DwayneEMTP

Before seeing your post I'd started one on my blog titled, "You may love EMS, but it will never love you back..." I'll try and remember to post a link to it here when I'm done... Good on you Brother. What they did was truly shitty, and you should never have seen it coming. For what it's worth, for each time I've been forced to leave a place, either fired or whatever reason, it seemed to be forcing me to the next thing that was way better, but I'd have never gone to one my own. Good to see you taking the high road..

You know what Bill? There's no apology necessary. That sucks. And there's not way to pretend that it doesn't suck. I'm truly sorry for you Brother...I know exactly how it feels. Keep your chin up my friend. And please trust me when I say that I don't believe that that is easier than it is. But all of the anger doesn't hurt them at all, but it can make your life bad. Take a deep breath, my deep breath usually involves inhaling a bit of tequila, then wake up, make a plan and move forward. If you've not believed anything I've said to you before. I've read your posts, I can see your spirit, You've got this! Keep in touch with all of your friends that you worked with and find out where they land. People WILL start to get jobs soon, network with them so you know when and where and ask for them to speak for you. And when you land on your feet make sure to remember those that you worked with that weren't douches and speak for them, so that they land on their feet too. Breath in, breath out, put one foot in front of the other until this is worked out, but don't let yourself sulk, and don't allow yourself the self indulgent self destructive right to stomp around angry. Edit: If you had seen through their bullshit, what then? What could you have done? Done a bad job? Broken something? Quit? None of us likes to get blind sided my friend, but the option is to be suspicious of everyone and everything...and I find that option completely unacceptable. does that mean that I get kicked in the nuts sometimes? yeah, and I fucking hate it. But you know what? 99% of the time, I'm getting really cool things, not broken nuts, and those are pretty friggin' good odds, right?

No worries my friend...We all used to post like that all the time and then some lawyer in Vegas decided to start a class action suit and chase everyone down that posted a story... Just make sure that when you post stories that you don't post them in their entirety and that you cite them clearly. It was certainly an appropriate story in the appropriate place. No foul.

So, as many of you know I work in PNG, out in the jungle. I work at a mine that has about 1,500 people onsite at any given time. I am responsible for emergency response camp wide, as well as in the local villages, and also for seeing the more significantly ill patients in the clinic. The issue here is that I'm usually really, really late on emergencies. Any time someone calls in an emergency they send Security to see if there is really an emergency. They have no medical training. Only twice they've called in for an emergency. Once was a stabbing with a machete. The other a bus rollover with 7 passengers. They should have called me 30 or 40 other times, but didn't. I've complained to my direct management who, as always, says, "That's just the way it is. Leave it alone." The problem is that we've had some significantly ill patients that could have benefited from prompt, professional care, but I wasn't called. I either saw them being dragged into the clinic, or discovered them there later. So, being the moron that I am I skipped my supers and went to the security guys and asked why they never called. It turns out that they really only have two levels of notification. "Not an emergency" and "Emergency." And Emergency starts a lot of important people moving, gets them into the loop, and if it's not really an emergency by the accounting of these important people then security gets their assess handed to them. So I asked, "What if we develop a protocol for, 'Not sure. We need medical to evaluate?" And they loved the idea because it gets the heat off of their backs. But now I'm not sure exactly how to develop the guidelines for non medical people to use. You need to understand that if I had my way that I'd go on every call for a sick person. But, though it's not supposed to be said out loud, the local national management will never approve that because they're terrified that I'll be busy with a local when an expat needs my care. Bullshit, yeah, but we either work within that understanding or create nothing positive at all. How to explain to the uninitiated where to draw the lines between "make them walk or have someone help them walk" and "call for an assessment" and "It's an emergency"?

