TechMedic05

So, just because a patient does not completely fit perfectly into a patient care protocol we can no longer do anything for them...Well, short of driving really, really, really, often unnecessarily fast?

I was always a fan of not putting a patient into arrest. COPD and Asthmatics, especially intubated, obviously require a longer expiratory phase in ventilation. If their body is producing a 5-7 second expiratory phase, like with pursed lip breathing, we should probably adapt similar numbers, if not longer when intubated. These patients are now getting 100% oxygen with pressure. A lot better than 21% oxygen without pressure. People look at me weird when I ask them to ventilate at 8 a minute. Anyone have any idea of end tidal CO2 monitoring in a non-intubated patient would be helpful in determining a need for a longer expiratory phase in ventilation? I haven't been able to find a good description of etco2 monitoring in the non-intubated patient.

Sounds like an instance of "Cardiac Asthma", or beginnings of CHF, and the albuterol helped 'push him over the edge', per se. Although some initial relief from the bronchoconstriction from irritation of some fluid buildup, the CHF has worsened. He may not be able to answer, is there anyone else on scene who may be able to help with HPI? Good to know he's afebrile. Any hints based on scars? medications lists, or bottles? Any response to 'Cardiac history?' I'd discontinue albuterol, change to a high concentration oxygen, ensure position is upright, and go ahead with some nitro SL. Considerations - Have we established IV Access? EKG? Consideration of a 12 lead fairly rapidly might be a good idea. Continue with nitro SL, Furosemide 1 mg/kg, thereabouts. Or double his normal dose. Consideration of Morphine 2-4 mg IV, repeated per local protocol. Reassess the patient between treatments, and go from there. It's a start.

My alarm clock was sponsored by Viagra. It helps me get up every morning.

Wow, I like it!

In turn, Paramedics are supposed to be better than Basics or Intermediates [including Canadian equivalents]. As an ALS provider, one should be more than thoroughly and utterly competent in all of their BLS skills. Hands down. Yes, we can still learn from each other, any level to level, but an Advanced provider should have no issues with the BLS. Now, I'm not throwing this out there to say we don't need BLS because we're better at it. guess what, we work in a system, where we should rely on each other to reach our goals: Transporting patients to definitive care, and performing appropriate and helpful interventions on the way. Paragods are the ones who will walk in, disregard any other healthcare provider, and only address the patient. I know I hated it when I called for ALS and was promptly ignored. Anyone can do an assessment, right?

Yeah. It's kind of funny, almost, up where I'm from. There are a couple Paramedic programs that are only certificate, where there's either a few month program, or a 16 month "Saturday and 2 night/ week" class, where expectations are quite different from the only degree program in the area, which has a 70 credit requirement. I know through all of the core classes, we never left a class early once. Actually, we rarely got out on time they had that much information on knowledge. And there still wasn't enough time. And "The more you know, the more you know you don't" is completely true. Even after several years of working, there's a huge difference between [most] of the degreed and non-degreed programs. I'm still going back to school.

Sounds like the Department of Redundancy Department. I've been a lifelong member all my life.

Dust - I agree with you completely. And that's a great way to put things. But do we expect people wanting to get into this field to choose a two year [if not longer] degree program versus a certificate program for less money, less time, and lower expectations...For the same pay? You expect people to become educated beforehand? Or, even, I know many who don't even care the quality paramedic they are, because 'All Paramedics are the same, we are all NR, insert state here', etc. etc. Jeeze, I'm going back to school :-P

Spock - Thank you, and that is a rather well written response. I, personally, had no idea of the possible biased opinions of that research. Just proves that EMS needs more research. Just one study isn't enough to go change practices. It's also interesting to hear more about intubations from someone who, I assume, works primarily in OR's. Thanks for noticing, and, do you work in the prehospital arena at all?

Sorry Admin and Forum... ...It's like the guy never takes a vacation ;-)

Cosgrojo actually doesn't do QA/QI, but only billing. QA/QI is a whole other department. He basically prescreens paperwork to ensure it's 1- there, 2- complete, 3- correct. That's it. then it gets sent somewhere...Ohio? to be coded, billed, and lost. Eventually it's lost, found, buried, fermented for 3-13 months, then used as finger painting paper for kindergartners before it's faxed back or notified back East as 'Lost'. I just drive the ambulance.

Then how on Earth am i to ever know I was wrong, and go and correct my mistakes? Yeah, I'm sure there's BATT charts on my paperwork, and memos, and near apocalyptic events daily, but why can't we/ you just tell people what they're doing wrong so they can fix it? And I do find it rather difficult that an intelligent gentleman such as yourself would need to work and slave in an ambulance for several years just to get the wondrous opportunity to audit EMS run forms for billing. I guess, to defend your company...It's only one of the largest EMS providers in the United States...not like they can afford such things.

"*auditor* I've seen your so-called "billing" skills." Oh, that's right. In an effort to save more money, the company will pay you your overtime rate to avoid paying an true honest biller/ auditor. GOGO EMS! And as far as my billing skills go...well, what ever do you mean, kind sir? I can spell, I'm honest, and I know what the words I write on my reports mean...And! I get signatures. What else is there? I feel I'm rather thorough when it comes to sufficient documentation. I guess if it means anything, nothing has ever bounced.

