Bieber

I don't think that our pay should be based on our call volume, but I do think that there should be incentive pay after a certain number of calls and even an incentive of some form (be it a bonus towards training, mandatory training days, extra pay, etc) after so many days without calls too. The truth is, most of us aren't even making enough to make it worth it to even sit around doing anything. At least, I don't think so. All of the time you spend sitting there doing nothing is time you could be dedicating towards other, more profitable ventures, but you likely can't do that either while sitting at a station all day (depending on how good your service's internet is!). Not to mention, there's the problem of retention and skills upkeep in a rural environment that have to be addressed. I personally get antsy if I don't run at least four calls in a 12 hour period, preferably more like six plus. Going an entire shift without running a single call is torture for me. While I know there are some folks who are more than happy to sit around making money doing nothing, I prefer to think that most of us got into EMS because we like to run calls, and in combination with low pay the low call volume of a lot of rural services can drive EMTs and paramedics away, which worsens the quality of the service overall. I know a lot of people say that their counties/cities/regions can't afford a paid department, but honestly, the money's got to be found somewhere. EMS is an essential service, and everyone deserves to have a highly motivated, highly trained and educated crew available to them when they have an emergency. Pay per call is simply not able to deliver that in a low volume, rural area oftentimes, I don't believe. As for volunteer EMS, that's a whole 'nother soapbox of mine!

All right, after having read some of the replies, I'll make one of my own. I know several of you were mentioning that the tube was (going to be) needed, and I completely agree. Regardless of her response to oxygen therapy, the ideal end game would be therapeutic hypothermia following proper sedation and intubation. But like Race said, without having RSI in my toolkit (much to my chagrin, rest assured), I believe (and I think the rest of you pretty much concurred) that ventilation via BVM or conscious sedation and THEN intubation were the proper method. As far as the patient's condition currently, I haven't had a chance to follow up on her yet. Hopefully I'll be able to find out something in the next few days. I think that a major component to the lack of fluidity and adherence of proper procedure that I see frequently around here is this persistent, misguided mentality that we've got to "go, go, go". Maybe it's just my service or region, but everyone seems to have such a strong "we've got to get going--NOW!" ideology to EMS care, and I personally am one for taking my time. Yes, even with post-resuscitation care. I am a firm believer that we take as much time as we need to to give the proper care that we are capable of giving, and THEN getting our patients to the next appropriate level of care. (Barring things which can be done en route without being detrimental to patient care.) Many a time during my internship I sat in the ambulance bay at the hospital still punishing a medication, and I regret not having given medications which were indicated because "we're already here" or whatever other excuse, as if brevity of transport was more important than taking a couple extra seconds, minutes, whatever to do what we're capable of and what's in the patient's best interests as opposed to buying into the mentality that skimping on our care is okay if it means the patient will get to the hospital sooner. Wow, okay, I'll get off THAT soapbox for now... Haha. Anyway, I think that's all I got. Oh, and by the way, we're supposedly not allowed to intubate nasally here. I say supposedly because that's what I've been told. Our policies and protocols are somewhat messy and incomplete, something which I believe they're planning on rectifying in the near future which'll make what we're permitted to do and how we're supposed to do it less ambiguous.

Wow, this thread just blew up with activity! Thanks again for all the interaction guys, I swear I'll start replying to you guys individually tonight. Hey Race, I'm out here in Wichita, though I've had the pleasure of speaking with the EMS director of Finney County EMS last year. He was trying to get me to come work out there, but I had to decline. Shoot me a PM sometime!

Hey guys, thanks for all the responses. I'll start replying to them by tomorrow or something. Had surgery to get my last wisdom tooth out today, so I'm not a hundred percent. Great conversation, though.

Race, thanks for piping in! I appreciate hearing your opinion, and I know it's hard to give one when you weren't there. This was very much a "secondary arrest" code blue, patient had a history of COPD and was complaining of dyspnea before she collapsed so I think that she one hundred percent needed the oxygen, I'm just not sure that the tube was appropriate in this situation. She was far from alert by the time we got her to the hospital, but she was biting on the tube and moving her eyes and I think she's going to end up being a clinical save, though it's too soon to tell. Hopefully she won't remember the event, but if she does then I hope I get the chance to apologize to her for the discomfort we put her through--I know that the wimpy little 2 mg of Ativan I gave her wasn't enough, and I wish I'd gone ahead and given 4 mg. I think this was, as I've noticed is very commonly the case (at least around here), a case of us rushing too much to go, go, go when we should have taken a bit more time preparing the patient for transport. That's another thread in and of itself, but for a brief glimmer into that soapbox I'll just say that I think we try too hard to race to the hospital unnecessarily most of the time instead of taking a bit longer to ensure that we're giving the full amount of care that we're able to in the field and THEN moving on to the hospital. Also, I see there's been almost a thousand views of this page already. Stop just looking and start posting, folks!

