treaux

I think it's much more cost effective and reasonable to have police respond to most if not all EMS calls for provider safety than it would to train all EMS personnel to a proficient level of firearm use as well as insure against the inevitable use of those firearms. Just a bad idea. There's a whole "tactical EMS" group at my work that wants to be armed and I think it's extremely silly (and I'm very pro gun in general).

I also would hope it would increase the demand for more extensive paramedic education. If not for all, than as a certification for community paramedic licensure as required. Anything that raises our education level would benefit the profession as a whole. Working in the SF Bay Area though, most of what I have seen is negative and reactionary actions by medical direction when it comes to the lack of paramedic education. Notably in my county they removed the needle cricothyrotomy from our scope due to one call where it was performed improperly by a medic. With an ever-shrinking scope in California, it would take some really progressive medical directors to make the community paramedic idea work. I am all for it however, and there have been some cases where similar programs work (I currently am part of a program that has a dedicated paramedic psychiatric/social services unit).

I know this is an old thread, but it caught my eye. Rings a bell with me since I am also a firearms instructor. First off, if that was the actual question, than it is a very poor one. Picking it up by the trigger guard is a BAD idea because the trigger guard is small and often polished and it would be very easy for a finger to slip and land on the trigger. The grip falls in the same category as it feels natural to put your finger on the trigger especially if you haven't trained with handguns to keep your trigger finger away from the trigger until ready to fire. Safest answer to the question would be two fingers on the slide, as the slide is incapable of discharging the weapon on its own. If it were me on scene, I would opt for this and screw PD and their evidence as they should have already been there and cleared the scene. Safety is paramount and I wouldn't want a loaded gun sitting there for anyone to grab. I would also clear the weapon as I am trained to do so (and frankly it's such a habit that I cannot touch a weapon without unloading it and verifying the chamber is empty). If not trained, I would have someone remove it from the scene to a safe (locked) place until PD could come secure it. As already said, if you were dispatched to a shooting, PD should have already been there. If they weren't there when you arrived, you should stage and call for them.

This is like the "guns don't kill people, people kill people" slogan. It's not the taking of the pictures that is such a bad thing. As has already been said, it's intent and use. Where I work, our resources are plentiful. I'll often arrive on major trauma scenes to find 6 people already working on extricating the pt from the scene. My job is really just oversight and assessing the MOI while the pt is extricated. I'll often snap a photo for the trauma center. Every trauma doctor I have given report to has appreciated a picture of the scene to help them build an idea of the MOI. We take for granted that we are there and can see it ourselves, but we are just the first step in a long line of communication. I have also snapped photos to document the lack of damage in so called "Allstate-itis" calls where the patient is crying 10/10 neck and back pain when there is not so much as a scratch on their car after a 2mph fender bender. I have taken pictures of unsafe houses and disarray when reporting to social services or CPS. They really appreciate having a photo before sending out a case worker. At this point I have many photos of many scenes. I keep them all very secure on a closed network just like our HIPAA security standards at work. I occasionally use them for education and building scenarios when teaching or precepting, and have found them quite useful for training purposes. Things to remember: - NEVER EVER EVER publish them on the internet with a public link unless you have obliterated any identifying information. Remember that all modern photos taken on digital cameras have EXIF data embedded that includes the exact date and time of the photo and possibly even GPS coordinates. Photoshop or Lightroom can help prepare images for the web and strip all data attached. - Always avoid photographing the patient. I am also a photographer, but I hate having my picture taken. Aside from violating HIPAA in so many ways, it's just impolite to take someone's picture without their consent. Some EMS people have no manners - Lastly, do not email them. Email is not a secure way to transfer anything important or private. Use flash drives or something encrypted when transferring. - Be respectful. I think this is the biggest problem here. Lawsuits come about when people post pictures up for shock factor or entertainment. Would you really want that done to yourself or your family? Photos can be a great tool in EMS, but must be used responsibly.

Including this call, I've seen lidocaine appear to reduce ventricular ectopy a few times. I keep hearing the general consensus is that it doesn't help, but my county still uses it both in the ambulance and in the hospitals. I had another patient whose AICD had shocked them some 17 times before arrival for what appeared to be a recurring v-tach (was really hard to see because the AICD shocked so quickly). I gave lido and the patient went from getting shocked ever 30 seconds or so to once every 5-10 minutes (for a total of once during transport). At the hospital the MD tried to switch to amiodarone and the v-tach started re-occuring. He then switched to a lidocaine drip and the number of AICD shocks once again reduced dramatically. It was a real world situation where it appeared to work.

