EMS49393

Well, since you all felt the need to jump my butt over the joking thing, I guess I'll have to clarify. We have a VA hospital here, as well as several elderly multi-residential buildings. A good many of the male patients will joke and flirt with both my partner and I, especially on routine transports. There is an exchange of jovial discussion, some story telling on their part, and a patient that was happy I didn't ignore them like so many other medics. I'm sorry I didn't explain myself clearly enough. I'll be sure any of my subsequent posts are at the fourth grade level.

What's wrong with a simple "what's going on today?" That's my standard line, of course it's more often than not directed at the fire captain already on scene. We rarely beat rescue, there are many more of them than there are of us. Occasionally, I have to start off with "okay, tell me what happened" directed at the family of an unresponsive or coded patient. I take in the information they tell me as I'm doing my physical assessment, interventions on said patient. I leave the joke telling for my non-critical patients, and only after I have established comfortable communication with them.

As a matter of fact, I have. I used to work for this subpar private ambulance company that had the goul contract of running all the dead bodies to the morgue for autopsy. For some reason, these bodies had to go by ambulance, and for why, I'll never know. I had a brand spanking new EMT with me one night. He was an excited, energetic, former sanitation engineer that completed the 18 day wonder EMT class and was now on his first solo shift, with me. First run out of the gate was to the local childrens hospital for a body pick-up. He was six weeks old. His mother slammed his head into a wall because he wouldn't stop crying. The sister got immediate power to make medical decisions, and after it was determined the baby was brain dead, they terminated life support. This was at 1900 hours. We arrived for pick-up at 2300 hours. His little heart was still beating, a terrible, agonal 40 or so bpm. I told my partner to take the stretcher and go back to the truck. I asked the nurse if we could just wait a few more minutes before putting him in a bag. Give his heart a chance to know he's gone. I carried him to the truck, strapped him on the stretcher, got up front and directed my partner on how to get to the morgue. I told him to remain with the truck. I scooped up the baby and took him to the morgue. The security guard in the elevator asked me what happened, and I told him. He said the most comforting words he could muster. He told me that at least one person had a chance to hold that baby with love and not hate. I guess he noticed the "mommy rock" I was doing in the elevator. My partner asked me why I let him off the hook on that call. I told him that I hated these coroner runs. They're goul runs, and we shouldn't be using ambulances to do this. He was so excited to get out there and "help people." I just didn't want his first solo run to be his last run ever. Every now and again I think about that baby. Luckily for me I have a strong belief in God and Heaven, and I know that baby is better off where he is. Surprisingly enough, women make great paramedics, great nurses, great doctors. We're inherently more empathetic than men. Unfortunately, that's often our career downfall.

I won't correct you simply because you're correct. It's a dangerous drug, like all drugs. I had an interesting diabetic case a few years ago. I had a patient, 50's year old female, insulin dependant diabetic that had been vomiting for two days. She had not taken any insulin during this time because she was concerned her glucose would fall to a level that would render her unconscious. She was alert and oriented, however she felt that her glucose level was lower than normal. I established an IV for fluid replacement, and to administer an anti-emetic, since she was still actively vomiting while I was there. Her BGL level was in the 40's. Her normal range was 100-130 mg/dl. I gave D50W 25 g IVP. Oral glucose was a bad option with the vomiting. Her BGL level rose to 75 mg/dl. I transported her, rechecking her glucose once more before arrival to the ER. It maintained in the low 70's. A follow-up revealed that her electolyte balance was very much less than balanced, and she had used up any available glucose in her body attempting to maintain her homeostatis while being sick. She would not have been a canidate for glucagon. What if she would have been met by a BLS crew? Hopefully, they wouldn't attempt to adminster oral glucose, since she's actively vomiting. Glucagon wouldn't have done much for her, and they still would have needed ALS to handle this very sick diabetic patient. On top of that they would have stuck her at least three times to come to the determination that they wouldn't be able to raise her glucose level. If they would have understood the pathophysiology behind this illness, they wouldn't have spent all those minutes on scene with a sick patient when they could have been on their way to definative care. There is one other very important reason to stick a diabetic as little as possible. They do not heal as well as a person that is healthy. They often have neuropathy, and if they are a poorly controlled diabetic, they may already have skin breakdown and sores that will not heal. The last thing they need is another route for infection.

