Bieber

Vorenus, I agree with you a hundred percent and think that that is more than reasonable. Thanks for expanding more on your practices. Kiwi, if you would please, do you care to clarify what you mean when you say "sick"? I'm assuming you reserve that to strictly those patients for whom walking may be detrimental to their care (or who are unable to ambulate due to their condition)? Also, good on you to get rid of the spine boards. J306, while I appreciate and agree that we should all do our best to remain in good health and capable to do our job, you have to concede that back injuries are by no means unique to paramedics and EMT's who are in poor shape, and that reducing unnecessary lifting is the best way to prevent injuries to providers. Also, I feel I should point out that the cot is hardly designed to endure the kind of enviroments we drag it through, and that there are even times where moving patients via stretcher poses a much greater hazard to them (i.e. the cot tipping over due to rough terrain, stairs, etc) than ambulation. Finally, I'd like to ask, do you believe that all patients should be moved by stretcher? To what benefit? If everyone should be moved by stretcher, should we then also give patients other forms of care when it's not indicated? Dwayne, you surprised me with your answer. You say you don't like to walk sick people, do you care to elaborate? Good discussion, guys. -Bieber

Is that your service's policy, Vorenus? What about patients who have a serious complaint but who are hemodynamically stable? Such as someone complaining of moderate abdominal pain (bad enough that a generous guy like you intends to treat it ) with normal or slightly elevated vital signs (they state they can walk)?

Who do you allow to ambulated to the ambulance? Who don't you? How do you determine which patients are appropriate to walk to the ambulance and who aren't? Is it based off of a written policy or is it provider discretion?

I'm with everyone else on this. We've all seen our fair share of naked patients of both genders and all ages, and it's part of our job to see and touch people in ways that would normally result in you going to jail (please, no one misconstrue this, you know what I mean), and it's important for all EMTs and paramedics to be comfortable and proficient in performing a physical exam. There's nothing shameful about it, and while doing it on non-patient classmates for practice can be a little awkward, that will get easier the more you practice. I would suggest making your students do additional patient assessments until they get it right, and emphasize that they will HAVE to (see, not should) be able to perform a physical assessment on any and everyone, no matter who it is, because you honestly do not know who your next patient may be. Your next call could be to a super model involved in a car crash or a little old lady or the biggest guy in the world, and they all deserve a provider who is able to look past their own discomfort and feelings and give them the most appropriate physical assessment in a professional manner that is respectful of the patient and their dignity and is also thorough and valuable to making clinical decisions and determining the next step of patient care based off of the information obtained.

I actually made a couple of comments regarding this incident on a facebook post the other day, though I'm glad to see that nobody here is getting as crazy as the folks on that facebook post were (yet). Honestly... I have no opinion on the matter, because I don't know all of the facts. If she really was fired unfairly and sexually harassed, then I hope that the truth gets out and that justice is served; and if she is lying and full of it, then I hope that the truth gets out too, and that she either learns the error of her ways and does what she has to to fix them, or she gets out of the job. We work in an interesting field where carefully drawn lines that work just fine in an office get fuzzy, and I'm not sure that politically correct policies to prevent people from getting offended on the job fit into our profession as well as the folks who wrote them would like. All the same, if people were saying or doing things to her that made her uncomfortable and she asked them to stop, they should have; but likewise, you kind of gotta have some thick skin working in this job.

Currently we just have lorazepam, but our new protocols will give us the option to use either lorazepam, midazolam or haldol. Never needed to use chemical sedation, though once our new protocols take effect and we don't have to call for it, I might be more inclined to employ it more liberally over physical restraints.

This is the first time I'm hearing about it too. It would be a shame if we lost some of the great reference and learning tools available to us.

The money, fame, and women. Actually, I started college going for a degree in international business and Spanish language. About halfway through that I got this crazy idea that now I wanted to be a doctor, don't ask me why, maybe I watched one too many episodes of Scrubs. So I happened to mention it to someone in one of my Spanish classes and she suggested I go and take an EMT course to get a taste of medicine before I dedicated that much time, energy and money into something I don't like. I remember that after the first day of EMT class I almost decided to call it quits. I didn't think there was anyway I'd be able to learn all of that information or figure this stuff out, but I decided to come back for one more day of class. Then another, and another, and I got hooked. I didn't grow up with any great interest in EMS and my only exposure to medicine was my mom, who'd worked as a CNA when's I was little (she'd been in nursing school, but had to drop out after me and my brother were born). So I was kind of a late bloomer, I took my first EMT course when I was 21, and the rest is history. But srsly, the money, fame and women, yo, that's what I'm really here for.

