usalsfyre

Small private service, a young inexperienced provider put in a position of authority and an owner who cares only about the bottom line is a recipie for disaster. As for dopamine...if your administering vasoactive infusions, yeah, you need to pay to have a pump. Just because "we do it all the time" doesn't mean it's right or safe. If you don't, put the dopamine away and look up push dose pressors. Small private service, a young inexperienced provider put in a position of authority and an owner who cares only about the bottom line is a recipie for disaster. As for dopamine...if your administering vasoactive infusions, yeah, you need to pay to have a pump. Just because "we do it all the time" doesn't mean it's right or safe. If you don't, put the dopamine away and look up push dose pressors.

Rarely are situations such as this. Frankly, I'm surprised the hospital agreed to allow the transfer to go forward, considering they arranged the transfer with a service they knew didn't have the proper equipment it's likely they could be included in any subsequent liability claims. I've had hospitals refuse to allow transfers in a standard cot before, despite the patient only weighing 400lbs for this reason. I'd be willing to bet their legal and risk management departments are blissfully unaware of how these patients are moved. Different setting and you know it. You've even commented non-emergent IFT and EMS should be separate. I haven't put a kid in their mother's arms in years. What makes an ambulance different than any other vehicle on the road? How often is furosemide administered routinely by EMS and community EDs for CHF without considering the situation? Just because it is so doesn't make it right. I've waited on scene for bari resources on 911 calls. 911 services should not get a pass, and I expect it's an issue that will become more visible as time goes on. This is also a place where community paramedicine of physician availability would truly excel as some issues could be handled without transport.

To sound weasly? I'd rather let the other company absorb the liability of this type of transport, both from a provider and a management standpoint. Especially considering this type of transport only pays a little over a hundred bucks. I don't know why owners continue to do this, other than "I haven't been burned yet".

If you'll recall back earlier, I answered you directly by saying it's not safe to transport in an emergent situation. It's simply that the risk benefit shifts. There's ZERO immediate risk waiting for the appropriate resources in this case, not so in the emergent case. The company I'm at now has four trucks set up for bariatric patients. Seriously doubt all you want. Not all of us panic and run to the ED without doing things properly when faced with a difficult situation. What part of RISK vs BENEFIT analysis do you not understand? If you can't grasp that concept, please refrain from making other medical decisions. This has NOTHING to do with dodging a transport. It's about safe, prudent action. Did I ever say I flat out wouldn't transport them because I find it distasteful? Or did I simply argue it's not safe for the patient given the equipment, and that it's better to wait for an appropriate set-up? Pulling out discrimination when you can't prove a point is poor form in an argument. Quite honestly, I'm insulted you would sink to this level when nothing I have posted should lead you to belive this other than your own biases. What you want to do is patently unsafe and frankly stupid when a better option exist. Cut the bull-crap of a "can do" attitude, it gets providers and patients hurt in addition to ensuring EMS will stay at the bottom of the food-chain in medicine.

So your saying you don't trust paramedics to make decisions about what's safe or not? Or do you just not trust medics not to be lazy? This is not determining who "doesn't need" an ambulance, this is determining safe vs unsafe. Emergent vs not emergent is key, not only here, but in all of medicine. Would an ED doc intubate a non-NPO patient if they weren't in respiratory failure? Would a cardiologist perform a cath on a patient with a labile pressure if they weren't having a STEMI? No, the risk benefit factor shifts when the patient presents emergently. You don't have to have every truck equipped for bari transport. But if your doing non-emergent transport of these patients you should have some equipped for it. This is the dignified, SAFE thing to do. Otherwise you should be rolling the call to someone who can. What are you basing your minimal chance of an accident on? You anecdotal experience? What happens when the drunk hits you? Part of patient advocacy is ensuring safety. Loading a bari patient on the floor of the ambulance to make a few extra bucks rather than explaining to them respectfully we don't have the equipment to safely transport them is not advocacy in view. As for the pedi arrest patient...they make devices to do this safely. Again, you pay to play, or you don't play.

Your really going to compare these situations? There's prudent, managable risk, and then there's stupid, unneeded risk. This falls in the later category. Since apparently I'm stupid now. Different setting, different needs. It's not safe to go to either facility. But again, it's about prudent risk. The risk of an undetected MI outweighs the risk of injury from an MVC. So sir, explain to me just what the risk of the patient hanging out at the sending is, and how it outweighs the risk of an MVC. Good luck. 1080. Yes it was on the floor and no I didn't like it, but I was too new to know to speak up. I've done 6-800 multiple times. If your not willing to buy the equipment you shouldnt be playing. As opposed to laying on the floor because she was too big? One of your jobs as a supervisor is to respond to these kinds of concerns and explain and/or fix the issues raised. If you can't, then perhaps it's time to look at why. The appropriate response is not throwing a tantrum and firing people when they raise a valid point. Doing so means you have no business being a manager.

Sounds like the kinda place it's a privlege to be terminated from. If you had read, she asked, and was refused. Yep, since that's safe to place the patient in a position of being unsecured in the event of an accident. By speaking up and saying this isn't safe or right? Fine, let them absorb the liability if something bad happens. The.Hell.It's. Not. Full Stop, end of message. It is absoloutely my decision, and mine alone, what ends up in the back of my truck. Because I guarantee if I had done this and it had gone bad the owner and supervisor would hang me out in the wind. If it means I get fired over refusing to do something...well, I was looking for a job when I got mine. Risking my job is one thing, risking my certification, career and ability to feed my family over the owner's pocketbook is another entirely. Sometimes this is what it takes to realize it's time to get out of a bad situation. You know, the kind of situation where managers ask their employees to perform blatantly unsafe actions. I'm fairly certain definitive care doesn't include head injuries from being unrestrained in an MVC.

