fiznat

I am a professional paramedic (3 years as a medic, 7 years in EMS total), with no intention of staying. The long-term medics I know personally are some of the most unhappy folks I have ever met. There are standout exceptions of course, but my experience has been that the great majority of those who choose to remain in this field as a career, either had no choice to begin with or regret it very much. This is commercial EMS, by the way. Perhaps the story differs in other environments (it seems likely...), but I can only speak from my direct experience and observation.

We have Buretrols here as well, although I've only used them once or twice. I think they are a good safeguard against catastrophic infusion errors, but they don't do anything to solve the fundamental problem of being unable to properly set a drip rate in the field. I think that if we want to align ourselves with our "equivalents" in the allied health professions, we paramedics are going to have to stop cutting corners and quit doing stuff that would be considered negligence anywhere else. No way "eyeballing" med infusions like this is the right thing to do.

Yeah, I guess hanging med infusions here isn't as common as it could be, but not for lack of protocol for it. I just feel like if we are going to have this as an option (and we should), then we should have the equipment to do it properly. How much do those mini med pumps cost anyways?

Yeah. I have to say that this wasn't all that obvious to me until I tried to actually set up some infusions under controlled conditions. Now that I know how easy it is to change a dose by 10% or 20%, it is amazing to me that our collective medical control doctors have had so few issues with EMS running "off pump" infusions in the field. If we can't even get close to the desired dose with any degree of accuracy, how are we still allowed to do this??

I've been a practicing paramedic for just about 3 years now, and thinking back, I haven't had many opportunities to set up medication infusions for my patients. I've done dopamine a few times, a couple cardizem drips and lidocane, but really I don't have too much first hand experience with it. On a whim I decided to set up a 250 NS bag with on a 60 gtt set and try my hand at setting drip rates the "old school" way (IE without a pump of any kind, just counting drips in the chamber). I've been using a little metronome I had around the house and I've found that this is actually an EXTREMELY difficult thing to do accurately. Even with the metronome and as controlled conditions as I can create, I'm having difficulty keeping the drip rate within 5 and 10 percent of the desired dose. For example, if I want to set up a 5 mcg/kg/minute dopamine infusion for a 220 lb patient that is 20 gtt/minute on a 60 drip set. That means that if I am off by even ONE DROP over a whole minute, I am over or under dosing by 5 percent. Increase that error to two drops in a minute, now that's 10 percent I am over or under dosing. That is a significant amount of error. I've found that changing the drip rate by only a few drops per minute is an extremely small adjustment on the "flow rate wheel," and a really easy error to make. You can move it an amount that isn't even really visible to the eye, and the drip rate changes by an easy 10 or 20 percent. This makes it really really difficult to set an accurate drip. I was wondering how many of you folks have tried doing this to such a degree of accuracy. In the back of the ambulance I'll be the first to admit that in the past I have fudged drip rates a little bit, estimating approximate rates and adjusting as I go along. ....But now that I have taken a set and started to count things out under controlled conditions I've seen how a tiny change can have such a profound effect on the actual dosage. It is no wonder that everywhere else in medicine these kinds of things are done on electronic pumps -- because it seems virtually impossible to be very accurate using the manual method!! I've spoken with a few old school nurses about this, and they largely agreed. Most have admitted that setting up a drip this way took at least 5+ minutes at the bedside rolling that wheel as well as several "check backs" on the patient using "tape counts" to make sure everything was moving according to plan. This isn't really feasible in the ambulance-- at least where I work. I'd like to hear what other people's experiences have been with setting up infusions, and whether anyone has any trips or tricks in getting these rates more precise without a pump.

You can generate "noise" or kinda v-fib looking stuff by touching and moving the patient, or a kinda VT looking rhythm if you tap the leads at a regular rate with your finger, but I've never really seen an organized rhythm show up over asystole from just passive contact with the patient.

I work for the big bad 3-letter corporation as well and we never have trouble getting the resources we ask for. Sometimes the dispatcher will try and play games, say something like "it's going to be a little while" or "can you try to manage it on your own," but if we really need the resources than the reply from us is always the same. I've found that at least part of the responsibility for maintaining this standard falls in the hands of the crews. If a crew folds when a dispatcher gives them trouble, than that dispatcher will think he/she can do it again next time. We have some issues with solidarity in our rank and file, but not when it comes to this. If someone asks for resources, they won't allow themselves to be unreasonably denied. I understand the environment is different everywhere you go, but if you need help then you need the help, and I don't see anything wrong with getting a little short with dispatch over the radio if they are going to start messing around with you.