I didn't want to get involved in this discussion, but I just can't believe some of the "pro" arguements. I can say, as a paramedic, when I'm faced with a patient that has an altered mental status, I have a methodical way of assessing and treating said patient. I assess the airway, especially the adequacy of ventilations and place oxygen/support the airway. I look at skin signs, and I assess the circulation. I place the cardiac monitor on the patient. While I'm doing this, I'm asking questions relevant to this particular patient. I attempt to get a history, both medical, and events leading up to the patients current condition. I establish an IV. The venous blood I aquire from the IV stick is what I use to check a BGL. If I absolutely can't establish an IV, I'll get a fingerstick. I'll continue with my assessments and treatments based on my initial assessment. I try very hard not to open up two routes of infection in any patient. A fingerstick, no matter how benign you feel it is, is invasive and breaks the skin, also known as the first line of defense against unwanted organisms feasting on the body. I'm against basics having oral glucose, and I'm even more against them having glucagon. There is a lot of pathology involved in diabetic emergencies. Giving them some glucose, waking them up and letting them eat a peanut butter sandwich while they sign your refusal may see like a logical and appropriate treatment. It's not even close to all that is involved in appropriate treatment, especially the refusal part. I don't often buy the "I took my insulin and forgot to eat" story. I rarely get refusals on patients after a D50W miracle. It's easy for me to stay away from refusals on these patients... I don't administer the glucose until they're packaged, in my truck, and on the way to definative care. I've seen too many patients with more than one problem. There is nothing that says you can't have a stroke and have hypoglycemia at the same time. I'm sorry if I hurt your feelings, but you are not helping me by getting a BGL off a fingerstick prior to my arrival. There are a lot of things I'd rather you do for me, that in my opinion, are far more important to me. Make sure the airway is open, and the patient has adequate ventilatory effort, make sure they have adequate circulation. Move all the crap in the house out of the way so we can expedite removal of the patient. Gather a name, history, allergies, event leading to incident. If we're going to intercept, then get moving out of the house so we can speed up time to definative care. These are the things I need from the BLS crew on scene before I get there. If you can't tell me everything I had to learn about a drug, than you shouldn't be administering it, period. Everytime you administer anything, you're jacking with homeostasis. Make darned sure you know what to expect. Now, give me all the pathophysiology behind diabetes, including all the types of diabetic emergencies, and how they are treated, and I might let you have a glucometer. Pros: none Cons: lack of education

I have to agree with ruff about starting in EMS so young. I started EMS as a (gasp) volunteer when I was a teenager. The state certified at 16, however we could only ride as a third until 18, otherwise known as the legal age of adulthood. I wish I would have stuck with my other hobbies in school instead. Now, I've been in EMS for 17 years, and about six months ago I had a bad two weeks. Every single call was bad. A two year old struck by a car and unresponsive; an emaciated man found dead in his apartment; an 81 year old vet having a STEMI telling me he knew he was having his last heart attack; a man in his 40's that removed his head from his torso with a 12-gauge shotgun shell; an 8 year old terminally ill child having new onset seizures that I couldn't stop. There were plenty more bad ones in that stretch, that's just the high-lights. I was the angel of death. You would have thought the grim reaper was paying me off. I had run plenty of nasty, awful calls in my career, but the one constant in all those calls was a break. I averaged two or three really bad runs a year, not 20 really bad runs in two weeks. I could handle this at a slower rate, but when it sped up, I lost it. I started dreaming about all the dead kids, headless men, and rigored elderly I'd run on in the past 17 years. I'd wake up screaming, sweaty, crying. I'd scare my partner. I had an anxiety attack nearly every time I was dispatched out because I knew it would be bad, and it would be my fault. I knew I had to get help or get out. I sought out EAP services, and now I'm a happily counselled and medicated paramedic. I'm not ashamed of needing help. I was even less ashamed when I found out nearly all of my coworkers are living better through pharmacology. Unfortunately, as women, we are inherently more empathetic and sympathetic than men. It can often hurt us, but it's also the most wonderful quality we possess when taking care of someone. We often listen harder, explain more, and treat kinder because we are female. We don't have to be macho. Of course the flip of that is someone telling you to find a new career because things are bothering you. Take it like a man! Well, we're not hardwired like the menfolk. It doesn't mean we should all just become schoolmarms. It only means that we have to remember to take care of ourselves, while we're busy taking care of the rest of the world. Get help, get better, get back to work. If you need anything, PM me.

