EMS49393

Oh my goodness, what perfect timing for me to read this post. I don't think you're a racist because I came from a large, mostly african-american city. However, after moving to this crappy little town in the midwest, I now see that the only reason most of the system abusers I had there were african-american was because that's what lived in that city. Here it's predominately Caucasian. We have the same clients I had in the big city, except they're white people. For instance, I ran four calls (including a long distance psych transfer) last shift. Four calls, five patients total. All five were drunk, all but one wanted to kill themselves. They were all on medicaid and all could afford their cigarettes and liquor, of course. On a daily basis I transport people that intentionally harm themselves, either with long term smoking, alcoholism, or laziness. Most of the time these people walk better then I do, get around easier then I do and they're on public assistance for their "disability." No one ever has a substantial medical history other then psychiatric problems, and most of them regularly admit to being "owed" something for the tragedies they have gone through. Now, besides really ticking me off, this problem goes much deeper then just tying up one ambulance. We have limited EMS in this town, primarily because it's a financial killer for the hospitals that run the services. Supply prices are high, gas prices are higher, and reimbursement is probably the lowest in the medical field. We may have 6 ambulances covering this county, and 5-6 of them on calls that are abusers that either don't need medical attention or can go by other means to a PCP or urgent care. We have just a couple of ERs in this little town. All of them are backed up several hours in triaging emergencies alone, and we bring in people that just need to sleep off their drunk, or tell us they're suicidal because they have Idontwanttogotojailitis. We don't have room for the patients that truly need medical help because the system is clogged with abusers. So what can be done? Well, after many, many years in this field, I have my solution and I may just run for president. Cut them off. Cut all their funding off. Show up in the ambulance and tell them it's not an emergency, but we'll taxi you to the ER if you can pay the 800 dollar bill up front. Let them show up to the ER and have them demand partial or full payment up front for frivolous garbage. Throw them out in the river and see how many make it back to shore. Sink or swim. I might sound mean, and hard, but I'm tired of these people, and tired of working my butt off for crummy pay, losing all this money in taxes only to see people in better condition then I am take advantage of all the tax money I pay into the system. They don't want to work to improve themselves, why should we care whether they drink themselves into an early grave or not. "Well if that's your attitude, maybe you should get out of EMS." It's not that I don't care at all. I care very deeply about doing the best I can for people that can't help themselves, that really need help. I just find it hard to care anymore for people that are honestly wasting our oxygen. Since that's really all that seems to be around anymore, in any town or city, perhaps I should return back to school and become an accountant. Rant off, I now return you to your regularly scheduled post.

No one struck a cord with me. I have my way and you have your way. I just happen to feel that my way is better. That's the beauty of our free country. I have a right to my opinions.

I work hospital based EMS. I do things the way my hospital and my medical director want me to do them. My hospital is the regional trauma center, and I assure you that I know what is expected in my radio reports. Because you don't care really isn't my concern. I will not change the way I practice because some nurse doesn't care about a patient until they fall to a GCS of 8. Around here we care take any deterioration in patient condition seriously.

When I give a radio report, if the GCS is anything but 15 (unless a lower number is the baseline, as with a dementia patient for example) I give the components. They are going to certainly need to know if the patient you are bring in is posturing because that points to injury in certain areas of the brain. I consider the GCS a very important, underused and even misused tool. I've used it my entire career and unless the directive came down from God to stop using it, I'll probably use it the remainder of my career.

Treat every patient as though they are NOT faking and you'll never go wrong. In the event they are a frequent flyer that is truly sick and you aggressively treat them, you keep your butt safe. In the event they are faking like a big dog, worse case scenario you insert an airway and they puke all over you and viola, they're saved. It's not your job to guess if they're faking or not, that's up the to the docs, that's why they have the big MD after their name... for My Decision (and their lawsuit if wrong). I, personally, don't have any desire to waste my malpractice insurance on a frequent flyer that I didn't treat to the best of my ability just because I've hauled him to the ER seven times in two days. Just my opinion, take it or leave it.

