Mateo_1387

Another update... http://www.latimes.com/local/lanow/la-me-ln-live-verdict-in-kelly-thomas-police-murder-case-20140113,0,5661959.story#axzz2qKI9CuI2

Seems like they need to go after the hospital for discharging him in an altered state. I really don't see how they security is to blame. And whoever the hospital staff is that expressed concerns.... they weren't advocating enough... I'm gonna see if I can get anymore info on this.... it happened fairly close by...

By chance is there a copy of the EKG that can be posted?

That was certainly an unkind thing for your friend to do. From reading your response, you seem to have a good grasp of how you want to handle the situation, by approaching her. It seems at the time of the original posting you were a bit emotional from the experience (which is expected, not to be taken as a fault). Sometimes it is okay to handle things while being emotional, as it certainly can add to whatever message you are trying to make (though should be reserved for certain circumstances probably). Otherwise, taking a step back and waiting until the brunt of the hard feelings passes gives you access to better tools you may use to handle a situation, such as logic and reasoning as Mikey said. Being a smooth operator in sticky situations will always make you the winner. Just sayin'... You asked what do you do... Well, what happened to you is an experience, and one that left you in a vulnerable position. To me, it seems this situation is one to store away and use to guide future encounters with your friend. It is up to you if you want to keep the friend's company, though if you do or do not, it is up to you to use this experience to keep from being stuck in the same situation. If you do get stuck in the same situation again, you'll get to claim your own asphalt. (ha, see what I did with that? Being left on the street... ah nevermind...) About you not being ready to do a ride along because you are an emotional 15 year old is true and false. Its easy for people to judge you based on age rather than character. Hell, it happens all the time with old folks. They say respect your elders, I say respect persons that deserve it, and base it off their qualities rather than physical age. Judging someone by their young age is not showing respect IMO. That is one of the real reasons you are probably not going to be able to do a ride along. The thing is right now you will just have to navigate the waters working against you. There is still much for you to learn (and most of us too, I suspect) but it seems to get easier and clearer in how you will handle these different situations. I think you show capability and maturity advanced of your physical age which is what the world needs to see in youth. Keep it up !

I have asked this question to a few people and I think I have two interesting answers, possibly worth using... 1st answer I liked was to just not ask, but bait the hospital staff to ask, cuz you know they will... haha 2nd answer from a friend of mine who is transgender states he don not know the best way to approach this situation. No help huh... Though he seemed to relay that just being polite and asking ought to be okay. Something along the lines of "no disrespect, are you male or female, I only ask to take your biology into consideration for a proper treatment plan". - As a side note my friend seemed to indicate he has encountered persons at work in which their gender orientation is difficult to determine. He said it is easier to avoid pronouns at times, otherwise, if you are comfortable (and maybe have to deal with persons longer than he may) to just ask their preference, respectfully of course.

Checking the NC procedures, pressure points are not specifically listed. That being said, it does not specifically prohibit it either. It uses language such as "control bleeding with standard technique" (saw this one on the tourniquet procedure page). Congratulations on passing the exam !

Levophed continued, support BP. For sedation probably just give Versed in small doses, 2 mg as needed for sedation. Probably hold off on the paralytic. As far as steroid, Methylprednisolone 125 mg to start with.

Welcome to the City from Eastern NC

With the patient's altered mental status and hypotension, I do not think CPAP would be the best intervention to perform. I know I mentioned pressure support on the ventilator, but thats with RSI and hypotension control. In her current state CPAP wouldn't be advised. I thought we would try a higher dose of Dopamine, or move on to Levophed? I think RSI would be warranted. Using Midazolam 2 mg, Succinylcholine 100 mg, pass the ET Tube and confirm. Its going to be important to control the blood pressure though. Looking at the labs (I'll be honest I had to look up a few values) I am not seeing anything spectacular. Glucose and BUN are elevated, the Hematocrit is slightly elevated. An NG tube and a Foley cath could also be organized. After RSI Albuterol may be administered to help with lower airway rhonchi/obstruction. Steroids may not be a bad idea either.

Thanks for the share, I like it !

I really like this !! Thanks for sharing Mobey.

