years- and the last 25 in a very busy urban system. Problem is, call volume is always increasing, so something needs to be done, but the limiting factor is warm bodies and money. To increase the number of rigs means money, and to staff those rigs means a lot of money, and when you are talking about fire based EMS- especially ones with single role medics- we all know how eager the fire bosses are to address the needs of their EMS people. When fire "adopted" EMS into their world, they simply made them conform to their work schedule, their rules, and their culture. There was no effort made to explore the differences in the jobs, and since the EMS folks are always the minority, their issues have essentially been ignored. We've been through this before- unless and until the culture of the fire service is changed, the same issues will arise. Again- we'll see if this Philly report generates any of those changes, or it's simply another report that will gather dust on a shelf. Let's just say I'm not too optomistic.

You could probably take this same report, substitute Phillie for nearly any major US city and the results and recommendations would be nearly the same. Around 15 years ago we had a similar study done here(different consulting company), as well as in several other cities around the US. I cannot speak for other places, but it essentially became a $250K paperweight here. Not only were most of the recommendations ignored, many of the identified problems were actually made worse by doubling down on the same behavior. In other words, there needs to be buy-in from all stakeholders-the members, the union, the department, the city, and even the citizens. That means you need proactive and progressive leadership, which in many places are not the hallmarks of the fire service- especially those with an EMS component. Simply mandating a change is not the answer- you need new leadership that agrees with the new plan. Without knowing anything about Phillie Fire, I can still almost guarantee that most of these changes will not be met with open arms by either most of the members or the management. I think there could be a better outcome from this study than in prior years, since the economy is in such lousy shape, and politicians look for ANYTHING that could make a department more efficient, and more cost effective. Granted, public safety is not about turning a profit- although at least EMS DOES generate revenue(albeit certainly not enough to make them revenue neutral), so streamlining and cutting waste is priority one. I get the hour change thing. There is an originizational culture issue, and with every difference between EMS and fire, it's simply another wedge between the 2 groups. Not saying 24's are bad or good, but I understand the rationale behind this. Personally, I am all for cross training- it simply makes sense from a management standpoint. It's more cost effective to have an employee who can wear 2 different hats, but obviously there cannot be a drop off in quality of care. Around here, many departments- especially the busier ones- mandate dual roles for various periods of time, but generally allow someone to opt out- if they wish- of working on the ambulance after- say 10 or 15 years of service. Unless the recommendations of this study were somehow binding- ie a certain percentage of these ideas needed to be implemented- I'm afriad this will be a long and ugly fight.

I never said Dwayne was advocating a communist idea, I was using that as a point of comparison for an idyllic concept. I also need my personal space-whether it is to decompress, or simply sort out the various conflicting voices in my head. LOL

I've read this thread with great interest, but I have refrained from chiming in until now. It seems my opinion is probably of the minority type, but it's not the first time I've been in this situation- ie not this cowboy's first rodeo. While utopian ideas like this sound great on paper, they are almost without exception, unsustainable. Taking away the historical examples like Russia and Cuba, communism is a great concept, but the fly in the ointment is always man's innate greed. There will ALWAYS be the have's and the have not's, but in concepts like communism and it's progeny- socialism, there simply are more have not's, who then become dependents to the ruling class and to the government, who become their great benefactor. I guess I'm simply too cynical to consider such ideas as being anything besides a nice rhetorical excercise. I'm also too set in my ways to adapt to such a drastic idea even if I thought it could work. I just returned from a road trip for a convention in Kansas City, Mo with 6 guys. We had 3 hotel rooms between us, and thankfully we all got along famously, but too often that is not the case. Even with the best intentions- everyone wants to get along, allegedly have the same interests and intentions, but personality clashes become inevtiable. Folks have different perceptions of attaining the same goals- whether they be a communal or co-op living arrangement, or a simple vacation or road trip. Couple that with a few strong, unyielding personalities and to me it's a recipe for disaster. So if Dwayne's idea comes to fruition, I would love to visit for a weekend if you guys would have me, but count me out as a permanent resident. (No offense intended to Dwayne or anyone who is still untainted enough to be willing to give such an idea a try)

OK doc, so is it time to switch professions yet? Isn't one of the money saving ideas of Obamacare to cut Medicare reimbursement to physicians? Couple that with this idea in Washington, and I would expect to see tons of ER MD's there packing their bags and heading out of town. I love this- under the FAQ's of the plan: Who will decide what is medically necessary? Answer: The Health Care Authority will use sound evidence and a collaborative process in determining what constitutes medically necessary care in an Emergency Room setting. Sound evidence? As defined by whom? Collaborative process? Would that be a bunch of politicians and bureaucrats, sitting around a table? Just WOW.