I started the 14th page. :wav: Snoopy dance time!!

216 hours! It can't be. That has to be a mistake. You mean 216 hours is enough to perform invasive procedures because you feel like it, and jack with someones homeostasis because you can? I've had well over 1500 hours didactic coupled with several hundred hours of clinical rotations in EVERY department in the hospital. Seems to me that I got screwed. I could be having all this fun for 216 hours instead. What a jip. (By the way, that's sarcasm.) I want a refund.

It's also a way for the cities to turn out fast and cheap "ALS." Baltimore's FPA program is a good example of this.

Traumatic injuries after being struck by a train.....

It's a recruitment video for nursing at University of Alabama at Birmingham.

According to Brady's Paramedic Care textbook, you place the first clamp 10 cm (that's CENTIMETERS, not inches) from the baby, and the second clamp approximately 5 cm above the first. Allowing this much of the cord to remain attached to the baby allows for IV access in the event it's needed for resuscitation. Even though you might deliver what appears to be a completely healthy full-term baby, be aware that occasionally one will go bad on you when you least expect it. As a BLS provider, and even ALS providers in many areas, you'll never access the cord this way, however I know the ER's and NICU's will appreciate you a lot more if you leave them some cord to work with should they need it. On a side note... Be careful how you read things. Most of medicine is on the metric system. There is a huge difference between 10 inches and 10 centimeters. My copy of the 10th edition EMT-B book is still in my car from teaching the other night. Frankly it's late and I'm too lazy to go get it and see how they word things, although you really have my curiosity peaked!

I took the first PHTLS course offered by MFRI in December 2004. I really enjoyed that class, and I recommend it to any level provider. The card you get will reflect basic or advanced provider. It's difficult to find it on the website and it took me a few minutes to bring it up. They are having a class at MFRI headquarters on 4-12 according to the schedule. Give the College Park office a call. Good Luck.

For what it's worth, I think you did the right thing. You didn't have just SVT. You didn't have just an MI. You had a patient that had a 12 lead indicative of an MI that happened to also have a rapid heart rate. You had a patient that was a diabetic, and obese. You had a PATIENT, not a protocol. My protocols are very liberal, and we rarely have to call for any orders. Based on what you explained I would have probably treated this patient the same way. I might have used Amiodarone instead of Cardizem. (Cardizem is a calcium channel blocker, btw.) That's only because I'm paranoid about the ejection fraction, and you stated your patient had a cardiac history. I wouldn't have given anymore NTG, only because it didn't seem to be effecting the patient in a positive way, therefore I couldn't justify further pollution of the membranes. If three doses doesn't get it, then I'm moving on. I'd have been a little ticked about being denied morphine. Your patient probably could have benefited from it. Beware the diabetic and the silent MI. As we have read they often do not present as a chest pain complaint but instead seem to have a lot of issues that point in many directions. Now, as for why you got ripped is really simple. You used critical thinking. You treated a patient instead of a protocol. I feel for you, and I'd be livid if I were in your shoes. The best thing you can do is document everything. I would write up not only what you put here, but I would go into detail as to why you felt you followed the correct line of treatment. I would then state what took place between you and both doctors. If this call comes to Q/I, you'll want to have it. One last thing, why the NRB at 10 lpm? Why not all 15? With the possibility of an MI, on top of the fact that the heart is not beating with much efficiency anyway, the more Os the better for the tissue. Incidentally, we flow 12-15 with our NRBs, which is the reason the 10 lpm struck me funny.