Hi everyone. I've been busy lately, but I had an interesting call the other day and I wanted to get your guys' opinion on it, because it's been a while since I've read up on airway management but I've had a lot of experiences with difficult airways lately, including the most recent one. To start off, I'll give some background on myself and my service. During my clinical rotations I had 29 successful intubations out of 32 attempts, and during internship I had 4 successful intubations out of 5 with the fifth one being a difficult airway due to a very anterior trachea. Since getting my big boy paramedic patch, I've had three attempts and one semi-successful intubations. -Attempt #1: Code blue female in her late twenties, airway was all full of vomitus. My error: failure to suction deep enough to adequately clear the trachea of vomitus enough to visualize the cords. -Attempts #2: Semi-successful intubation. Late 50's male code blue. I successfully intubated but at the time I was uncertain of the patency of it due to excessive chest wall tissue diminishing lung sounds. I saw it go through the cords but didn't trust my eyes and pulled the tube unnecessarily. -Attempts #3: Most recent attempt. Early 80's female code blue. Initial rhythm was PEA that quickly turned into a pulsatile sinus tachycardia with chest compressions and BVM ventilations alone almost immediately upon our arrival. No meds given, and after we retriaged her code red (critical), I attempted to intubate. She fought the tube and was biting it and I wasn't able to pass the tube. My partner was, however. This most recent attempt, however, got me thinking. I'm not sure if intubation under those conditions was really desirable or advisable due to the fact that while she had an uncontrolled airway, she was coming around very quickly and fighting the tube. I believe that if we WERE going to tube her, it would have been best done under RSI; however we don't have RSI at my service--the best we could have done was sedate her first. She WAS breathing spontaneously (though poorly), but I think that we might have been better served by either managing her airway via the BVM or getting some sedation on board initially. I don't like having to fight a patient to force a tube down their throat, and I question whether we should be trying to tube someone if we have to fight with them for it. I WAS at least able to convince my partner and my captain to get some sedation on board AFTER my partner successfully passed (see, forced) the tube, but my captain commented that, "I hate to knock out her respiratory drive right after we got it back." The problems I see with that comment are these: I am NOT, I absolutely am NOT, going to leave someone with an ET tube down their throat without giving them some sort of sedative--not if they're awake or conscious in any way. That's beyond inhumane and cruel as far as I'm concerned. Secondly, if we're going to insist on jamming a tube down their throat, we're not going to be concerned about their respiratory drive. We've already made the decision that WE are going to be responsible for their airway, so WE are going to be the ones to take care of it. If we insist on forcing a tube down their throat, we're not going to leave them in pain because we want to preserve their respiratory drive. Either we're going to assist them in breathing for themselves, or we're going to breathe for them--not some perverted mix of the two. We've got the tube, we've got a BVM, the hospital has a ventilator. We can make them apneic if we have to and be all right. (Though I didn't "snow" her with the sedative, or knock out her respiratory drive with it.) So, yeah. Tubing folks who are conscious enough to fight the tube?! Am I the only one who sees a problem with this? Someone call me out if I'm wrong here, but if we're going to be tubing folks who are capable of fighting us, shouldn't we have adequate RSI in place before that? Is it acceptable to force a tube down a fighting person's throat? Am I totally off base here? Thanks guys, -Bieber

Rest in peace.

Dwayne, there's hereditary angioedema (Quincke's angioedema).

Herbie, you're absolutely right. I don't know the statistics, but anecdotally the number one cause of uncontrolled seizures is poor medication compliance either due to financial reasons or some other factor. Dwayne, there just might be! Stay tuned. Mobey, I actually gave Ativan 'cause that's all we have (currently, heard we're supposed to be getting Valium (back)), but to give you guys the scenario I had, let's say that the additional Valium fails to completely suppress the patient's seizure activity. Between seizures his vitals are stable and about what you would expect from a patient post-seizure, and he does not react to the NPA. So, the kicker, why is this patient in status? Are there any other questions you want to ask the patient's mother? What do you want to do now? Time to move or do you want to continue to stay and play?

Dwayne, that was an excellent PCR brother. Seriously, reading that has made me rethink the way I write my own PCR's. Thanks for sharing that with us, man.