If memory serves... Back in the day when I had my pick of the litter for anti-arrhythmics, WPW was a contraindication for adenosine. Procainamide was the drug of choice at my particular service. If immediate cardioversion wasn't necessary, a 12-lead was obtained prior to any drug therapy to better determine if the arrhythmia was atrial or ventricular in nature. Of course, I have an aging memory. I also have my pick of lidocaine and lidocaine for antiarrhythmics at my current service. -'93

:banghead: I wouldn't have a problem with fire and EMS classes being offered in a vocational/technical setting in high school if they enabled a student to have a career when they graduated. That is not the case in most places. You can roll out of the auto mechanics program and into a career. You can roll out of the cosmetology program and into a career. You can NOT roll out of fire and EMS vo-tech into career placement. An evening class a few nights a week is one thing, wasting half a day is entirely different. I grew up in the great state of Maryland. We had vo-tech schools in several counties. The purpose of the fire/EMS vo-tech classes were to let students waste quality educational time to benefit their volunteer fire departments. There is no career involved in this. They can't even work private ambulance, as the minimum driving age for most services is anywhere from 21 to 25 years old. They can apply to the various career departments in the state, but they don't give a rats behind if you have fire or EMT training. If you're lucky enough to get hired, you'll go through all that training again in the academy. Career departments often like candidates with NO previous experience. You'll have less bad habits they have to beat out of you. Now, it seems to me that a student would get more benefit from upper level math, English, science, etc. Classes that would help them when they go to college, and pursue their dream of being a paramedic. I can tell you from personal experience, and I'm fairly certain I'm not alone here, that college graduates have a far better chance of being hired than someone that dismisses half their high school education so they can play around in their volunteer house all day. I feel that same way about cutting class to run calls. You need an education. It doesn't matter how much you think you know, or how much homework you keep up with. Nothing can replace your lecture time in class, and your interaction with your teachers and fellow students. Let the adults handle the emergencies while you handle your learning.

What a fantastic idea!! Let's forget all about algebra, English Lit., Chemistry, History, and all of those other useless classes they offer in high school. It's much more important to learn how to put out a fire or sling a bandaid at 16. It's not like you have to be literate to be an EMT anymore. :roll:

I never said my eyes weren't as big as saucers when I saw that printing out. :wink:

Purely prophylatic. I believe the benefits of giving an anti-emetic with that large dose of morphine, in the presence of an acute coronary event far outweigh the risks. I'd hate to be in the middle of busting my butt trying to ensure this gentleman arrives to the cath lab alive, only have him start vomiting, thereby increasing the oxygen demand further on the myocardium. In this particular call, I had the gut feeling that the stress of vomiting would end this man's life rapidly.

47 year old male, found on the bed. States he was mowing the lawn when he developed severe substernal chest pain. No radiation of pain, mild shortness of breath. Wife called 911 less than 5 minutes from onset of symptoms. Our arrival less than 6 minutes from call. 12-lead performed within 2 minutes of patient contact, rapidly moved to ambulance, thanks to the fire department cooperating. Scene time less than 8 minutes. (They're always in the back room of the house.) Less than 10 minute transport to ER. Treatment included: 18 g IV x2, ASA 162 mg PO, NTG x2, high flow O2, Morphine 10 mg IVP, Zofran 4 mg IVP, NTG drip established and titrated to 50 mcg/min by arrival to ER. Unable to transmit ECG, however called ER en route with patient report. Onset to cath lab, less than 40 minutes. The patient's wife caught us outside the ER a day or so following this call. She told us her husband had gotten 3 stents during cath and would be coming home in a few days. Everything came together for this patient. Quick access by his wife undoubtedly saved his life. The fire department were invaluable removing this man from his dwelling. I happened to be working for a hospital based EMS service and transported to my hospital. The ER staff know all of us, and trust all of us. This call will always be the best call I'll ever run.

Nope. I certainly don't. I don't care what I see bleeding, hanging out of sunroofs, or laying across the ditches. I'm rather fond of being alive, so fond in fact, that I choose to stay in my unmarked honda rather than brave on-coming traffic. I also refuse to carry a whacker bag. I have no ambulance, therefore I am no paramedic. I'm just a chick on the way to the grocery store.

I hope you meant 2800 calls in 2007. If that's what you meant, your service is in no way, shape or form "busy." My PAID service did over 80,000 calls last year. I even got a paycheck, continuing education, and health benefits. I bet I would have had a better paycheck if people wouldn't do my job for free. As for taking the EMT-B class in high school... You're 18, go ahead and take it. I do side with the educated few that believe you should continue with a college accredited paramedic education without stopping. Don't take the time to develop bad habits and the false sense of thinking you know it all that so often happens when people go and get some field time before progressing. I hope one day EMS will move forward from this archaic thought process. Please continue with your regularly scheduled bashing session.

I've never had one break off, they're very secure, and the cylinders also have a protective steel handle around the components. Should one break, we carry three portables, I'll simply change it out and report it damaged. I work on some pretty mean ghetto streets, averaging 8-14 patients in 12 hours. I treat my equipment like my patients, with respect. The more things we break, the more we have to buy, and the more my raise dwindles.