Yeah, I wouldn't be terribly afraid of fluid overload depending on the age and overall medical condition of the patient. I think that most medics give their "Be careful of fluid overload!" warnings based on what they were taught in school as opposed to what they've seen themselves or read in the literature. I once had a 90ish year old woman, lifelong health nut, in amazingly good health, still jogged, etc. She was complaining of leg pain. She'd gotten out of bed, felt light headed, fallen, and pulled a groin muscle (in my opinion.). She had no other complaints at the time. She claimed no significant previous medical history or meds, and I believed her as well, her really healthy looking family that she lived with stated the same. During the assessment it was found that she had been ill for a week or so and had spent much of that time in bed. She'd not been feeling like eating or drinking much. Skin turgor was poor, pulse elevated, (can't remember) b/p was 80ish/50ish, lung sounds diminished all fields. Her main complaint, after we'd moved away from the leg issue was a persistent dry cough for the last several days. She agreed to transport, I started an IV, ran a 500cc bolus of NS and monitored for a few mins. It was about an hours transport. She seemed to feel better, lungs sounded like they were expanding better, so I ran another 500ccs. This was followed by another after another assessment, with perhaps 40 mins passing before the last bolus. She reported feeling 'wonderful!', her lungs were expanding much better it seemed, she'd developed some really light, dispersed rhonki, which I'd expected after being rehydrated after several days of a dry cough, her pulse dropped down to the mid 70's, and her bp came up to the low 120s/systolic. I was really proud of this treatment. I believed, and continue to believe that it was appropriate and that the patient was much better off than when I'd found her. The nurse in the ER went friggin balistic! "You never give an elderly patient more than 500ccs of fluid! Never!" I said, "But she's doing really well, right?" She said, "Yeah, but you don't have to be here for the CHF that you've caused!" (Really? I caused CHF with fluids?) Having seen her reaction, I was confident that this was going to generate a complaint so I followed her through the day. I asked the ER doc what he thought, and he felt that it was appropriate treatment. I followed up with her doctor who later came to see her at the ER who stated, "Pretty aggressive, but not inappropriate, and she's had no negative effects from it." and then the next day (They'd held her overnight secondary to the muscle strain for some reason.) her family doctor claimed no issues. So, was it good treatment? Yeah, I think so. It was also one of two calls that this company used to fire me, so there's that. Would I recommend this treatment for all geriatrics? Of course not. But I feel that my assessment was solid, and it seem appropriate here. Why am I writing, and making you read all of this bullshit? Two reasons. The first is that I'm sitting in the middle of the jungle while it rains buckets outside, so I have nothing to do but torment you. The second is to try and make the point that we don't have nearly enough information to know whether or not we would be afraid of overloading your patient with fluid. Again, not sniping...A thorough assessment followed by continued assessment is the answer to your question I think. Excellent thread. See what you've started? We're all learning things from it..

I don't know the answer to the above two posts, but I love that it became part of the thread. I do know that most of my patients need quite a bit of fluid and that I tend to run it through 16s/18s most times, and that drops in the drop chamber become a stream instead when I squeeze the bag, but of course I can't guarantee that that means increased flow. I've just always assumed that it did.

Hey Aaron, welcome to the City! Jump in Brother, we can use some more folks with experience...

Sorry Brother. It was late and I was just making a pass through the City after a late night call..Didn't even occur to me. Thanks for taking care of that though...

Fixed that for you... And I've nothing against Mormons. I've just heard that there might be one or two in Utah. Good on you for posting. Many want to wait until they have some schooling. They want to wait until they 'know' things so that they don't look foolish. So they just never post....most, like me I think, never learn enough to 'know' a lot of stuff in this crowd. But that's the point in posting, right? If I wanted to hang out with a bunch of rah rah bullshit wankers I'd go to that other site. Not sure I know what I'm talking about when I mention 'knowing enough'? Take a look here... I should probably be embarrassed. And I am a little, but more than that? I'm really glad that I don't have those same wrong thoughts any more. You're off to an excellent start. I look forward to your thoughts. Dwayne

Hey Hannah! Welcome to the City! I'm afraid that I've got no Utah specific advice, and I'll skip the Mormon references. A word of advice for EMTCity though. Jump in. Watching is OK, but you will get a hundred times more value here if you participate. Ask, answer, guess, theorize, joke, but POST! Trust me on this....I'm a paramedic, what could possibly go wrong? Good to have you girl... Dwayne

If you take her appearance, respiratory rate, pulse rate, combined with her lower than expected blood pressure, particularly the systolic reading, all together, that should have had you for sure getting really good lung sounds before moving forward, and ;that might have given you some hints to go down a different path. I'm not saying that it should, but in this patient the lower than expected b/p would have initially moved asthma attack to #2 on my differential with a, hopefully temporary, question mark for #1. It feels like, and of course I don't know, but this is just sort of the vibe that I'm getting, that you're looking for 'points' that you can put together to make sure that you don't make the same mistake again. Maybe, try instead of looking for things to memorize, to build the physiological picture in your head. I think that if you do that, then you'll see that the b/p doesn't fit. The hole for that puzzle piece is there, but it's the wrong shape. In this case we all want really badly to hammer it into place, but you can't Brother...you have to keep looking (asking questions) for the right piece.. Excellent post, and I know that we've gone off in a direction that you didn't intend, so just raise the yellow flag and we'll try and get back on topic. Thanks for your response above!

How did you reconcile the B/P with the rest of her symptoms when you diagnosed the asthma attack? With a patient in this state wouldn't you have expected a catecholamine dump, vasoconstriction and a relatively elevated B/P? I swear that I'm not bagging on your Brother, just voicing my thoughts. What do you think? Also, and I'll ask that you believe that this isn't a criticism but a preference only....I like your posts, but could you break your larger posts up into smaller paragraphs? It just makes it easier for old People like the Mike's and DFIB to read. Me? No problem...I'm just trying to watch our for our brothers... As to the Recemic epi, I'd have to Google it as I have never used it and have no idea off of the top of my head...we'll wait for the smart folks to work that out for you. Good post!