Dwayne, share a glimmer of what you learned with us. I'll post a sample PCR of mine tomorrow--time for me to go to bed. -Bieber

Well, Dwayne walked into the apartment and now the mom is crying. Haha, just kidding. Our multinational team of skilled medical providers is able to calm her down somewhat and obtain a semi-thorough history. PMH: Epilepsy, poorly controlled but never this severe before (first time status episode was earlier this morning, usually seizes about 3 times a week with no complications resulting from those seizures). Mom also states he's been "sick" lately. Mother adamantly denies any recent trauma. Meds: Unknown seizure medication (does not take it due to financial constraints), also supposed to be on some sort of antibiotic starting with a K. ("K... Kef... Kef-something?"). Mother denies any illicit drug use but states he was taking diphenhydramine recently to help him sleep. Allergies: Penicillin. And because you are an astute and also very handsome paramedic, you wisely have your partner get a BP in between seizures ("GET A BP QUICK WHILE HE'S NOT SEIZING!"), and also because you are a skillful (and did I also mention handsome?) paramedic, you successfully obtain an IV 18 ga in the left forearm in between seizures. Vitals are as follows: HR: 125 EKG: Sinus tachycardia, no ectopy. BP: 132/88 SpO2: (between seizures) 98% on 15 lpm O2 BGL: 80 mg/dL You push the diazepam, and the patient continues to seize! However you do note a slight decrease in the strength of and a lengthening of the interval between the patient's seizures.

You are working in a smaller city on the outskirts of a county with two level I trauma centers in the principle and much larger city (about twenty minutes from your location) when you and your paramedic partner are dispatched at around 2000 for a patient complaining of a seizure. You drive emergency traffic to the scene and arrive to find the patient, a 23 year old male, lying on the bed of his third floor apartment actively seizing (grand mal, currently in the clonic stage if you care to know). BLS fire personnel are already on scene and have safely removed any hazards from the patient and applied oxygen (15 lpm via NRB) to him. The patient's mother advises that the patient has a history of seizures and was brought to the hospital by EMS earlier today for the same reason, given dilantin, and discharged. She also advises that the patient began seizing approximately 10 minutes prior to her calling 911 and suffered three seizures prior to the arrival of fire. Fire personnel advise the patient has seized two times since their arrival, with each seizure lasting approximately 1-2 minutes. Good luck. -Bieber Edit: Added a couple of details.

I sensed a disturbance in the force, and now I know why. You've been talking about me, Dwayne! As for the OP, do what you think is best. Take your time to make the decision, and consider the pros and cons to carrying any sort of first aid/medical equipment with you. There's plenty of both. Personally, my cell phone is the only thing I keep on me when I'm not at work, and that's honestly always been more than enough. I don't even hardly ever use the basic trauma supplies (4x4s, trauma dressings, etc) when I'm AT work, so I doubt they'd ever see use off duty. You may find that your views about carrying equipment off duty change over time, and you've got your whole career to tweak how you do things both on and off duty, so if you just want to experiment--do it! Test the waters both on and off the clock and see what feels right to you. -Bieber

We don't have a specific protocol for patients complaining of pain with sickle-cell disease. I'd probably call for orders for fluid and fentanyl as needed to control their pain.

I used an ammonia inhalant tonight on a patient who was extremely lethargic. Found sleeping in her car by some people way out in the county, sheriff's officers had her in the back of their cruiser when we showed up. I tried multiple times to speak to her so we could get some information on what had happened (she had multiple prescription meds + presumed illegal drugs found on her person), and while she was oriented x3, she was just so quiet and lethargic and unwilling/unable to wake up enough to talk to me much that I couldn't hardly get anything out of her. Used an inhalant to get her awake enough so that she could talk to me and tell me if she had taken an overdose of her prescription meds/illegal drugs (which she denied), and then let her sleep on the way in. In this case, I wasn't trying to be a jerk, but I needed to get some information out of her and my repeated attempts to rouse her verbally had failed. Also, on another note, my IV success rates are sucking lately. I'll get good flash, but when I try to advance I meet resistance. Help? With her, I can at least blame it on her veins being scarred (multiple scars on her arms suggestive of IV drug use), but I don't know how long I can count on that excuse--and there's no excuses for missing an IV to begin with! -Bieber

I've heard about ketamine, unfortunately we don't carry it and I don't know anyone around here that does.

Anecdote is the seed which spawns research to either confirm or deny the observations of an individual or group of individuals as being true or usually true on a universal scale. We have to recognize what it isn't, but we also have to recognize what it is: possibility that may merit further exploration into something that may or may not have already been confirmed but which nevertheless deserves more of an answer than just "maybe" or "I don't know". Anecdote isn't scientific fact in se, but at the same time if we stopped asking questions and exploring what may or could be based on our own experiences, then we would only stifle research and further growth by limiting ourselves to only investing our energies in studying what has already been proven to be scientific fact. Science and medicine will never move forward without people who are willing to say, "This is what I experienced, but I want to know if this is an anomaly or reality and we deserve to know the answer."