I don't need to carry an O2 wrench, we have the high tech portable cylinders that have a toggle built in to turn it on and off.

I'm not really sure why paramedics in my area feel compelled to transport a patient that is in cardiac arrest, found that way and stayed that way despite quality ACLS interventions. Personally, I prefer to work a code and contact medical control. The last two services I was employed with did not want a patient transported if they were obviously deceased. Generally, we'd have to have one incredible excuse when CQI got ahold of our report and discovered we'd worked a code for thirty minutes, than proceeded to transport said code to the ER, all the while never having any ROSC. That being said, I'm probably one of the very few in my current service that will code a patient, give it my very best effort, and consult medical control for termination if I can't get any sign of life. After speaking with a physician and given a cease efforts order, I'll approach the family and explain to them that we worked very hard to save their loved one. "Despite all our best efforts, medications, etc. your loved one never regained a heartbeat. I've spoken with ER physician Dr. SoAndSo at SoAndSo hospital, and he agreed that we should stop efforts. I'm terribly sorry for your loss, is there anything we can do for you or your family?" I'll ask the family if they need me to call anyone, including clergy. I'll often remain on scene an addition ten or twenty minutes to help the grieving family members. I feel that I've done all I can for the deceased, and I focus my attention on the surviving family. I honestly believe ACLS is ACLS whether established by an ER Doctor, or myself. If I can't get them back in twenty minutes, they have already suffered an anoxic brain injury in addition to the cardiac arrest. It's a complete waste of very valuable resources to transport this type of patient. When a paramedic brings in a cardiac arrest, there are several nurses, techs, and a doctor in the room for however many minutes the code continues. There is an astounding amount of paperwork for these people. There is a bed being taken up that could benefit a critically ill person that is still salvageable. I'll bust my butt to try to save a patient, but in the end, some people are just going to die. At that point, I turn my total attention to the living.

Actually, I do my job because it gives me a paycheck. Helping people is something I rarely do, however in some instances, it's a perk. I'm not against people, I'm again people taking away my value as a paid professional because they'll do this job for free. I'm also against the lackadasical attitude toward education and competency assessment. It's hard for me to understand how a provider can be comfortable taking care of a patient when they run one call every three years. You are entitled to your opinion, even if it does oppress my salary.

This near miss happened to me while I was hospitalized with kidney stones. While on my way down for stent placement, I was offered two pre-procedure PO medications. Being the ever cautious paramedic I am, I asked what I was being fed. The nurse responded "Pepcid and Reglan." I'm allergic to Reglan, and this was documented in my chart. The nurses failed to give me an allergy bracelet, and the doctor failed to inspect my past medical history. To make matters worse, I was supposed to have lithotripsy along with stent placement. The urologist had my records from my ER visit two days prior. These outlined what medications I had received, etc. Turns out you can't have lithotripsy if you've had any NSAIDS. I had been given Tordal in the ER. Because this doctor over-looked (or never looked at) these records, I was sent to a hospital I wasn't crazy about instead of the one I like very much. Subsequently, I had the worst hospital stay I have EVER had, and with over fifteen blood transfusions in the past six years, I have enough experience to know good from poor treatment. Needless to say, that hospital is under JCAHO review now, thanks to me.

I'm going to stop complaining now. We only did just over 80,000. Of course we can be down to as few as 8 trucks on any given day to fully manned with around 22 trucks. I can always tell whether it's an 8 or 22 truck day, without looking at a schedule. I can run from one call in 24 hours to my record of 22 calls in 24 hours with two of them being triple transports from minor MVC's. Ratio counts. So does showing up for your shift.

My partner, morphine, D50, war vets, little elderly ladies. I'm sure there are plenty of other things I love about my job. My partner makes me laugh, usually at the most inopportune moment, and generally causing soda to shoot out of my nose. She's dedicated, hard-working, willing to learn, and she tolerates all my quirks about patient care, clean trucks, and complete paperwork. Morphine, because I may not be able to fix a fracture, but I can ease the pain of the 76 year old lady that just fell and broke her hip. D50, because my patient goes from unresponsive to talking to me in a few short minutes. I'm also pretty good at convincing them to be evaluated further at the local ER after bringing them around. War vets, for their stories. I can sit and listen to them for hours, and I'm lucky for the few minutes I get to feel history through their voice. Little elderly ladies, because they are often so nice, so apologetic for being ill or falling, and so talkative about all the children, grandchildren, and great-grandchildren they are so proud of.