In that article above, is it in reference to a stretcher in a moving ambulance, or a stretcher being moved on the ground? It refers to "riding the rails" such as when a person stands on the carriage of the stretcher while attempting to do compressions. Obviously this does not work well, but as with most extrication times, there is no chance of having effective CPR done without a device. In the back of an ambulance, I'll contend that quality CPR is quite possible. The article also didn't mention if the patient was on a long board or CPR board which is an absolute must if doing compressions on a soft surface. This is relevant in many applications, i.e. will you sit on scene with a hypothermic/drowning victim because you can't effectively do CPR while transport? I think not. What about v-fib/fast PEA arrests etc? I don't think that is a relevant argument for not transporting cardiac arrest. Transporting arrests that have had ACLS performed and remain in asystole, however, has been shown needless and I think any areas that still transport them are either uneducated or overcautious and distrustful of their field medics. Where I work, we have permission to determine death if ACLS was performed for two "rounds" and the patient remains in asystole or a PEA < 40. We also do not work-up or transport any traumatic arrests (though I'm curious if this will change with some of the ongoing hypothermia studies that some of our hospitals have been doing). There will always be a reactionary element to patient care in the pre-hospital environment. When mistakes are made, heads roll and everyone gets cautious (including the medical directors). About 4 years ago, we had a medic mess up a needle cric and leave a catheter in the subcutaneous space while bagging a trauma patient who later coded and was left on scene. The coroner and our medical director decided to remove that skill from our protocols because of that one incident. That one person changed the protocols for an entire county with their mistake. Long before that, I worked in a rather notorious county that had two medics who called a young drowning victim at the scene after a mediocre effort all while being high on heroin. When the coroner showed up, the patient had warmed and regained pulses, though died later in the hospital due to organ failure. How long does it take a county to overcome incidents like these? Why are there still medics out there that are capable of this? I think we're headed in the right direction, but in EMS we seem to end up only being as good as our worst medics in the eyes of the public and the courtrooms.

I agree with your statement Bushy, hence why I did not administer any NTG on this call. Just curious as our protocol as would dictate to give it, and it's our discretion to not administer as appropriate. As Paramagic said as well, the risks outweighed the benefit in this case. However, I did read a while back about some testing done that came to a conclusion that administering NTG increased the v-fib threshold, which is why I have posed the question. I haven't put defib pads on every STEMI patient in the past and I'd say I transport around 30-40 a year. This is the first STEMI patient I've had that has gone into v-fib. I'm not sure if it will change my practice as it only takes seconds to put the defib pads on someone. It certainly wasn't a hindrance on this call.