Dilaudid was the first drug I ever pushed! Word to the wise, slow push! We carry fentanyl, but recently reduced our dose from 1 mcg/kg x2 to a straight 50-75 mcg x2 with no more diluting it, and we're getting morphine as soon as the medical society approves our new protocols (see, in the next era). Other than in clinicals, I haven't ever used dilaudid, so I don't have a great deal of experience with it, though we're feeling the hurt of this drug shortage too. We just recently switched from carrying the 100 mcg vials to 500 mcg vials of fentanyl because that's all we could find. Needless to say, we're wasting a lot of fentanyl right now.

All right, ladies and gentlemen, the topic of this thread is simple (and I couldn't find another one like it after searching, but if there is one and I made a duplicate please let me know): what patients, if any, benefit from a lights and sirens response/transport? We know that under the best conditions we don't routinely save more than a minute of time driving lights and sirens, and that the risk to both us and the patient increases dramatically with lights and sirens response, so what justification do we have for it? Some literature: http://pdm.medicine....es-baptista.pdf (not a very large sample group, they retrospectively looked at 112 transports and compared them) http://www.emsworld....-time-and-lives (cites a study that showed time saved by lights and sirens, while statistically significant, is not likely to be clinically relevant as well as a study done in Pennsylvania that provided a more stringent protocol for lights and sirens use and compared the outcomes of patients) There WAS a study done that showed that response times, when under 4 minutes, resulted in an increase in good outcomes for critically ill patients (can't seem to find it now), however I think we all know that the likelihood of a universal 4 minute response time is pretty low. Now, there ARE patients who do benefit from not dawdling on scene longer than necessary (AMI, CVA within the window of treatment, trauma or disease that requires surgical intervention, etc), and patients whose conditions are so critical that any delays in medical care can be detrimental (cardiac arrest, acute respiratory failure, etc), but aside from those few who benefit from every second saved between the time of onset and the time they receive medical care, are there any patients who benefit from the extra couple of seconds saved getting them to the ER? And is lights and sirens response appropriate for patients who don't fit inside this narrow range of conditions that might benefit from us arriving a couple seconds sooner? I'd really like to hear from the docs and everyone else who's smarter than me (see, everyone), because maybe I'm forgetting some illnesses/injuries that are time sensitive (to the point that seconds or a couple of minutes makes a significant difference), or don't realize how time sensitive a lot of these injuries/illnesses are? What can be done with a couple extra seconds or even minutes for these patients that can make a significant difference in their condition? Thanks, guys.

At my service we alternate between working a city post one month and working one of the outlying "rural" posts the next. This month I'm out in the county and we average about 20 minute transport times to the nearest hospital. Not really rural like most of you guys, I know, but compared to my city post (which is less than a block away from one of the local hospitals), it feels rural to me! Anyway, back to the topic, I notice that I do more en route when we're out here in the boonies than I do in the city. In town, I'll have an IV bag set up and ready to go and I'll usually get my EKG and my stick before we get going (and a med or two depending on what it is and what the patient needs), but when we're at the vacation station I tend to just get my EKG and do the rest en route. Personally, I like taking my time on scene (or, rather, in the back of the truck on scene) to get stuff done (and make sure it gets done and I don't run out of time before we make it to the hospital), than to fumble around the whole way in and find out that I wasn't able to get any care done en route. I guess I'm not so great at the "mobile" part of the job, haha. My advice for you would be to take as much or as little time as you need to deliver the most appropriate care to your patient. Most of our patients need no treatment from us, and those that do typically don't need high flow diesel to be stabilized.

Aussie, you're right, I got that one all sorts of twisted up. Shows how long it's been since I've studied up on that stuff! You're correct that oxygen is what stimulates the closure of the neonatal heart ducts, and that certain duct dependent congenital heart diseases will experience an exacerbation of their condition with high flow oxygen due to the closure of those necessary ducts. P.S. The funny thing is my presentation for paramedic school was on congenital heart disease!