I am thinking this patient may also have sepsis, possibly due to a pneumonia. The patient presents with Coarse left lung sounds along with diminished right lung sounds. If she is overdosed on narcotics, she is likely sedentary, breathing slowly, which I think would allow for bacterial growth and/or an aspiration pneumonia. After Naloxone is given thus reversing the effects of CNS depression, we see that she becomes tachycadic and has a slight raise in temperature. I think by this point it may also be prudent to start administering Dopamine. With her low perfusion status, end organ failure may be a real possibility, being we don't know how long she has been like this. Lets say we start out with the standard 5 mcg/kg/min, which at her weight of 150 (using a 1.6mg/mL Dopamine Concentration) would be 13 gtt/min. RSI may be an option, though I'd be weary of administering sedatives in lieu of the profound hypotension.

There have been LVAD patients in multiple districts I have been positioned in. I have never had the pleasure of interacting with one of these patients though. It was required for me to take a class about the LVAD, which consisted of a representative from the manufacturer, an RN I think, to give a lecture to us. It was quite informative. I will endeavor to relay that information to you, though suggest you confirm the information, as I really do not have a source for the information. Anyways here goes... When trouble shooting a problems, as others have echoed, and as the link Mike shared, use the family, call the coordinator, but be humble that you may not be the most knowledgeable about how the device works. Know though that a common alarm is a low flow alarm. Apparently, these patients often are dehydrated and may benefit from a fluid bolus. High blood viscosity can cause a low flow issue, thus fluids may help dilute the blood the promote circulation. There are three other "common issues" these patients may have along with the dehydration. Frequently LVAD patients are prone to stroke, Gastrointestinal Bleeds, and infection. I think some of these are self explanatory, such as stroke being due to the "thick" blood, probably clotting issues from trying to repair the surgical implants and permanent body openings (I'm really guess on this one, maybe someone else knows better than I). GI bleeds make sense to me as these patients will also be placed on anticoagulant therapy. Infection due to insertion site of the LVAD. As said before, no CPR.... But everything else can be done. These patients can receive all ACLS drugs and they may be defibrillated/cardioverted. Keep in mind theses patients have failing hearts and are usually waiting for a transplant. We were warned in class to not be surprised that a patient may present with things such as ventricular fibrillation and lethal heart rhythms, though are still able to communicate (though will likely be weak and have poor circulation). Also, keep in mind the patients are prone to have medical problems not related to the LVAD, so do not let it be a distraction during a differential workup. I hope this is helpful, I have tried to recall some of the more important information I remember from the class. It may be beneficial if your agency and local hospital (mostly emergency room staff) can put together a few classes with a representative from the LVAD community. Again, I suggest you confirm my information, as its not from a specific source, and some of the information may have changed by now, as I took the class a few years ago. If anyone knows better, please do not hesitate to correct me. I'd benefit from it too. Anyways, one last note, speaking of asking your coworker to take a blood pressure... I always enjoy going to a class and hearing someone say in reference to ventricular fibrillation "they won't be talking to you"... I usually comment back "well... if the patient has an LVAD, they might be talking to you".... Always looking for the exception to a rule... Matt

I am interested in knowing its significance too. Also, my interpretation of the EKG would depend if it is electrical alternans or not. I'm leaning between sinus tachycardia with electrical alternans, or sinus tachycardia with premature escape complexes, and I a few others. A-fib is one on the list, though this EKG sample has a pattern, every other complex group has the same R-R wave distance, leading me to think its not A-fib. So, what was the answer given with the sample?

On the bottom lead (I assume lead II) view every other complex has the same R-wave height, almost like a slight electrical alternans.... Is this what you are referencing?

I know you are not in the United States. I've known that. Nothing new. But look, I never meant to convey you lack morals, I just thought your views on this subject were lacking in them. That make sense? I thought my counterpoints explained that, maybe I failed in that respect... I can only take what I read on here and go with that, unfortunately I do not know you on a personal level where I may have a better understanding of what you post. So much is lost in text alone when having conversations and at times I do miss the finer points of expression via text, it is a downfall of mine. Maybe we are talking about two different patients. I've only applied physical restraints once myself and chemically restrained a slew of other patients. Its just not something I take lightly, which I thought you did. Anyways, my idea of a patient possibly needing a restraint procedure is usually the patient I meet where within the first minutes of arriving on the scene we are already in a physical situation that is not deescalated by other means. I took your examples to be the patients that hint at violence, had a previous episode of abnormal/violent behavior, and the like. I guess for me I tend to try and treat on the current situation and have yet to have a patient "turn". This may be the point where we are not seeing eye to eye, different experiences... different thinking process... Anyways, try not to take it too personally, please. I've had my thoughts and viewed slammed on here more than once and I think I'm better since most of it. Hope this helps to ease tension and improve understanding. G'day