So I'll give a quick recap of the funny parts of this call first, without trying to be too hard. So I respond from about 15 minutes away to a call for a 50y/o male patient with "Chest Pain." Upon arrival at the scene, there are already two Sheriff's Deputies there, I hear angry voices upon walking in and the first thing the fire captain says to me upon walking in is "Just hang back, it looks like this is going to be an AMA." So I peak in to see a very agitated man sitting on his bed with his shirt off reluctantly letting fire do a 12 lead on him and constantly trying to get up and saying "I'm fine, I'm fine, leave me alone." He also vehemently denied any CP or SOB, though he admitted to some "tingling" in his left shoulder and arm. I can see from across the room what looks like pretty significant lead II ST elevation and I asked the captain if the pt had any cardiac hx. Captain says he has nothing except for emphysema, some alcoholism and ITP (a blood thinning disorder that reduces platelets). So sure enough the 12-lead comes back showing significant elevation in II, III and aVF as well as some slight depression in the anterior leads. This is when I step in and tell the patient that he needs to go to the hospital and that he is having a very serious cardiac event. I try to explain to him that he is having a heart attack and he simply says "I'm not having a heart attack." He continues to argue (in addition, a bit of ETOH on board as well) with me and adamantly refuse to even let us get a fresh blood pressure. He proceeds to rip off the leads and starts storming around his house. He ends up going into the other room and lighting up a cigarette and when we try to approach him he just storms past us. I get a physician on the line on speakerphone who repeats to the patient that he is having a heart attack and will likely die if he doesn't go into the hospital. Long story short, I eventually convince him to get on our gurney (this is after 20 minutes on scene already!) after talking him out of having his wife drive him (she was crying anyways and begging him to go with us). We have about a 30 minute transport even code 3 due to our location so after getting him in the ambulance we take off right away. I redo the 12-lead on my monitor and transmit it to our STEMI center and I put the tourniquet on to start a line (I prefer to have a good line before administering NTG to an inferior MI). Within 2 minutes of us going in route and as the patient was mid-sentence telling me how much alcohol he had that day, his eyes roll back in his head and down he goes. Pulseless, apneic and in v-fib on the monitor. I have my partner pull over and notify the engine that we need a rider. As my partner hops in the back to grab a BVM I get the pads on the patient and deliver one defib at 200J. Before my partner can pull the BVM out of the bag the pt lifts his head up and asks "What happened?" I told him what had just happened and he says "well I still feel fine." By this time the rider has hopped in and we start rolling again. We get a couple of IVs established and I gave some lidocaine for the post v-fib status (yes, we still use that here). Pt's BP drops a little, but still in the 160/80 range and he has literally zero ectopy and a perfect sinus rhythm all the way into the hospital. He STILL denies any CP even after the defib (ETOH likely a culprit here) and we get him in and up to the cath lab right away. So after this fairly intense call I do my usual self review. First thing off the bat was that I wish I had taken a rider in the first place. I've run in tons of MIs without one and it's gone fine, but hindsight is 20/20. I've also had a septic patient who were extremely stable code on me in the back of the rig with no fair warning and no rider as well during a code 2 transport. Am I going to take a rider on every septic patient from a con home? No, but I'll likely be bringing one with me on every STEMI transport that's more than a few minutes away from the hospital. Second off was debating giving NTG post v-fib conversion, especially in an Inferior MI (where a good percentage of them have a right sided MI aspect and NTG could possibly bottom out their pre-load and cause more problems). Granted this patients BP was pretty high, but I have had other patients with right sided MIs drop 40-60 points systolic after a single NTG administration. I also read an interesting JEMS article regarding the possibility of NTG even CAUSING v-fib (http://www.jems.com/...nt-goes-prehosp). Lastly, I didn't know too much about ITP before this call, but after a little reading it makes this an interesting case study as AMIs are unlikely with people who have ITP. My patients unhealthy lifestyle (2 packs a day and heavy ETOH) may have been prolonged even by his condition basically keeping his blood thin all the time. Another interesting article I found on STEMIs for pt's with ITP: http://cardiologyres...ewArticle/11/25 Anyways, I welcome discussion on the topic. Would you or would you not give nitro post conversion? They were in no rush to do so at the hospital and preferred instead to get him straight up to the cath lab. I have copies of his ECG and the v-fib conversion and will try to get them scanned shortly.

What an entertaining post. I think the issue with the original medics was that they left the dog on the street and didn't accommodate it or the patient. I have transported a service dog with a patient once and it did end up giving me terrible allergies. Not a big deal as it wasn't an emergent transport, but my response to someone asking for a dog to come with us in the ambulance on a code 3 or trauma call would be a swift no. I would however notify my supervisor who would make arrangements to have the dog transported (we have done this several times in the past) including coming to pick it up himself. I agree that the dog is not needed in the ambulance and I'd be hard pressed to ever bring an animal into the back of an ambulance due to the danger to that animal. Imagine a hard stop or turn that could throw the animal into something sharp (like the brackets that secure our D-tanks) or into the step well on the side that could injure or kill it. Imagine the lawsuit you'd get if that happened vs this "complaint" about the patient not being accommodated for properly. Remember, our job is also a customer service job, so it's a given that we try to work things out to our patient's satisfaction. Anytime you act like an a-hole to a patient a complaint is likely to follow.

Don't generate transports if they are truly unnecessary, but also don't write off patients that look fine just because they look fine. Think of all the medical emergencies that we don't have the ability to confirm or deny with the tools we are given. I'm glad you are encouraging them to go in their own vehicle if their needs don't require an ambulance. This is one of those things though that can really come back and bite you in the worst ways. Always think of the patient's condition and possible outcomes. Forget thinking of wasting people's time, "cheating the ems system" or money issues. Patient care always comes first.