"but we do run a strip on all deceased for hard copy to go along with our report form and if it is the stupidest thing you have ever heard....there is a lot out there that would really amaze you, " Well, kind of a side note...A state in my area advises against performing any ECG on a patient you will not be working. Most likely for the traumatic patients, it's a 'Don't go looking for something you do not want to find."

omg. Chaz, you are SO correct! I so completely forgot about that. All joking aside, the Goffstown, NH Fire department likes to staff it's ambulance(s) with at least one Intermediate to be able to bill for ALS...If it's a B/I crew, the Intermediate can not triage any patient to the Basic. The Basic is only allowed to drive. Why? For the all mighty ALS billing. Stupidity runs amok.

33% Dixie. You are definitely a Yankee. A Yankee, yes. But I despise them. I'm a Sox fan. Of the Red nature, to be specific.

Yeah, I smell what you're stepping in for sure. I am going to have to continue to be feisty and correct something else...Medics are good for more than just pain management and cardiac. Something like...Airway?...hrmm...and a few other things. And I'd even bet many are familiar with BLS, too.

As from NH's Protocols: Restrain if necessary and only for the patient's and crew's safety. Use soft restraints and monitor distal circulation. Consider Paramedic Intercept Restraint Notes: Use minimum force necessary. Restraint is never for punitive reasons Frequent Airway Monitoring Do not restrain patient: - Face Down -With hands behind back -With both hands over the head to the top bar of stretcher [one is acceptable] -with straps over lower thorax or upper abdomen - Using a "sandwich" restraint with scoop or backboard. Paramedic Standing Orders - Adult Consider: Haloperidol 2 mg IV or 5 mg IM, may repeat every 5 minutes to a maximum dose of 10 mg and/or any one of the following: Lorazepam 1mg IV or 2 mg IM, may repeat once in 5 minutes or Midazolam 2.5 mg IV may repeat once in 5 minutes or Diazepam 2 mg IV or 5 mg IM, may repeat once in 5 minutes. Flumazenil 0.2 mg IV over 30 seconds to reverse the iatrogenic effects of benzodiazepines Diphenhydramine 50 mg IV/IM for acute dystonic reaction to haloperidol. NH State Protocols Other than that, most places I've worked have had a policy that the patient be evaluated in under an hour by a physician for continuation/ evaluation of possible injuries caused by restraints. And it is typically easier to just let the police restrain people. They have better toys for it. And I don't fly, but I know if anyone is going to be flown, the Air team will just RSI.

Cosgrojo- Knowing the area in which you are employed [Read: New Hampshire, for everyone else], I happen to know your protocols. BLS can do a lot more than many think. In NH, anyways, Assess assess assess. Just because a provider is BLS doesn't mean they can't become familiar with, and provide, ALS assessments. You have oxygen at about any quantity you'd like, Aspirin is normally a good idea. And also, if the patient has their own nitroglycerin you can 'assist' them with it x3 as long as their blood pressure is over 100/p. A couple more things NH is getting to is, as recently added to almost all of our protocols: "Minimize On Scene Time.", and also Basics are now allowed to perform 12 leads to Fax to the receiving ED. Sure, asking basics to go and learn how to interpret 12 leads may be a bit too progressive, but fax them to someone who can. Early notification to a receiving facility is also a huge part of this system we work in. [Now, yes...I understand the company you work for doesn't have 12 leads for BLS trucks...Hell, as an ALS truck I didn't have 12 lead a portion of the time...and I know said company also doesn't like providers to think. ::bangs head on wall::] And I'd take good BLS over bad ALS any day.

AZCEP - I agree with you. good BCLS and ACLS makes a world of difference...however, once you've been on scene for 10-15 minutes, and say on your third round of Epinephrine...Heaven forbid you get a pulse back. now, instead of being 35 minutes from a hospital, you're now still at least your normal 40 minutes. I don't see why sitting on scene for the entire code is all that great of an idea. Especially if you do have a return of spontaneous circulation. does it happen often? No. Does EMS play by frequency? Shouldn't. Yeah, we don't do childbirth everyday, but many carry pitocin. We don't have traumas every day, but we carry traction splints. Not everything is about what does happen, but what could happen. I, myself, wouldn't want to be at a family's house for 20 minutes, only to then be rushed about packaging and transport a then critical patient and leave any doubt to the family that I somehow delayed patient care. EMS is still a part of a system. System is one third of our name. We are also not definitive care. I feel our number one priority is to deliver our patients to definitive care. If we happen to treat the patient appropriately and properly, all the better. That being said, the appropriate treatments, and continuing education are an extremely close second.

Cosgrojo - Been around a while? It was only in the 1950's and 1960's that we were run from funeral homes, and "You call, we haul, that's all." Compared to, say, nursing, we haven't been around all that long. Just now people are realizing what EMS can and should be doing. And just now research is focused on prehospital measures, not just hospital based applied to the prehospital arena....say, like, 2 amps of sodium bicarb as the first line arrest drug. We have a long way to go, still.

The Autopulse looks to be a bit better of an option than the pumper. unfortunately, they're [i believe] still investigating a thoracic spinal fracture that was possibly caused by the Autopulse. Realistically, with new research coming around, it should be neat to see the new toys people make.

Congratulations! Now you can start to learn. :-D Have fun with it!

Yeah. It would then make it rather difficult to explain some situations. What if you intercept a service for a patient in an asystolic arrest, and work the patient on scene? Happens. Now, after working for a few minutes, heaven forbid you actually get a return of spontaneous circulation. Is there anything there to protect providers from a potential liability for not transporting in a timely manner? It would seem rather...silly...to work a patient on scene for 10, 15 minutes, and then be all hurried to transport a serious patient. Just my $0.02