Without actually being there and without more information, any guess at the etiology here would be just that... a wild guess. We don't even really know whether this patient was hypotensive or not, as there are 3 different blood pressures ranging 30 points systolic. A blood pressure of 90/whatever might even be normal for this 100 year old patient. I think in general in these kinds of situations it is better to do a complete assessment from head to toe before you start getting caught up in etiology. Wild guesses without all of the information have the nasty tendency to color an assessment before all the information is really discovered, which can sometimes be a big problem.

I've had problems in the past also with ordering uniform stuff online, but I have to say I've had some good luck recently with 5.11 Tactical (www.511tactical.com). I like their EMS pants a lot, and I think it is worth the risk of possibly having to return 1 pair one time before you find the right size.

I'm not saying he should lie. I'm just saying he should decide for himself what he wants/needs before going into an interview and trying to hash it out there.

Don't tell them that. Decide ahead of time whether you need to work full or part time to fit in everything you want to do, and then go to your interview and tell them that you will do that job (be it either full or part time) to the best of your ability.

I think the best way for a "newbie" to answer this question would be to describe how "young" EMS is compared to the other public services, and talk about how our future depends very much on the choices we make today. Describe EMS as in it's adolescent stage, equally capable of great success and great failure.

I've actually caught a few of these lately. College kids with symptomatic tachycardias between 180-220 (some of them fib or flutter). I think it is less common to see this condition in such a young population, but not necessarily unusual. Cardizem works great...

Do you guys really always remove the bra? I almost never do. I know someone is going to say that you cant get good quality or placement with the bra on but I don't seem to have too much trouble with it...

Sooorta dude. I can tell you that my work frequently brings be through two (level-1 trauma) teaching hospitals, and I have witnessed atrocities performed by residents and interns that you might not even believe. Much like we are, doctors in training are quite frequently simply "thrown into the mix" to sink or swim on their own. Yes, they get instruction/training/education/preparation beforehand as you say, but there is a point where palpating the ABD is the only way to really learn how to palpate the ABD, and it often takes a few mistakes in order to really learn how to do something well. That said, I think there is a bit of paramedic glorification here. Do some of the paramedics here really believe that they have achieved such a level of expertise and delicacy of sensation that they alone are capable of palpating the ABD properly in the back of an ambulance? With few and rare exceptions I'm sure, those people might want to take a step back and look around. We're not doctors. We have limited experience that - for the most part - revolves around anecdote and hearsay. If you want to play yourself up to be some sort of Gregory House M.D. wannabee, you gotta go to more school to be the least bit convincing. *I'm not talking about anyone in specific here, just pointing out that we often talk a bit bigger game than we should be playing, sometimes.... Dusty, Don't be so dramatic. He's heard it here before, because lots of people (including myself!) have supported that position in the past. This isn't the first of this type of thread, I'm sure you're well aware.... What you mean is-- he didn't hear it from YOU. ...And don't get me started on this ridiculous prerequisite curriculum you've got listed here haha.

I agree with others that have questioned the practice of leaving the ED without first finishing the paperwork. I like to think that our documentation is an essential link in the chain of emergency care, and to allow submission of it as much as 10 or 20 hours later really undermines that purpose. As I said earlier, I am lucky enough to work in a service that prescribes to the "we are clear when we are clear" philosophy. Our medical control actually specifically states that we CANNOT clear from the hospital without leaving paperwork for "trauma alert" patients. I'm not sure why only significant trauma patients are specified in this rule, but it is a good example of a system that places a high value on the role of EMS in continuum of patient care. Even if our supervisors get involved in trying to get units clear from a hospital, there is a (mostly) unwritten rule that patient care comes first - regardless of who wants corners cut at that particular point in time. I complain a lot about where I work, haha, but this is something I think we do right. ...Let dispatch whine all they like.

Bamx- are you writing PCRs at the hospital prior to clearing?

I'm interested to hear how other people handle this aspect of our jobs, especially because I've been hearing some complaints lately that we are doing it wrong. From arrival at the hospital (with patient), what is the average time elapsed before your unit is back and available for another call? Do you write the whole PCR before clearing from the hospital, or do you put it aside to write it later? Does your hospital have rules as to how soon the PCR must be supplied to the hospital? Please specify whether you are referring to an "ALS" or a "BLS" patient. Just to start, it usually takes about 45 minutes on average for our units to clear the hospital after an ALS call. This includes bringing the patient through triage, then to hospital bed, report to nurse, write the PCR, and making the truck ready for a new patient. Some crews average over an hour. Dispatch will sometimes try and call us out of the hospital to handle an emergency call, but it is usually up to the individual crew as to whether they are able to clear for the call or not. How does your system compare?