Big congrats. We always need good EMTs. Good luck with collecting your experience and always be proud of your accomplishment. Keep your skills sharp

RSI is one of many things on a list of skills that have been removed from our scope here in California. The county I work in has also taken away the needle cric due to a single case of it being used inappropriately (on a traumatic code no less) and now we will never have the chance to use it again. RSI was taken away years ago due to that "San Diego Study" that basically showed we couldn't be trusted to make the right decision on when to RSI. The general attitude of the fire medics where I work is one of apathy and laziness. Many don't want to run medical calls and when they do their attitude is a bored and uncaring one. This leads to their understanding of medical emergencies dwindling back to the pre-EMT level of not really knowing the underlying causes of the problems we treat. Day to day I get great one liners from fire like "We give albuterol to fix CHF" or "His blood sugar is 16, but we can't give dextrose because he has a CVA history and I heard it can be bad for his brain." This really dilutes the expectation of us being medical professionals and it's a reputation that is becoming very publicly known. I'm not claiming this to be the state of all fire departments. Many do train often and want to provide good patient care. Several, however, prefer to show up on scene and not even take a blood pressure unless the patient very obviously appears to be dying immediately. They just wait for the ambulance to show up and then hand over their run sheet with a name and a birth date before leaving. This is why we lose respect and therefore the trust of our medical directors and health boards. All we can do is try our best to lead by example and stay on top of our knowledge and skills so that we can maybe sway others into doing the same. It would be nice to have some slightly stricter standards for re-certification so that those who let their skills wane will be held accountable. Now it always seems those interns who "just don't get it" just get passed around until they find a preceptor they can bully into passing them, and the same goes for new hire field training and trainees. I know it's a bit of a rant as well, but I look at myself and then I look at those medics I really look up to and find we're a small minority in a sea of medics who I wouldn't trust with my own life.

I'm considering taking an intern for the next bid I have coming up. Send me a message and we can talk. I work for AMR in San Mateo.

Having preset notions that fire can't handle the job only adds to the animosity and detracts from a real solution. Who's to say fire run EMS is worse than private ambulance service? One angle of this is that the FD is created to help the public vs private ambulance which exists to take money from the public. Fire could run EMS well if the right people were in place. Personally I constantly talk with fire-medics about their continuing education and modern EMS practices. I also have been giving some of their interns some ambulance time as well. If any given FD staffed ambulances and had high quality control and care review, they could probably do a very good job (and without the overhead of a profit margin they could have better equipment/pay/etc.).

Unfortunately, dealing with psych patients is an integral part of our job in most places. I don't know about you guys, but we did not cover too much about psych in medic school. I've learned most of what I know from extra reading and experience. Where I work, the ambulance transports all psych holds. This is due to the fact that our health department doesn't feel that PD can differentiate between an altered patient and a suicidal one (though it still gives them the authority to place them on a hold). If they are larger than me or I feel they can seriously hurt me, I will either have PD follow or ride with me for extra safety. Since my employer doesn't seem to care what you do unless someone gets hurt or sues, I've made it my personal policy to restrain all 5150s. I explain to them that they have been placed on a hold due to the police feeling they may be a danger to themselves, so while they are in the ambulance they will need to be in restraints. Most are understanding and allow it cooperatively. Some occasionally lose it and become combative, but I'd rather them do that on scene where I have help than in the back of the rig on the road. I don't take risks on this anymore. I've had one patient jump out past me when I was an EMT (thankfully we were parked at the hospital) and after hearing stories like this I just take the safe route. Secondly, I always have a communication system with my partner so she knows what to do. If I yell "Brakes!" from the back, it mean's I'm holding onto something and to get off the road and stop as fast as possible without accelerating. Usually the force of braking would prevent someone from jumping out the back anyways. Lastly, I judge every patient I see (not just the holds) on how well I could fend for myself alone with them. I'm a pretty big guy, so putting myself on the bench next to the pt, I can usually hold them down or restrain them myself if they somehow get out of our soft restraints (and I've been there, believe me). That's when I yell brakes and my partner pulls over and comes to help. Being lazy or inconsistent with your methods is what allows things like this to happen. The one time you think, "ah, it'll be fine. let's just go" is the one time it goes wrong, and that can be a career-ender.