http://www.ncbi.nlm.nih.gov/pubmed/16029830 Paramagic, you're welcome! Dwayne, I'm trying to find any studies that support/deny the use of titrated pain management and its effects on pain. And man, you already know, the only dumb question is the one not asked. You don't look stupid at all, you look like someone who is seeking answers, which is exactly what this forum is all about. Also, I've found a couple of protocols supporting the use of pain management in trauma as long as the systolic BP remains =/>90 systolic. The studies and literature I've also read indicate that hypotension is an extremely rare complication of fentanyl, with bradycardia and respiratory depression being much more common. http://www.emsworld.com/print/EMS-World/Prehospital-Pharmacology--FENTANYL/1$6016

http://www.google.com/url?sa=t&source=web&cd=3&ved=0CDoQFjAC&url=http%3A%2F%2Fwww.denveremresearch.org%2Findex.php%3Foption%3Dcom_phocadownload%26view%3Dcategory%26id%3D38%3Ageneral%26download%3D209%3Asafety-of-prehospital-single-dose-fentanyl-in-adult-trauma-patients%26Itemid%3D8&ei=qC98TpZqppCwAoGzrEQ&usg=AFQjCNHGh4Js_dPl8ZKnK2swt1A-jTYKpg http://www.dhmc.org/dhmc-internet-upload/file_collection/11.18.04%20-%20Pain%20Mgmt%20-%20New%20England%20Trauma%20Competition.pdf I'll post more as I find them.

Dwayne, if your goal was to minimize spinal movement, I'm not sure how forcing someone onto a hard board that'll just make them writhe more would accomplish that. I think you did the right thing to withhold immobilization. As far as pain management goes, I can't say for sure what I would do without having been there, but I understand your hesitance and share it. Titrating to me means initiating therapy at a lower level than typical and cautiously trying to find the balance between benefit/risk. Good discussion man. -Bieber

...ahem... well... no... So... guessing that means we do know that she's got a pelvic fracture, unlike what you knew at the time... so... yeah, like I said, maybe we won't sit her up... Titrate fluid and fentanyl starting at 0.25 mcg/kg as tolerated by the patient! And let's strap a KED around her waist upside down.

Vorenus, she's hypotensive so I'm going to stay away from CPAP for now, but anecdotally I've gotten good results with resolving pulmonary edema with just sitting them up and high flow O2. I suppose we could assist ventilations with a BVM too, though if CPAP is contraindicated with hypotension I wonder if all PPV would have a similarly negative effect on their blood pressure... I'm guessing so, anybody think I'm looking at that wrong? The problem is PPV is gonna increase the vascular resistance for the right ventricle, which could further exacerbate her hypotension, but with that fluid in her lungs we don't want to risk drowning her with fluids and dopamine is contraindicated until we've replenished her volume (if we've identified this correctly as a fluid problem as opposed to a pump problem by now). Ideas? I agree with Paramagic that a small fluid challenge might be appropriate, assuming we're getting good oxygen exchange to begin with otherwise we'll just be throwing more problems onto the ones we already have.

Dwayne, was the first patient acting normal and appropriate compared to her baseline or was she altered from her normal status? I think as far as fentanyl in the setting of an already hypotensive patient it comes down to a judgment call. You said her perfusion status was critical? What was the rest of her presentation with regards to her end-organ perfusion (besides the altered mental status, assuming it was altered from her baseline)? As far as treatment, if I had no clue she had a pelvic fracture, I'd try to localize the source of her pain/distress, which if she was too distressed to state because of the pain might be facilitated by carefully titrating fentanyl until she was at a level of comfort that she could give you some clue as to what was going on. If she's got the crackles, fluid might exacerbate that especially if her heart isn't keeping pace (which if she's got fluid in her lungs, it isn't), and unfortunately hypotension is a contraindication for CPAP. Let me get a full history and vitals from you and I can tell you more of what I would do, but to start us off why don't we: -Sit her up if she tolerates it. It might drop her pressure but we can't give fluid if all it'll do is fill her lungs up, and we don't want to go the dopamine route until we have a better history so we're not giving it in the presence of incomplete fluid replacement. -Get her on an NRB at 15 LPM and see if we can get some of that fluid out of her lungs so we can deal with her circulatory problem. -Get a line in place with NS TKO for the time being and do a 12-lead EKG. -Get a full history of present illness, along with any other medical history not already noted along with meds and allergies! Also, an open book pelvic fracture occurs at the symphyses pubic and at one or both of the sacroiliac joints, usually from injuries to the groin. Gonna need surgery. And the patient's presentation (assuming she is altered from her baseline) is consistent with end-organ hypoperfusion. Addendum: I'm going at this scenario from the presumption that we don't know that this patient has a pelvic fracture at the moment.

The current treatment guidelines for hemorrhage go something like... Significant Hemorrhage? (Yes) > Direct Pressure > Hemorrhage Controlled? (No) > Tourniquet Although I think there is a "Consider Cauterization with Lightsaber", but only if you're a Jedi Master...