System Status Management is a good idea on paper, too.

Search Amazon for Peter Canning.

This may seem like a silly question - but if you don't have anything to say, why start a topic? I thought this episode was okay. Once I got a chance to calibrate my expectations for the show I've found I can actually enjoy it for what it is.

I think whenever you start throwing around words like negligence in regards to a more highly trained provider, you'd better have a rock solid case. There is a whole lot we paramedics don't know about really sick infants, and honestly, PALS doesn't always cut the mustard in the ICU setting. It doesn't sound to me like you have all the information you need to question a physician's care so directly. It is quite possible you even did this kid some harm, sticking a laryngoscope down the throat of an already brady patient and then possibly blowing out a lung with overzealous bagging. I imagine the MD you turned care over to could have been equally critical of your work. Believe me I've seen what I believe to be incompetent doctors (especially at the VA) too, and I'm not suggesting that you did the wrong thing here. Still, I've found it is usually better in the end to be humble and try and learn from a situation than focus all my energy on the criticism of others.

I think you guys are all up in arms for nothing. -The medicine will never be 100% accurate in a show like this, we're just going to have to get over it. For the lay public (read: the vast majority of the viewership), the medicine is just a backdrop anyways. Nobody really cares whether it was actually VF on the monitor or if you treat it with analgesics versus electricity or whatever. That stuff is esoteric detail that is only really important to a minority of viewers already in the know. -EMS workers are not so "professional and dedicated" that it is a sin to portray their moments of weakness. The NREMT is upset because the show had a scene that involved a paramedic driving under the influence. What is the assumption here, that such a thing cannot and does not happen? Get over yourselves. We're not special, we fall victim to the same mistakes everyone else does. -Say what you will about the so called profound effect television has on the hearts and minds of the viewing public, but I don't think there is any real expectation out there that the show is a perfect portrayal of EMS. Police officers on Law and Order routinely abuse suspects and break the law, House MD crosses the line on every single episode, and most car chases on TV break the laws of physics on a regular basis. Viewers don't bat an eye. Shows like this aren't about reality, more like hyper reality, and the viewers know it. - Count your lucky stars. At least the characters on this show all seem genuinely interested in their work, are compassionate towards patients and dedicated to providing (at least what the show considers) quality medical care. These providers have excellent, direct working relationships with doctors and nurses, and the profession is portrayed as an essential and necessary component of our medical system. That's a BIG step from being an "ambulance driver," guys.

Please comment on what you think would be the most efficient way to handle these patients. Start to finish. You You are a double medic crew dispatched to a crash at a major intersection. On your arrival you find two vehicles, one ("CAR") with heavy 8" intrusion damage to the driver's side door and another ("SUV") with moderate front end damage. Both cars have airbags deployed. Patients: 1. Young male, driver of "CAR," out of the car and limping around, holding his head. BP 180/75, RR 22, HR 122, GCS 15, complains of head pain. Reports positive seatbelt, negative LOC. 2. Young male, front passenger of "CAR," still seated in the passenger seat. Screaming about pain to both legs, no obvious deformity on a quick exam. BP 110/82, RR 24, HR 100, GCS 15 but there is a language barrier. Reports positive seatbelt, negative LOC. 3. Middle aged female, driver of "SUV," leaning against passenger side of pain holding belly, 7 months pregnant. BP 134/68, HR 98, RR 20, GCS 15, complains of ABD cramping. Reports positive seatbelt negative LOC. 4. Young female, font passenger of "SUV," 15 feet away from car sitting in the grass. Neck and back pain. BP 114/82, HR 76, RR 18, GCS 15. Reports positive seatbelt negative LOC. 5. Infant in car seat, with patient number 4, reportedly secured in rear of "SUV." No obvious distress or complaints, HR 118, RR 24, skin warm/pink/dry. Resources Available ambulances are: 1. BLS ambulance with 12 minute ETA 2. BLS ambulance with 15 minute ETA 3. ILS ambulance with 15 minute ETA 4. Paramedic supervisor fly car with 10 minute ETA There are two level 1 trauma centers in town, both about 6 minutes away. Please describe what resources you would utilize, which patients would go in what ambulances and in what order. Also please describe the things you would get done while these resources are enroute.

I don't really see the big deal about ECG transmission. Research has shown that paramedic 12 lead ECG assessment in the field is both sensitive and specific for recognition of STEMI. Is this really anything other than hospital physicians trying to keep a grip on their "turf?" If we can do this in the field I see no reason to add another step, especially when everyone seems to agree that time is of the essence.