Ok, I admit I did go on a rant and was not very nice about presenting some of my thoughts. I also sincerely apologize for treating you in such a manner. You deserve more respect and I should have offered it. I hope we can move forward. I also hope we can continue the conversation, as I think it is an important topic. The only patient I presented and wrote about is the example you used. I tried to make my discourse based on the ethics of restraints, but used your example to support my statements. I never accused you of only using restraints. I did try to make the point that your liberal use of restraints ought to be restrained.  Based on your reply to Captain… • • I understand there are times where involuntary commitment is necessary. No argument there. The right to autonomy is not lost though. Exercising the right may need to be restricted at times, though the goal should not be to maintain that restriction, but to restore the full use of those rights. Being able to be an active part of the treatments by being allowed to make decisions and choices would seem to be the better option than being on the sidelines without having any input. That is how we treat our animals when we carry them to the vet. It is not the way our mentally ill should be treated, if it can be helped. It could be that way. Just because there are some non-rational thoughts does not mean all thoughts are non-rational. It will be situation dependent. Maybe I was harsh with the smug comment, but, from what I read scubanurse said to musiclife “Your wording in this also makes me concerned that you really lack the skills to deal with psych patients, the bolded statement in particular.” Then you come back and claim she assumes therapeutic communication always works, she says she didn’t. Then you come back and say she did and based your argument on a few points. • One point being that she bashed a volley. • Another saying “you don’t know how to communicate” comment Neither of which happened. A concern was noted and then a suggestion made on her part. Then you tried to say that since musiclife is an EMT-B therapeutic communication was not taught in his curriculum and that he is probably not the only one lacking knowledge and then blame it on the system. So yeah, way to protect the volley from New Jersey and take a jab at everyone else… You cannot have it both ways either sir… Then you turn around and talk about willy nilly use of restraints. I quote from you “…so they get restrained or the don't travel with me "just in case". You restrain in the name of safety because you had a compliant patient bash your skull and abscond from the ambulance. It bothers me that you would cry on about his education then try and support your use of restraints on morally irrelevant previous patient contacts. I was not expecting this type of reasoning from an educated person. I digress… Now you are just reaching. Restraints may be necessary in the course of treatment, which has never been the argument. I am fairly certain you do not treat patients as you described above (ref. 16 y/o depressed kids). I will though try and answer your scenario question. The patient you describe could be an Autism patient, mental health patient, not competent, prone to violent and aggressive behavior and everything else you said. Maybe letting their family member ride to help keep the patient calm rather than restraining them could be a more appropriate treatment. Maybe talking to the caretaker about how to best handle the patient would be beneficial in altering how you approach the patient. How about using techniques the patient may have employed in the home like using music to keep the patient calm. These are a few examples. It may come to a point where physical or chemical restraint may be necessary, but if you jump to that first thing, I do not see the good that would come from it. Your posts have been riddled with your continuing support of restraints as a first resort, lacking impartiality, and based off of morally irrelevant information. You give me hell about trying to preserve civil liberties and ranting, but your views are not necessarily correct. That is why I offered my own take on the subject. I am not going to attempt anymore inflammatory remarks. It is not my ultimate goal. On the other hand I am not going to stand down for something I truly think you are wrong about until its proven otherwise.

Scene presentation - safety, weather, whats in the shopping cart? If its relevant Patient presentation- Level of consciousness, obvious injuries, signs of distress? Airway, Breathing, Skin color, temp, radial pulse qualities? If she is talking then "Hi, I'm Matt with the ambulance, how are you?"