Before all you volunteer people pull that "You never volunteered, you don't know" crapola on me, I was a volunteer, and I can write this with personal experience. Eliminating volunteers will protect not only my paycheck but my craft. I have strict training requirements to meet to keep my job. They have optional training requirements. I have a duty to care for my patients to the best of my ability. They have providers that want to call helicopters for respiratory distress instead of waiting three more minutes for a paid ambulance to arrive. I don't want to be a hero, and have warm-fuzzy feelings. I want to do my job, not pick and choose what calls I feel like running based on the dispatch. I am a professional. We don't have hospitals of volunteer physicians, nurses, radiology techs, etc. We shouldn't have volunteer EMS. Yes, it's about ME... It's about me arriving to a patient in a timely matter with the skills, the education, and the equipment to deliver quality care to them. The ride to the ER is a bonus. 8)

Same situation for me. I saw this coming before I even finished reading your original post, because of my father. He had a major accident and shattered his tib/fib and kneecap. He had surgery to pin the fracture at the trauma center and while recovering in the ICU developed trouble breathing and pulmonary edema. He denied chest pain. The first doctor called it a PE secondary to surgery. The next doctor called it pneumonia secondary to surgery. The "dockling" asked for a 12-lead and enzymes. My father had a "silent MI." You can bet your sweet hiney I'll never, ever forget that. Diabetics and women I am extremely cautious about with any complain from the abdomen to the neck.

Well, I know albuterol for sure. I'm also responsible for Atrovent (ipratropium), solu-medrol, diphenhydramine, sub-Q epi, and racemic epi for respiratory problems. I'm also responsible for assessing my patients to determine what course of action is appropriate for that person, at that time. Go figure. I submit the following little story for educational purposes... Asthma can be a part of a bigger problem. My brother is an example of this. He's been a severe and poorly controlled asthmatic for over 20 years. He was instructed to stay away from ibuprofen and ASA because they are "triggers" for an attack. After seeing a specialist last year he was finally diagnosed with Samters-Triad Syndrome. Samters triad is characterized by nasal polyps, asthma and a allergy to and aspirin, hence the triad. Through his childhood he underwent surgery to clear his sinuses several times, and either as a result of surgery or nasal polyps has no sense of smell. His allergy to aspirin is so severe that a little residual dust can throw him into anaphylaxis. To break his attacks quickly and keep him from going into respiratory arrest requires several different treatments. Albuterol/Atrovent nebulizers, diphenhydramine, and solu-medrol. He has been both intubated and on steroids several times. My best advice is to assess your patients very well before you give them any medication. Albuterol and albuterol/Atrovent are wonderful drugs for simple asthma, if in fact you know it's just an asthma attack and nothing else.

What do people have against punctuation? Did they stop teaching that in the elementary schools? :roll:

What's downtime? We rarely get enough time to use the bathroom, let alone have extended time to goof off. As for run reports, in an ideal world they'd all be done before we get our next call, however that's pretty tough when you've got dispatchers telling you to throw your patient off the cot, "We've got emergency calls holding, and no cars available!!"

It's about the first time I actually agree with dust on a topic. I once had a partner that was not only green as grass, not only dumb as a box of rocks, she was a whiner. I had roughly 10 years in EMS, and she had just become a basic. I NEVER had a problem at my previous jobs with anybody like I had with this person. She not only went to management first, but managed to blame me for every wrong thing she did. I spent every shift for months sitting in the supervisors office getting screamed at. It was miserable, but I maintained my stance that I would try to work out problems without management, and she could be the one that ran there every day. I thought from a management perspective that a complaining, whining employee would eventually play out all her cards and just become a nuisance. Let me tell you I was WRONG!! I nearly lost my job over this and was told repeatedly that I don't play well with others. It really made me miss the good organization, and management I had been a part of for so many years. With that being said, I feel your pain, and I agree that bringing management into it may be your best solution if you can get to them first. She wants a war, then THROW DOWN!! Good Luck!!

My program used: Brady's Paramedic Care, five volume set with workbooks Brady's BTLS for advanced providers BTLS International Pediatric BTLS BTLS Access AHA Neonatal Resuscitation ABA Advanced Burn Life Support Brady's 4-step method to drug calculations Martini - Fundamentals of Anatomy and Physiology Incl. Applications Manual and Atlas of the human body Brady's Basic Arrhythmia's (Walraven) Bob Page - 12 Lead ECG for the acute care provider AHA - ACLS AHA - PALS Prentice Hall drug guide for healthcare professionals ALS/Critical care field guide Paramedic drug guide On my own I purchased a comprehensive medical dictionary and a review manual. My understanding is the five volume text is far and away better then the large one volume book. My significant other used nearly the same textbooks, including the five volume Brady set. Nothing against Mosby, but when I took my first advanced class we used a Mosby book. Brady just seems to have text books that are informative and easy to read. Mosby would probably put out a great cookbook.