I see quite a few diagnoses on this list that I would consider emergent conditions, and even more that can only be determined to be non-emergent after a thorough workup to rule out serious diseases and etiologies. Some other interesting ones I found: Mittelschmerz Cervicalgia Tietze's syndrome Headache Shortness of breath Now I'm just a lowly ambulance driver, but it seems to me like most of those diseases are diagnoses of exclusion after life threats have been ruled out (i.e. ectopic pregnancy, cervical spine injury, MI, CVA, asthma/COPD/CHF/PE). But again, I'm just a lowly ambulance driver, and I'm just paid for taking folks to the hospital and a preset "level of care" provided. =)

Honestly, man, my opinion is that an associates degree paramedic should be the minimum--and I mean the absolute minimum--level required to work in EMS. Eliminate EMT all together, basic and intermediate alike, and go to a system more akin to that in Australia and New Zealand where you have a "basic" paramedic with an associates degree and an "advanced" paramedic with a bachelors degree. Kansas and Oregon both require associates degrees to become a paramedic, and I can tell you that even with my bright and shiny AAS that our educational standards need to be elevated. Ironically, Kansas, which has higher educational standards for paramedics than the majority of the country, has absolutely no bachelors degree programs in paramedicine... Also, with regards to knowing when it's safe to transport and not safe to, educational standards are just one half of the equation. We need to talk about the elephant in the room, and that is provider-initiated refusals. Nowhere in my education, nor in my orientation at my job, were provider-guided/initiated refusals ever discussed. Not once. Nobody, and I mean nobody, in EMS wants to talk about them. And then we wonder why EMS providers end up getting sued when a patient they "refused" has a bad outcome. If we're not willing to talk about it, and we're not willing to educate ourselves on when it is and is not appropriate to "refuse" a patient, we are going to have bad outcomes. The system is working exactly like it was designed, the problem is that it was designed for failure when it comes to refusals. Until we're willing to accept that it is OKAY to discuss patient-guided refusals, we aren't going to educate ourselves on them, and there will be no standards for when it is appropriate and when it is not. And that means a lot of education on the difference between a diagnosis and a prognosis, how to make educated prognoses based on the information we obtain, and how to take that knowledge and turn it into sound clinical decision making.

Like chbare said, certain congenital heart defects are a contraindication for high flow oxygen because they can end up having undesired blood pathway shunts which bring oxygenated blood where it isn't supposed to be, like the pulmonary trunk causing the ductus arteriosus to remain patent and messing with the pulmonary and cardiac pressures. That's one case where less is more. Other precautions for oxygen use include AMI and stroke, due to the risk of free radicals increasing the size of the infarct.

Routine oxygen use for uncomplicated strokes and MI's has been discontinued in the newest AHA guidelines. Unfortunately, our current protocols still require at least 2 lpm for those, but all other patients oxygen use is basically provider's discretion. I don't put someone on oxygen unless I feel they need it (or unless I'm required by protocol). Oxygen is a drug just like any other, it has indications, contraindications, and adverse effects. You wouldn't push epi without considering all of those, would you?

Exactly. The goal has to be to provide a system where EMS providers can make reasonable decisions on the behalf of their patients given the information they have available to them, and protection from them when patients slip through the cracks. Like it or not, there WILL be that patient who has a history of anxiety and panic attacks, presents like a panic attack, and ends up having a PE and dies an hour after the EMS crew leaves. EMT's, paramedics and the lawyers all have to understand that the goal is not and cannot be to prevent everyone from dying or having a bad outcome; that's an unrealistic goal that expects and demands punishment for any and all failure. The goal is to provide adequate and reasonable care based on the facts available. The "you never know" philosophy is a slippery slope that leads to both financial ruin and unacceptably high levels of unnecessary transport for unnecessary ER evaluation for too many low-risk patients. And the 25 year old male who is otherwise healthy except for a history of acid reflux complaining of chest pain is simply not the same as the 58 year old female diabetic who is feeling nauseous and short of breath and nor should they be looked at equally when they have bad outcomes due to a provider initiated refusal. One of those refusals would be grossly negligent, the other would be reasonable--even if they had similar outcomes.

This is a perfect example of an unsustainable business model, and if it trickles its way down to the ambulance services, I can't imagine how they will be able to stay afloat. If they provide 911 services, they have to transport any patient who requests it, and unless Washington is going to create a mechanism that allows EMS providers to refuse transport based on the patient's condition, they're going to get screwed over hardcore. I'm all for incentives and mechanisms to prevent and avoid unnecessary hospital admission and readmission, but what they're doing is telling folks to work for free--and that is simply not feasible. EDIT: After reading the linked article, I notice that hospitals will be paid a screening fee so that hospitals are paid for the assessment of the presenting patient, so that's good and I think that this kind of system that deters non-emergent patients from the ER is appropriate. The problem is just that such a system won't work for ambulance services unless mechanisms are in place to allow EMS providers to refuse to transport a patient. EDIT #2: I also notice that there is little clarification or extrapolation on what systems will be established to ensure that medicaid clients receive adequate primary care. Without providing primary care options, the elimination of the ER from the already limited list of resources available to medicaid/low-income patients may end up being detrimental. There needs to be more options available to those on medicaid to receive the right kind of care in the right kind of setting.