It is a really confusing situation. I was dispatched to the local detox once for a well known EMS abuser with a complaint of 'twitching eye.' ( I usually don't describe people in such a way, but this man, his family and friends used to all get drunk on the same night and call the police on each other so that they could sober up in detox with decent good and a warm clean bed.) I was the only ambulance on duty in the county during the nighttime hours. Enroute a second call is dispatched for 'unresponsive, not breathing.' I notified dispatch that we should divert to the apparent arrest call, they refused and called in the second unit, approximate time to the ambulance bay, 15 minutes. I disregarded dispatches instructions and went to the arrest instead. Upon arrival at the 'arrest' it turned out that there was no patient on scene. A mom had tried to wake her drunken adult son, couldn't, believed him to be dead, and called 911. He'd heard her call, didn't want to deal with them so got dressed and left the scene. I left there, and went to the twitching eye, which turned out to be a minor tic, as I'd suspected, but what if it had been an early stroke instead? I took a pretty good beating for diverting, which I accepted gracefully, and to the best of my knowledge my cert was never in danger, but I'm still not sure if that was a good decision on my part or not. When the late Dust Devil was here he posted a thread about a crew transporting an infant secondary to seizure. They witnessed a car hit head on into a telephone pole. The crew stopped, the driver of the ambulance went to see if the driver of the car was ok, the driver of the car started shooting at them forcing them and their patient out of the ambulance and into a cafe until police could clear the scene for them. They were lauded as heroes, but I, and Dust, kind of thought that they were off in the ditch. My main complaint being their claim that the child wasn't in danger because it was simply a febrile seizure. How did they diagnose that in the back of an ambulance do you suppose? Is stopping for a moment the right thing to do if you have a non critical patient onboard? Morally I think so, ethically the issue is as clear as mud, and legally, well, then it's just a crap shoot.

Doesn't sound like a tonic/clonic seizure. My guess would be that this was syncope from another cause, or possibly a stroke. I've never seen, nor heard that I'm aware of, of a patient actually seizing that is breathing adequately. Almost certainly something else was going on here that was mistaken for a seizure.... Edit. Question, and I'm not sniping at you...If she was unresponsive, breathing adequately, and not showing significant 'flailing', what was the reason for the Valium?

Right, wrong, or neutral, the case will likely once again give people cause to walk by those in need instead of stopping to help. And that's too bad.... It sounded to me like the ruling from the Supreme Court didn't come with any joy. When he mentioned that it was their job to interpret statute, not to create it, he seemed to me to be making a point...

Hey! Welcome to both of you!I Notice, as DEFIB said, that 'participation' in the forums will be benificial? There is a lot to be learned from reading, but if you want to work on the street you need the courage to think, make decisions and then act on those decisions, and these forums are a great place to practice that. Good luck with school. Hang around, be brave, ask questions, answer questions, but don't just sit and pretend to be doing your best, ok?

I do agree that if they had no right to pronounce, then sitting on site is probably going to look bad. But then again with one basic in back and one driving you're not going to do much for rescus anyway. But it would probably have been better to do nothing enroute than do nothing on scene. Also, as 1040 said, as basics they really didn't have the information necessary to decide to sit on scene...

Hmmm.... This seems like it could be a hornets nest of legalities.

I can't cite specific law, but you not only, to the best of my knowledge have an obligation to stop in most places, but you have no right to stop. You have a duty to act with the patient that you're currently caring for, stopping, particularly for a fender bender is neglecting that duty. This topic has been often discussed, but instead of referencing another thread I hope that we can have it again with the new providers that we have one the site.

Yeah, that story says nothing really....

Yeah, man, DFIB is the boss on this subject, he and Terony... Both are wicked smart and committed to EMS and both swear to the integrity of the above mentioned program... Good luck Brother. Thanks for your service.

Excellent question! If you started two big IVs running 'open' and had someone squeezing the bag, gave epi, then I'm not sure. Maybe Dopamine would have been a better alternative to the epi, but man, I don't know. But, if I go with what's in my brain at the moment without doing the wuss Google move...I don't know what I would have done differently... Wait till the smart people show up, they'll have some ideas for the next call like this. Edit: Having said that, the definition of 'very aggressive' varies quite a bit in the paramedic world in my experience. Most medics I know shit bricks over delivering 1L of NS. I've just never really seen fluid drown people in an instant like so many claim that it does. I often run 1L open (without obvious contraindications) and it's not uncommon in a patient like that to run three or more. How much did you all push before arrival at the ER?

Good on you Brother! Welcome back! And as a welcome back present....watch your friggin' capitalization and punctuation! This isn't a teenage chatroom! Jesus Christ! (See, you've missed that, right?) Truly, good to have you back man...