usalsfyre

Heavy.... I wouldn't look for the Lybians to show up anytime soon though.

I have in the past, but won't do so again. It's simply shifting responsibility, and really only gives false hope to the parents. Not to mention places providers in danger needlessly during a code 3 transport. Dead is dead, no matter what the age. I don't advocate refusing transport, simply informing them completely of the risk and benefits of proceeding. Including telling them that realistically you won't make it to the receiving, and even if by some chance you do, you realisticlly won't survive the surgery, or the organ dysfunction associated with it. Not saying "there's a slim chance" that, again, gives false hope. The physician and transport team both saying, in unison, "I don't think you will survive the trip, how do you want to proceed?" is what's needed.

Parts of my county would kill for a 30 minute response.... Every service has days it's overloaded, that's why contracts tend to be built on percentages. I'll bet if you look back over 17 years the previous provider has at least one 30 minute response. If it's happening consistently, then it's a whole different matter. Getting out bid/taken over/consolidated is not disgraceful, it's reality, especially if money is tight for a city. Welcome to healthcare. Did Rockingham really have something better than AMR? If not then it's a hard sell keeping the incumbent there when more money come knocking.

I have no problem trying to uphold his wishes as long as it is made crystal clear what his chances of dying from this bleed are(which I'd say are around 80-90% as described). If he still feels he wants to go through with it, we'll go. Emergency medicine does a crappy job if INFORMED consent. We get consent, but we rarely talk about the downside. If I told you "the only way you'll live is to go somewhere else" would you do it? Now how about if I told you "In my opinion there's a statistically improbable chance you'll live if we transport you somewhere else but most likely you will die enroute prior to ever reaching life saving care". Changes the picture a little doesn't it? This question rarely gets raised in normal EMS but regularly comes up in CCT and critical care as a whole.

You can't base practice of andecotes, "miracles" or the provider's personal belief system. It has to be based of science and informed patient decision. Transporting "to give them a chance" uselessly ties up resources, often places providers in danger (code 3 transport or HEMS), delays the grieving process and presents families who may not be able to afford it with a financial burden they may not be able to be bear. "The best hope" in the face of damn near certain death may be saying goodbye to family and friends and passing in peace rather than being used as a high-fidelity skills lab on the side of a mountain road somewhere. The patient should certainly be informed of this and that living would be a massive improbability. I'm not from Canada, but my understanding is you see far more fixed-wing use due to the distances involved. HEMS in the US is massively oversaturated anyway, 75% of the aircraft in our country could close up shop tomorrow and not significantly affect outcomes. It's time for EMS to move past the "miracles" and "one-in-a-millions" and start focusing on providing good, realistic, cost-efficient care.

I just opinioned on another forum that the guy most likely had an unrecognized ROSC at some point.

So have him dump it down the toilet prior to transport. Still no reason to involve the police. It would be the same for any substance. Whether we're "public safety officials" or not is massively up for debate (although I get the feeling from your positions that's the direction you think EMS should go). A meth LAB is an entirely different ball of wax. First off the scene and the patient are very possibly contaminated (i.e. not "safe"). Then there's the fact that a lab represents a danger to a whole lot more people than just the patient. I'm not sure why your so interested in sicking the law on your patients. As noted however, in one situation laws may not have even been broken depending on jurisdiction, and your simply imposing your personal morals on others. In the other case your viewing the patient as a lawbreaker who needs to be in jail rather than a patient who needs treatment. Neither one has a place in modern healthcare, which EMS is a part of. If you want to put people in jail, I'm sure there's a PD near you hiring. If your simply playing devil's advocate I apologize...

Are they both charged with statutory rape? Neither one of them is technically able to give consent for sexual activity. Most DA's wouldn't touch this with a 10 foot pole. Not to mention in MY jurisdiction it's not a crime. Different situation, as one party was an adult. That said, Texas has set up the age of consent so the sexual activity still wouldn't be a crime, between the ages of 17 and 20 it is allowable to have a 3 year or less age difference between the participants. Most often it seems like cases like you mentioned (one participant being 17 and the other 18, a VERY small age difference in the grander scheme) are used by DA's to make a statement on morality. Which brings up the question of the morality of ruining another person's life to make a statement/get reelected. I personally find this FAR, FAR more morally bankrupt and corrupt than sex between two people with a year of age difference.

I've seen trainwrecks leave too, but I think it's important to recognize the difference between a 40 year old who is a 30 minute flight from a tertiary facility and a 70+ year old who is two hours from a surgical solution. And a hemoglobin <5 tells me he's been bleeding a while, and it doesn't appear to be stopping. An INR of 3.2 doesn't really shock me as he's on coumadin (in fact, I'm suprised it's not much, much higher. With this level of blood loss I'm expecting to have coagulopathy) but I agree we should take measures to reduce it if we can I'm curious as to the reason as to for phenylephrine over say, norepi as the pressor. I've got VERY limited experience with neo (I've transported only twice) but my understanding is you have to have sufficient levels of endogenous catecholamines to be effective. This patient would seem to be at high risk for depleting his own stores. Am I missing something? Again, I really don't have any experience of note with this med so any info you have is appreciated. Thanks.