"Just in case"... I'm shocked that with your smug attitude of lacking U.S. EMS training and education that you spout off crap like this. The moral and legal issues of restraining another person are more profound and farther reaching than "just in case". Morally speaking, the willingness to restrict a patient's freedom willy nilly, because you had one patient become violent towards you, surely lacks a moral basis of preserving a patient's right to autonomy and right to refuse. The previous sentence speaks to your impartiality of applying restraints and is morally irrelevant in dealing with your next patient. I'd like to think you want to provide good care for your patients, but automatic restraint of psych patient's "just in case" will systematically violate personal freedoms in order provide care and prevent harm. Sure, a utilitarian view of protecting others is a consideration to be taken, but there is still one person who is not "most benefited" by the procedure. Tell me, how is restraining a patient therapeutic? Or is it just containment? Do you think your patients see restraints as treatment to getting better, or more as punishment? It seems these considerations matter when deciding to restrain a patient. With your better psychiatric education, do you even try to use less restrictive measures in your 5 hours ago raging storm but now compliant paranoid schizophrenic patient? It makes about as much sense as putting you in handcuffs because you were royally pissed off with road rage 5 hours ago.... wouldn't want you running down and hurting someone... Legally speaking, committing acts of battery come to mind first. I'm not the most legally savvy person, but restraining patients based on previous patient's or "just in case" situations, would seem to be a form of battery. The schizophrenic patient that previously exhibited a "raging storm" extreme of behavior doesn't mean that five hours later, while being compliant, deserve to be battered. Again, this type of systematic use of restraints violates a persons right to refuse medical care. Now, this is a double edged sword, I agree, but the point I'm trying to make is that systematic use of restraints can leave one liable in violating another person's rights. In no way am I saying that restraints should be banished, but rather the decision to restrain should be carefully considered in regards to moral, legal, therapeutic, and safety aspects. Its not an issue to take lightly and very much should be a last resort when other less restrictive ways of behavior modification have been exhausted. In regards to safety, I realize two persons on an ambulance certainly raises concern when dealing with an acutely violent psychiatric patient. Placing patients and personnel in situations that are dangerous and make the requirement of the most extreme measures necessary as the primary intervention in lieu of not being the most appropriate treatment.....system error much...???

I think a slew of wonderful things are being wrote here. I find the writings thus far to be eloquent and touching. Therefore, I must apologize for blundering this post with my half wit, straight to the point nonsense.... The EMS spirit expressed through compassion and mercy, are the truer marks of a professional. Something that really catches my eye is the reminder of a certain power we sort of hold while being invited to view the lives of so many people, especially those in vulnerable positions. I know we are trusted with this responsibility, though it is always good for me to be reminded of that position once in a while. I truly believe it takes a personal motivation to want to be a better practitioner and simply a better person. As I said before in the post recently about the poster frustrated with their partner and taking it out on that person, our actions are a choice we make as to what kind of person and practitioner we strive to be. Now I'm going to take the rocky road and go against the general grain/direction of this thread and offer my spin. As I sit and type this, I have reread my last sentence about actions and contemplated a few different things. Most of my thoughts left me feeling like a shithead, and it may be rightfully so. I haven't quite figured it out in my head, but my thoughts are along these lines... I had a patient recently that is still on my mind. To give you the quick and dirty it was an elderly female with alteration in mental status. Initially no response to painful stimuli. Upon starting an IV we get a response from her. She says "ouch, take that out" then goes back to not responding while trying to talk to her (now that she is finally talking). I used a trapezius muscle squeeze to illicit another response from her. She would talk and come back with short and seemingly snide remarks. I admit, it made me a bit frustrated. I did a few more squeezes during the call, and continued to engage talking with her to illicit responses. I find no glory in trying to make her talk, rather I wanted to figure out what was going on with her current mental decline. Did she take something? Is she hurting? Ya know, the usual things that help with our field diagnosis.... To get to the point, I feel like the crappiest paramedic alive right now. I have no malicious intent for doing what I did. I felt it prudent that talking to her was important and since I know she can respond I continued to engage her. Point blank, I was frustrated too. In my mind, I also seem to be associating my actions (squeezes and talking) as being a manifestation of my frustration. I do not think my bad feelings would be there if I was not frustrated. Did I commit battery? I feel like I may have, wanting to cut up my cert card and attach myself to an ass kicking machine. At the same time would she be getting the timely and necessary care she needed without eliciting a response and acquiring information? I doubt it, though it doesn't make me feel any better. The point I'm trying to reach is that meeting our patients with compassion, respect, mercy, and a desire to "gift them with our advocacy" are wonderful things, though other influences such as frustration, fear, anger, and those other lovely emotions we possess are capable of leaking out of that professional EMS spirit cape we all wear. That is the human element we all face, IMO. I do not think the EMS spirit is a bunch of rah rah feel good bullshit, but rather an important part of who we are as EMS professionals. As an introspective person who has an introspective race car track without a finish line in my head, its hard to think I'm the sum of the not so great things I feel I have done, in an EMS spirit kind of perspective. I do not think I agree that just because one can have certain negative feelings about interactions we have with our clients means that we succumb to the whacker level, at least not until the point is reached where we let those feelings guide our EMS spirit. Some folks (whackers) get their kicks off by sharing and probably exaggerating their feelings (and at the expense of others), though I guess I just live with it in my head. ______________ A separate point I want to address that has been discussed in this thread is the "thank a paramedic" and "we don't need no thanks" parts. So they promote the idea of saying thanks to EMS folks during EMS appreciation week and it is pathetic? It seems to me that appreciation would be healthy. It promotes people to say thanks which in turn makes them feel good. At the same time a stranger that takes the initiative to do something good, oftentimes for a stranger, makes me feel not only appreciated, but contributes to the idea the world is not as bad as we often perceive it. Where is the harm? Now, I will say that the facebook posts I see about "we get up at 3 am to save your sorry tails, so thank us" is bullshit. That is pathetic. As I previously talked about that, what is the harm in genuine appreciation?