Wish I could help, but I honestly don't know how much a DUI/DWI can hurt your chances of getting into EMT class or getting hired on at a service. Like some other people have already said, I'd suggest talking to a legal adviser and/or the EMT program director or a local service director. It honestly could be that you're not employable for the next ten years, or they might not care at all. Good luck in your medical career, and don't let this small bump in the road bring you down. There's plenty of areas to go in medicine, and nearly all of them are better paid than EMS. =)

There's always the middle ground... i.e. we make our own ambulance service! Call it City EMS. =)

So we got a preview of our new protocols (which are, for the most part, awesome), and they made a forum for us to post our comments, concerns, questions, etc. in and I (predictably) have been posting a lot of threads there, but one thing I hadn't tackled yet was the pain management protocol (yes, we finally have a dedicated pain and nausea protocol now). However after reading this, I was motivated to do so and have inquired into the possibility of adding a sedative to our pain protocol, based in large part on this thread. So thanks Asys and I'll let you know if we get it!

The most recent info I've read still calls for the treatment of seizures lasting longer than five minutes, citing that neurological damage is suspected to occur after about 20 minutes of continuous seizure activity. As far as withholding oxygen, someone smarter than me is going to have to explain that because it's my understanding that seizures rapidly burn through brain oxygen and glucose stores, which is why we give supplemental oxygen to both actively seizing patients as well as those who are postictal.

It could be fun... =) I've always been a fan of large families. Though I gotta say, I imagine that living with you would require double bolt locks on my door just to stave off any pranks you might pull on me as I sleep!

I got the chance to attend a presentation earlier this year led by Dr. Gordon Ewy, who you may know as the doctor who came up with the idea of cardiocerebral resuscitation (or CCR). In essence, what Dr. Ewy and his fellow researchers have discovered is that there are two forms of cardiac arrest: primary and secondary. Primary arrest, which is the most common form of arrest (>70%) occurs when a patient's heart stops and they collapse. This is usually due to heart disease, and when the person goes into arrest their spo2 levels are still high (because they were still ventilating and oxygenating normally at the time of the arrest). In primary cardiac arrest, you can expect that the patient will retain acceptably high blood oxygen levels for a while, so the principle concern is to get that blood flowing; oxygenation can be passive via blow by with an NRB without risk to the patient. Secondary cardiac arrest, on the other hand, is the rarer form and occurs when the patient is suffering some form of impedance in their ventilation or oxygenation, and their blood oxygen levels fall and fall until their heart is no longer able to meet its metabolic demands and ceases to beat (or to beat effectively). These are the patients for whom ventilatory support and oxygenation is indicated and, in fact, necessary to regain ROSC. The principle problem with our management of cardiac arrest is that we treat all forms of cardiac arrest as if they're the same disease, when in fact they're not. Likewise, cardiopulmonary resuscitation is essentially futile in a patient suffering from a traumatic form of arrest, because either they don't have blood to circulate (massive hemorrhage) or there is an obstruction to blood delivery (tension pneumothorax, pericardial tamponade, or tracheobronchial/great vessel damage/obstruction, etc). Because we've tried to treat multiple forms of cardiac arrest with the same care techniques, we've had limited success to resuscitating patients (in addition to other factors, such as inadequate post-resuscitation care). One of the things I've started to do is to try and identify whether or not a patient is in primary or secondary arrest right off the bat. The best way I've found to determine that is to ask bystanders about their HPI. Were they okay and just collapsed? (Possibly primary arrest.) Were they having trouble breathing and just got worse and worst and collapsed? (Possibly secondary arrest.) What kind of past medical history do they have? (Asthma, CAD, diabetes, etc.) In order to make significant progress in our treatment of cardiac arrest, we have to recognize that primary cardiac arrest, secondary cardiac arrest, and traumatic cardiac arrest are three very different diseases with three very different treatments, and begin to focus our efforts on optimizing our care based on our impression on the etiology of the arrest to the best of our ability. The reason for the change in the ABC to CAB approach to cardiac arrest is because primary cardiac arrest is by far the most common form of cardiac arrest, while our old treatment was best suited for secondary cardiac arrest (the minority of cardiac arrest forms).

Hey, I'll come live in a commune with you! =) Just don't ask me to try the punch. As far as reading suggestions, I'll do some poking around. To be honest I hadn't ever thought too much about communes, so this gives me an excuse to learn something new.