You have to balance the fear of anesthesia awareness with the need for sympathetic stimulation. See the next thought below. So the thing to remember is that paralytics actually have VERY little effect on sympathetic drive. The sedatives however, do. Reduce pain and anxiety, you remove a portion of sympathetic stimulation. There's a couple of likely possibilities as to what happened in cases like you mentioned, one is they weren't watching K+ when pushing sux (which is why I don't miss the stuff at all), another is that they removed the respiratory compensation of a severe acidosis leading to cardiovascular collapse. The final likely possibility is that the sedation reduced the sympathetic stimulation enough that converting over to positive pressure in the chest knocked out all venous return. This is one of the reasons to hold/severely reduce the dose of the sedatives. Agreed. Yes and no. We don't like to "write patients off" because we're supposed to "save" people, but sometimes you've got to realize futility and not waste the resources on it. I recently had a discussion over a very similar case with former paramedic/med student. He reminded me that blood is a very finite resource, especially in this type of setting, and dumping it into a patient that's not likely to live is a misuse of it. You can't focus completely on the patient that "might be", but it's just as irresponsible to not at least consider it in a case like this.

I agree, I'm not sure how a base physician could "deny" a patient refusal. Doing so amounts to kidnapping without the appropriate legal maneuvering.

This guy will die enroute. No doubt about it. I doubt the local ED has enough blood on hand to manage this case. Call the receiving physician and my med control, get a three way conference call going if need be. Explain your concerns. I would do everything in my power to avoid taking this transfer. He doesn't sound like he's going to make it a 30 minutes into this transport, much less two hours. Even IF he makes it to the receiving, he's got to make it to surgery, through surgery, and through a uhhh, "complicated" ICU stay. He's VERY likely to have multi-organ dysfunction NOW from mismanagement (who in the heck thought a LITER of colloid was a good idea?!) not to mention two hours of bleeding later. Sometimes being a patient advocate means making people aware of the facts, probable outcome and that it might be better to die somewhat comfortably with family around rather than in the back of an ambulance or ICU two days later with a $250k bill. Barring making everyone see the reality of the situation, every compatible PRBC the hospital has with an equivalent amount of FFP and platelets for the trip, intubate with VERY little sedation and a heavy dose of paralytics, set your vent to minimize pressure in the chest, and consider that you may need catecholamine infusions to keep this guy alive, as he may run out of his own endogenous supply quickly. Cross your fingers and pray to your deity of choice, it's gonna be a LONG trip.

Most states have VERY narrowly defined required reporting requirements. It's not your duty to report every crime.

1. Nope. Not a reportable incident. 15 is hardly a child in this case (yes as a matter of fact I do have kids)If at 15 years old she is not aware of the consequences of having unprotected sex then her parents have quite honestly failed her. If you were truly concerned about the "duty to the child" you would include the male participant, however this seems to be about the morality of a boyfriend "taking advantage of" a young lady. It's not my job to impose any ideas I have about morality on others. 2. Assuming nothing other than an illicit substance laying on a table, why would you even consider it? Medical care people, not "public safety". If there's a report of rape, it's a different matter entirely. The nurse should tell you about that. Unless that's the case, it's not required to report it.

The more I think about I'm wondering in WHAT jurisdiction consensual sex between two minors is a crime and how officials think it's in any way enforceable....

Texas doesn't have "Fire 1&2" per say. Texas Commission on Fire Protection issues a Structural Basic certificate upon completing the IFSAC Firefighter 1&2 curriculum, HazMat Awareness and Operations and Texas DSHS ECA or higher and passing the state certification exam. What the online academies do is issue course completion certificates saying you have completed a curriculum that meets IFSAC and ProBoard requirements for the above courses (with the exception of ECA). It is NOT a certification, but will allow you to sit for the TCFP exam. Whether your state, or agency, will accept it or not is up to that certifying body. The online academies have a mixed reputation here, some thinking they're the best thing since sliced bread, others demonizing them. I don't think they're "the end of firefighting", but I have seen more people struggle both completing them and post-completion than the conventional route. From what I've heard trying to get a firemedic job in FL is pretty much a waste of time period.

#1. In Texas two minors engaging in consensual sexual activity is not a crime. Even if it is by local jurisdiction, it doesn't meet required reporting requirements under DSHS rules. #2. Not only no, but he!! no. It's not my job to become involved in law enforcement functions (especially where the victim is themselves) unless I'm subpoenaed. Not to mention this will discourage the patient and possibly others from seeking medical attention when they need it in the future. Why would any healthcare provider report this?!?

Considering Texas doesn't have a fire 1&2 cert, my guess would be no...

What's really interesting is there's no indication that Triad's lubricant is contaminated, rather, they just had -an issue with their recordkeeping.

Agree more could have been done (IN fentanyl is a wonderful thing if it's available) but how does O2 play into her needs?

A single saturation level of 92% in a longtime smoker with COPD probably wouldn't even show up on my radar. If it did, I'd check the probe first. In the absence of increased dyspnea/a respiratory complaint or something related to a respiratory complaint this means positively squat. How exactly could she have benefited from "some air" (for that matter wasn't she breathing "air")?

Fearless, nope. I practice scared $hitless paramedicine. What that means is I understand and fear the consequences of: Not fully assessing my patients Doing needlessly invasive procedures Growing complacent with certain patient populations Not having a plan B (and C,D,E and F) Not understanding the capabilities of local facilities, and not putting the patient's need to get to the proper one above my need to get off on time, eat, ect. More that don't come readily to mind. So mark me down in the yellow-bellied coward category.

If you end up on the VA side I recommend NVCC.

So your recommending a $15-20k device that only fits one segment of the population that doesn't arrest all that often (relatively healthy) and as noted before had a trial halted because a few patients that were brought in had multi-trauma caused by the device, and is difficult enough to use that the "with practice" caveat has to be added? What's inadequate about CPR? The autopulse has only been shown to work as well as CPR. I'll stick to a high-drag, low-speed mark 1 mod 0 firefighter...

Any device that has a clinical trial of it halted due to the severe damage it caused should be looked at with a VERY wary eye...