While we're on the subject of "logic fails" last time I checked 7-10 minutes of hypoxia waiting for succinylcholine to wear off isn't exactly good for the patients. The ONLY people crowing about letting succinylcholine wear off are people with a misguided sense of what RSI should be. My question simply is, if you can simply let the sux wear off and go on like nothing happened, why in the fuck was the patient a field RSI candidate in the first place? I'd be seriously questioning your patient selection at that point. Succinylcholine is the preferred drug for RSI because of rapid onset. Nothing else. It has some nasty side effects to boot. I don't like vec, however it's due to the long onset, not the duration.

So you would rather do what exactly? Surgical airways as back up are PART of safe RSI. In the case I'm referring we can't intubate the patient and we can't ventilate the patient with a rescue due to airtrapping and high airway pressures. So your suggesting?!? A BVM is going to be less effective than the rescue airway. Perhaps you should examine your own logic prior to calling "logic fail" on others.

The only time I've found analgesia to really be an issue is in the strongly sympathetically-dependent shock patients, i.e. anyone that has an extremely tight vascular bed to maintain perfusion. I've had two of these patients take a crap on me after fentanyl, one post-ROSC that was chewing on the tube and one patient with severe internal hemmohrage that was still conscious. Other than that I've had no issues medicating really any patient experiencing pain. On a personal note I have been a "multi-trauma" after an MVC/possible ejection (I was outside the car when found, no idea how I got there) and revived no analgesia till PO at discharge. By the grace of God I only had deep contusions, a couple of lacerations and abrasions and a kick ass concussion, but I still remember the pain associated with those injuries clearly even if everything else is extremely fuzzy. Anyone who's not medicating their patients for pain is doing them a disservice, and if your service doesn't have protocols for it, you should be screaming at the top of your lungs to get it written into them.

Alex EMS personnel are not, repeat not, firefighters. It may say Alexandria FD on the side of the truck, but it is essentially a third-service EMS organization. If I were to go back, they would definitely be who I wanted to work for (coming from a former knuckle dragger at a city FD in the area).

Some days I miss NOVA pretty badly. Most of the time though, not so much and I NEVER miss trying to get somewhere during the rush-three-hours.

Baltimore to Springfield is a LONG commute to make regularly... In the metro area your looking almost exclusively at fire department based EMS. Meaning interior firefighting is in your job description, and expected of you. It's not fair to yourself, your coworkers or your employer to take a job knowing your not willing to fufil all of the job requirements. That said, single role EMS exist at the City of Alexandria VA and I believe Baltimore City. DC FEMS is a seriously dysfunctional department. The single role EMS department had some issues prior to the merger, then you throw an uninterested management and disgruntled employees in and you've got a recipe for disaster. Which if you google DC EMS, you'll see has happened over and over. Another option if you can stand interior firefighting is Fairfax County VA. You will do some time on an engine but there are career tracks that are primarily EMS based.

Choose who you learn from carefully, gobble up every educational opportunity that comes down the pike and throw you EMS centered books away. It's entirely possible to end up as a good medic, but understand your starting from a disadvantage.

Doczilla covered it before I could. The only thing I could think of was concern over potential hemodynamic instability.

Homework or something else?

So I'm guessing enemas of alcohol to "beat a breathalyzer" would be another new one for you?

If they're sick enough to need intubation from asthma or COPD, they're sick enough to break out the scalpel if you can't intubate them and a backup airway doesn't work.

Are you sure you don't have the midaz and etomidate reversed?!? Etomidate is a short acting sedative hypnotic that shouldn't be used for ongoing sedation. A better way to keep patients comfortable, but breathing on their own is a fentanyl infusion with just a touch of benzodiazepine PRN.

Great, so our presumed primary cardiac arrest scenarios are simple. What about peri-arrest, and arrest of other etiology scenarios (where you can make far more of a difference). Should we continue to dumb these down as well?

Here's the issue I have with the "short off" when discussing sux. In the OR, this is potentially fine. You do apenic oxygenation, the patient wakes up, we try a different option. If your counting on this to save you from the CI/CV scenario in out of hospital medicine a question if you should have been screwing around with the patients airway in the first place, as we're now 5-10 minutes further into the call, with a patient that still has crappy ventilatory status and/or can't protect their own airway. Field RSI is generally less than elective. If I dive off into a RSI and can't get the tube, I best be looking at a backup airway or scalpel post-haste. As such, a long acting NMBA isn't a horrible choice. I dislike vec, esp at low doses, due to the long onset. The best thing sux has going for it is rapid "on". Rocc is another good choice.

More nitpicking but.... If by some miracle I had a gas I'd expect the gradient to remain fairly stable in this patient. Generally you see changes in the ETCO2-PCO2 gradient when there's a change in hemodynamics or alveolar status. Unless I have some reason to suspect there has been a change in one of this two factors, I'd be willing to trust the initial gradient.

Define symptomatic. You'd be suprised how often patients walk around with what are "lethal" dysryhtmias according to paramedic text. Including frequent runs of V-tach, ect.

So I'm way late to this, but I have this thought. Why are we rushing to treat the HR? Do we have any signs she's about to decompensate? Is there any hemodynamic instability? Assuming none of the above, I'm doing bupkis for this ladies HR. One of the hardest things for new medics to learn is when "benign neglect" is appropriate. This sounds like one of those cases.

NAEMSE will work...but cost roughly twice what the progrs we're referring to do.