We use 800mHz radio systems here. All our radios have an orange emergency button we can push. We can also request PD via radio. Our dispatchers are to respond to us "is the crew 10-4 (meaning okay)." If we need immediate assistance and can't answer, they call police, if we answer "we're 10-4, or we're okay" they also call police. If we are alright, or we accidently trip the emergency button, we have to respond "crew is 10-4" followed by our medic number. This is the first place I've ever worked with real emergency procedures in place to protect us. We are allowed to use our discretion with regard to holding back for safety on calls, no questions asked. If I were in your shoes, I'd propose development of a system for safety, and take it as high up the food chain as necessary to be noticed. If your company refuses to put in crew safety measures, then they suck, and you should seek alternative employment. Every shift I work, I repeat to my partner... Today will be a great day, and tomorrow, we're going home. I'm not dying for EMS.

I said very nearly the same thing in a chat a few weeks ago and I was labeled "arrogant." Not everyone that is educated is arrogant, and not everyone that is arrogant is educated. I often find it's the undereducated practioner that ends up calling the confident practioner arrogant. I'm perform thorough assessments. I know what drugs I carry (the list is short at my current employer) and I know when they are indicated in my protocols, and when that indication is followed by a "consult medical control." I rarely reference my protocols. I do however reference my trusty broselow tape every time I have a pediatric patient requiring pharmaceutical intervention. I'm not arrogant. I'm educated. I worked hard to learn above and beyond what I was responsible to know. I also had one amazing paramedic instructor that refused to take "the protocol said so" as an answer for performing an intervention or administering a medication. He wanted to know why we thought it was the right choice. He would kill our patient swiftly with one incorrect answer. He was good, and I owe him my career. I guess I have to wait until I'm crusty like Dust before I can be taken as educated instead of arrogant.

I'm not going to pick one of your choices simply because they do not fit in my case. I have broken my coccyx on a call, a long, long time ago. I blame my partner more than the heavy patient. Around ten years ago, I ran a respiratory distress in a nursing home in which the patient weighed in excess of four hundred pounds. After getting this patient on the stretcher using a slide board, we had to get our stretcher back up into the high position put it into the ambulance. The nursing home staff refused to assist us, citing a regulation stating they were not allowed to touch our stretchers. I had called for lifting help, and my partner promptly cancelled them. I asked him several times if he was sure we could lift her and he assured me that we would be fine, and that the patient was so critical that we didn't have time to weight for lifting help. We lifted, he dropped, I slid under the stretcher, landing on my keister, and it was donut cushion heaven for the next two months. I don't blame the patient, but I do blame my partner for cancelling help. As a result of this accident, a critical patient had to wait for another ambulance and lifting help. I still don't know his reasoning behind trying to cowboy on this call, and I'm sure I'll never figure it out. I'm very protective of my back, my partners back, and my patient. I'm only about 5 foot, 2 inches tall with my partner only having another four or so inches on me. I've learned to use my thighs to handle most of the weight load, and we practice lowering the stretcher to waist level for patient transfers. It unfortunate schools and employers do not spend more time teaching proper lifting techniques.

I performed a 12-lead on a female patient today. She was of advanced age, with a complaint of syncope, and left arm discomfort. The 12-lead was more than warranted, and something I would have never thought twice about doing. She was understanding of what I was doing, and I was careful to explain why I felt it was needed. I also took great care to explain every step of the process. I have always explained procedures, etc. to my patients. I've also always been very careful to protect privacy. In the back of my mind, I had this story in my head. I was concerned, almost worried, and even more cautious about how I cared for this patients privacy. I felt this way despite being a female paramedic. I can only imagine how my male colleagues feel after this negative press. I personally know a service that utilizes a type of video in the back of the ambulance. I don't believe there are actual recordings, however I do know that the images are sent to the receiving hospital. The idea behind that program was to enable the doctors to actually seeing the patient, how they are presenting, and what treatments the team are performing. They would be able to give better online medical control with this device. These were NOT emergency ambulances. They were inter-facility, hospital-based, critical care transport vehicles. They were used to transport patients from small, rural hospital ERs to the regional trauma center. I do not know how HIPAA plays a role in a program such as that. In my humble opinion, anything that ultimately benefits my patient is a good idea. I'm a patient advocate, and if that means letting an online physician actually SEE what I'm seeing, and be able to be a partner in my patient care prior to arrival at the ER, I'm not opposed to it. I'm not uncomfortable painting a visual for online medical control, but I often find physicians that are very reluctant to allow a consult drug or procedure be administered or performed by a paramedic. I haven't personally had this problem yet, but my career is still young.