As far as Benadryl goes, it could be an allergy due to the dye of oral Benadryl, not necessarily to IV Benadryl. Also, remember Phenergan is also an antihistamine that could possibly be used.

I tend to agree with everyone thus far. I do want to add to the overall tone and echo more of what croaker260 has said. In a nutshell, how you decide to treat patient's and treat your coworker is a choice you make. It is okay to have feelings, frustrations, but when you start reacting to the stresses on calls, instead of responding to the situations at hand, you hinder the good qualities you may have a leader. I don't mean for what I'm about to say seem like taking a horse pill, though, you are going to have to get used to explaining things, especially in stressful situations. Sometimes, you are not paired with the experienced partner. If you are unable to explain things to your partner, who probably looks to you for guidance, then how do you expect patient's, their family, or other medical providers to respect your position when you start losing your cool? Again, the choice is to bully your way through or show patience and understanding. Anyways, off the soap box, which I hope you take as constructive and not bashing. I offer this because I started out as a young paramedic (guess I still am) working with those old enough to be my parents. I've made my share of mistakes, but have striven to be respectful to others, especially my coworkers. To answer your question about great or terrible things while being a no0b, I'll tell on myself. In essence, I started out pretty bad. I had no experience, especially life experience, much less seemed to grasp how things were ran in EMS. I guess in essence, I had a hard time picking up on how things were supposed to run on a call. The ebb and flow of things were foreign to me, and I think this happened for a while. I am sure I had to be told to do many things I was expected to do. It didn't help when the situation was stressful and adrenaline was running. As far as no0b coworkers, I think the greatest thing I see from them is a willingness to learn and more respect to patients. The worst qualities seem to be scene control and a lack of confidence. I hope this is helpful. Good luck on your paramedic journey, I'm sure it will get better, as you are willing to participate and ask for assistance. Kudos... Matty

While a motorcycle can be dangerous, they are loads of fun ! I own one and enjoy riding. I also took a motorcycle safety course before starting to ride, which I highly recommend. I also recommend you buy a good helmet. Seriously, when buying a good one, think about how much your head is worth. When riding, defensive driving is always a must. Keeping an eye out for the other driver is a priority, as well as yours is to take it easy and drive safely. For instance, if you are rushing to leave, maybe the motorcycle isn't the best choice. Same thing if you use any substance that may alter your mental and or physical functions ( as in alcohol, drugs, prescriptions, or just being tired). I have been to some bad motor cycle wrecks, and while it is scary to think that could be me, it makes me try and be all the more safer. Of all the accidents I have been to, the ones where someone died, they were doing stupid stuff like running from the law, racing, and the like. A few others I went to ended up with minor injuries as they were able to have some sort of reaction before an impact to reduce their injuries. Not saying they couldn't have serious injuries, but its been my anecdotal experience that the more serious injuries, leading to death, have been due to stupidity. In North Carolina, where I live, we require helmets, which I hear may be changed. Why, I dunno, but I'd say riding without one is a stupid action. I read ERDoc's post about it, but not all motor cycle crash victims riding without a helmet will die. They may still cost taxpayer's and their families a lot of money. My 0.02 cents... Matty

Yah, I hear ya. Out of curiosity, do you have a policy on the standard practice of searching patient's belongings? Also, is it truly permissible to refuse to transport someone because they don't want you rummaging through their personal belongings, and then make them fill out a refusal of medical care, when in fact it was the patient's refusal for you to search the bag? Especially, when you may not have a reason to suspect something is in the bag, but search just because there is a bag? I ponder the legality of searching someones bag as a standard practice in an ambulance. Anyone familiar with such things, legally speaking?