Check the Department of Transportation Web Site for information about what the various cirriculums are all about. The number of hours for each licensure/certification level are outlined, as well as what these programs will include. That is a good starting point, since from there states can be quite different as to what their programs are all about. Not sure how much detail you are looking for. Policies and programs generally vary from town to town, county to county, and obviously state to state.

Hey wannabe- First and foremost- congrats on being a new dad. Next- you are in for a LONG road ahead, my friend- a dad at sixteen? I cannot even comprehend that. I wasn't ready until I was 34. Finally- you have enough drama in your life- why look for more here? Your priorities are with your baby's mom, the baby, and taking care of them. PERIOD. Finish school, take as many jobs as you need to take care of your responsibilities, and then start worrying about your future, Good luck.

I agree that this guy is probably in denial. He KNOWS he's in trouble and is afraid of what the doctor might tell him. I know at 81, I would not want to be given a diagnosis like cancer- not that there's ever a good time for such a revelation.

I think one of the biggest problems we have these days is the entitlement mentality and a feeling that the world/government/society/everyone owes you something. That was not the mentality that made this nation great. We were defined by our work ethic, our spirit, our ability to dream big, to take chances, and to work towards a better life. We also knew that there were NO promises in this world- of success or of wealth- unless you were a trust fund kid or born into wealth. At some point in the recent past, a movement developed that fed the notion that we somehow "deserve" something- for whatever reason- without ever needing to work for it. Sorry- some folks will be wealthy, some will be poor, and the vast majority will simply be struggling to keep their heads above water. That's life. Some will be dealt a shitty hand in life, some can overcome the odds despite coming from humble beginnings, some can seemingly have it all- good family, money, education- and still throw it all away. I'm not a religious person, but since when did we give the green light to covet thy neighbors goods?

"Fake" seizures. I love those- quite entertaining. My favorite is when they are "convulsing" on the floor, looking at me and telling me that they are having a seizure and need medication. I've had a couple actually try to generate some spittle, but then wipe their mouths when it starts to run down their chin. LOL I generally tell them to be careful so they don't hit any furniture or hit their heads, and many of them actually do look around while they are "seizing" to make sure there are no chair or table legs within striking distance. I then tell them to let me know when they are finished so we can "treat" them and give them a ride to the ER. They get their taxi ride, I tell them we don't have the "right" medication for their "special" type of seizures, so they need to wait until they get to the ER. There's no point in arguing with these folks or pointing out they are fooling nobody- they either want a free ride to the ER for a Rx refill, or they are drug seekers. Either way they won't quit until they get what they want.

I'll agree with what doc says here about how everyone at least CLAIMS to have a loss of consciousness. I cannot count how many times someone has told me- even after very minor accidents with no MOI to suggest a loss of consciousness: "I think I blacked out for a minute." After further questioning, their "loss of consciousness" was more like- I was shook up, I couldn't believe I was just rear ended. I can't believe I just wrecked my car, how am I going to tell me husband/cousin/boyfriend I wrecked their car, etc. They recall events leading up to the accident, they recall the crash, they recall taking off their seat belt before we arrived(or putting it on before the cops get there), and their exam is completely benign. The way I word such incidents in my verbal and written reports is: Patient alert and fully oriented, c/o of a LOC(I'll generally quote their exact words here), but does recall all events prior to, during, and after the accident. I let the hospital evaluate the need to further pursue the R/O head injury treatments but generally we give them the benefit of the doubt with treatment. In our protocols, a simple loss of consciousness- in the absence of other factors or injuries- does not mean a patient needs a trauma center- just a comprehensive ER, which in our area means they will be equipped with a CT scanner, so their potential needs are covered.

Welcome to the city. I have to say- I LOVE the moniker- quite creative. I'll echo what CM said about IFT's. This is exactly where everyone should start in this business. You learn about patient assessment, dealing with people- sometimes who cannot communicate effectively with you, you learn about medications, how to take vitals on patients who may be contracted or confused, how to deal with hospital and facility staff, how to properly operate and care for all your equipment, you learn about driving an emergency apparatus, about documentation- the list is endless. In essence, this is where you learn the job- no matter how many licenses or certifications in EMS you end up pursuing. It helps you get a firm grasp on the basics in a generally more sedate environment than the insanity of a 911 service. More than anything, you also learn how to talk to people- both patients and family members. You learn that the little gestures and words you use are remembered and appreciated far more than your medical knowledge or skills, and that applies to folks in every aspect of EMS, and at every level.

After I drop off ,my run report, I always wish the patient and/or the family good luck or hope they feel better. Nothing but common courtesy in my opinion.

Welcome to the City, Derek. Can I make a personal request? I realize you may be posting from a mobile device, but PLEASE try not to post as if you were text messaging someone.

Spoken like a true socialist. Obama would be proud of you.