Thom Dick wrote an article about this same topic that appears in the Dec. 2005 JEMS. Great article, valid points. Personally, risking countless lives by blaring sirens and spinning lights for a dead body seems ridiculous to me. On the flip side of that argument, there have been a few news stories about "survivors" lately. Paramedics have pronounced people only to have them wake up later in a morgue. Could there be a reason why the ER physicians are wanting to see these bodies before they call them dead? The doctors should trust that paramedics know what dead is, by the same token, we need to prove that we know what dead is. The recent negative publicity isn't going to help our case for more liberal field termination of cardiac arrest protocols. Don't you wish you had the power to cut up licensing cards sometimes? :violent1:

PRPG... I agree with it all, but especially your #3. I worked a few years for the standard private "chuck" service before getting a job I truly loved. Any honest job pays honest money, and there's something to be said for paying your dues. Most EMTBs aren't going to roll out of school into that great 911 job with the great company or fire department. Sometimes you have to settle a little lower and make your name.

That whole thing pained me for so many reasons. I'm originally from Maryland, so I know first hand how the system works out there. I have never heard of being in high school while being in paramedic school there. Now, there are several vo-tech programs scattered throughout the high schools that will give a student hazmat ops/FFI/EMT-B. There isn't anything specifically in the rules for having a high school diploma, but of all the ALS programs I'm familiar with there, they require it on an institutional level. I will say that nearly all if not all the "Paramedic" programs are now fully-based college programs. The EMT-I classes are still available at selected fire academy's. So that would mean chickie would be going to high school and taking on a college load concurrently. Not likely. Still in high school at 18? I guess that's alright, but I figured you'd be about out of high school at that age or a few months after. Maryland does NOT let people under 18 participate in ANY ALS clinical rotations or skills. Honestly, after reading into that post a little, she talked about studying for her IV test. In most jurisdictions in MD, IV Tech is a 24 hour add-on class for the EMT-B, and most EMT-I programs require you have it before you start the class. It leads me to wonder if she is honestly involved in a paramedic class anyway. You can not live in the Baltimore/DC corridor and work only 20 hours a week unless you have some trust fund somewhere, or live with your parents. The rent starts high in Baltimore, and increases exponentially as you travel down I-95 to the surrounding DC area. Bethesda is also in one of the wealthiest counties in MD. Anyone can do the math on that math. The mouth on that little girl was by far the most embarrassing part of her posts. I felt ashamed for her. (Insert sarcasm here) All this AP education, college, and full-time job and she can't command the English language well enough to get her point across without resorting to obscenities. My father always told me obscenities were a sign of ignorance, and I can certainly see why he says that after reading that. Running into a burning house without protection? Oh, no, no. A good indication of maturity is following the first rule of the job, "I'm going home." After my long-winded explanation about a few things from my home state, I'll conclude with this... Children do not belong in public safety, period. With all the talk of a national scope of practice, perhaps they should standardize the ages as well. If you can't drink a beer (legally ) then you're not old enough to play in this sandbox.

Bob Page teaches to "monitor" in Mcl1 not lead II :!: ... His book is well worth the investment. Bob is also a renowned speaker throughout the country. Check your local conferences, he might be coming to a town near you!

Laryngoscopy is a skill. Placing an ET tube with a laryngoscope is a skill. "Hit or missing" while attempting to place an ET tube should constitute some remedial education and OR time. Combitubes serve one purpose in my service... FAILED airway device. You can't drop drugs down a combitube. You can truly prevent aspiration of stomach contents. Too many providers believe you just "shove" it in, which can cause damage to tissues within the airway. Combitube should not be a basic skill, mostly for that very reason. It is my opinion, and mine alone that the combitube is a product of the devil.