fiznat

I have been to several scenes that could be considered legitimate "MCIs." I have learned that these calls don't happen as frequently as people sometimes think, and it isn't a rare occurrence that providers (myself included) aren't quite sure what to do right away. The failures I have seen have been mostly related to lack of coherent leadership on scene, organization of incoming resources, and patient prioritization. It never goes as smooth as the triage advice seems to suggest it should, and often we are happy to simply have got through it without any major blunders. One lesson I learned the hard way - even though it seems obvious - is that the first provider in to an MCI should be the last one out. That means if you are the first truck to arrive on an "oh shit" call, your job isn't the same as it is on other calls where you focus on getting to the patient's side. Your primary job as the first arriving is to count patients, get resources rolling, and start delegating responsibilities. Patient care is secondary. That's a tough lesson to learn, especially when you are used to treating patients.

CB- nicely done. The best part about this story (as boring as it may be) is though you recognized the pathology, you still knew enough to double check with medical control before you went ahead with the treatment. I think it says a lot about a provider when they realize they're dealing with something they haven't handled before, and seek guidance to make sure the job gets done right.

I'm not completely sure (again), but I'll give it a shot. Looks like a sinus rhythm at 72 bpm. The complexes are narrow and the axis is in the normal range. The interesting part is obviously the precordial leads V1-V3. There are some FLBs ("funny lookin' beats haha) on the 2nd complexes which I guess we can call Q waves being that they are the first downward deflection after the p wave. Other than that I'm not sure what they are (possibly ectopy or some kind of fusion beat). The T waves are pretty peakey with some ST segment elevation as well. In my differential would be an impending MI (hyperacute T waves, ST changes) and hyper-K (peaked T, flatter P). The rest of the story and the patient's presentation should help differentiate between these two possibilities. Also of note is the r wave progression in the anterior leads, which point towards right ventricular hypertrophy. Is this patient a COPD'er?

I'm 99% sure there is no such federal law. I'm also not aware of any CT law that specifically prohibits EMS workers from carrying a weapon. A (Connecticut) law that might be applicable though is one that requires guns being transported in motor vehicles be unloaded and kept in a place "not readily or directly accessible from the passenger compartment" (CGS § 29-35). EMS workers wouldn't be able to carry guns on their person when driving, which is kinda a big portion of our work...

I imagine the results would be confounded by the fact that paramedics - regardless of "education level" - largely follow a standard set of protocols. The output of work from a paramedic still depends much more on what the protocol says than any independent (educated or not) decision made by that provider. There is an assumption here that longer training times correlate with more advanced protocols, but I'm not sure even that is true. I imagine establishing that relationship would be the first step in this kind of research.

I don't know for sure but I would imagine the feeling is mediated more by sympathetic tone than parasympathetic tone. ...More "fight or flight" than "feed and breed."

The highlighted error was one of many. It is clear that he doesn't take the time to review what he says before he posts it. That says something to me. Look, I'm not saying that experience isn't a good way to get better at something. It is. My issue is with the suggestion that experience can serve as a surrogate for rigorous education. The poster above seems to have confused years on the street with years at school, and it is my personal opinion that his perspective is not only incorrect, but dangerous. ANY EMS provider (be it EMT or medic) should well understand that he/she is familiar with only a VERY small slice of medicine, and should have a profound respect that which he/she does not know. I think the above poser is proud of his 17 years, as he should be, but to suggest that he - or any EMS provider he knows - comes close to the diagnostic/educational level of a physician is pure hubris. I think it is the same subject. The issue at hand is whether we are even capable of making such a diagnosis in the field. It is my position that we cannot.

(re-quoted the strip so we don't have to keep going back to the 1st page) I'm really not sure what this is. Looks like we have a regular, borderline wide-complex rhythm at about 100 bpm. I see P waves that correspond to the QRS in regular fashion and are of regular, consistent morphology. The P-R interval may be a little bit long, but it is difficult to tell on the small tracing. There appears to be a right bundle branch block as well. Based on the above information I would consider calling this a sinus rhythm with RBBB, possibly a 1st degree AVB. However, there is left axis deviation and the R-wave progression through the chest leads is really funky. These changes could be due to the abbarancy in conduction through the ventricles, or it could be a hint about an alternate origin of the rhythm. With everything else, though, I think I would still call this sinus with RBBB. I'm not seeing any evidence of a pacemaker here, though I could be wrong. Good strip!

Wow.

I don't know about the actual laws in your state, so I will answer this question the best I can based on my experience and how I would likely do things if I were on the call. In my opinion, nobody can sign a refusal FOR an adult patient unless that person has a legal power of attorney. It doesn't matter if they were his parents, your patient was an adult who makes his own decisions regarding his health care, and he was not alert and oriented enough to understand the consequences of refusing. I also feel like the doctor on the phone is irrelevant. You don't work for him or under his license, and he wasn't present to assess or take care of the patient. In my opinion, it really doesn't matter at all what some other guy on the phone believes about your patient. He's not there. If the parents were going to make a big fuss if you attempted to transport, I would have got my medical control on the line and let them hash it out. Leaving this patient behind with a refusal signed by someone other than the patient him/herself or a POA is not a decision that I would want to bear on my own. I would involve as many other people as possible: medcon, supervisor, police, etc. By the way, lol, what?

We should have this kind of database here at EMT-City

I'm sorry, but where did anyone turn this into an ALS vs BLS debate? What guns exactly should NYCEMS stick to and what is it that he is holding dear? This warm and fuzzy stuff is all well and good, but it really isn't making much sense here.

Thank you for posting that ventmedic. That is what I suspected based on reading that other little synopsis. Ahhh sorta. Granted the company sounds like they are being rude to you based on your account of the conversation, but what I'm thinking is you probably pissed them off a little bit by accusing them of breaking the law to serve their own interests. In addition, it doesn't seem you were exactly crystal clear on the letter of the law considering that ventmedic just posted the actual statute that contradicts your original point (that you can't work inside the grace period). The fact of the matter is you don't even know for sure whether this medic was illegible to work or not. How far do you really want to take this? Not that it is completely relevant here, but I think you are also incorrect in your point that (re)licensure ensures medics are up to date on medical guidelines. In my state, all that (re)licensure means is that you've paid your fee and submitted a 1 page demographic application. Maintenance of clinical competency is the sole responsibility of medical control, which will review the proper documentation annually and (re) grant active medical control letters as they deem fit. I would be surprised if it were different where you are, but here, clinical competency and licensure are not the same thing. For those that say you have a moral/legal/ethical/professional responsibility to report the company, I would argue that you need to be absolutely sure of the facts before you take that step. At the moment, unless there is more information we don't know, you really can't be sure whether this medic was in the 60 day period or not. I don't agree that any moral responsibility can exist that mandates action on an assumption or incomplete information.

With a national registry number you should have no problem getting certified (not licensed) in CT. I'm not affiliated directly with the office of emergency medical services of course, but I can say with a pretty high degree of certainty that if you've got your national reg, all they really care about is collecting their fee.

Based on what Lone Star posted, I don't completely disagree with the company's position that this medic should have been able to work within that 60 day grace period. The license doesn't "lapse" until after the grace period. My personal opinion here is that you kinda jumped the gun a little bit on this one. It wasn't really your concern, and there is a chance you were wrong anyways. It isn't your responsibility to police the certifications and licenses of everyone you work with, and without knowing all of the details it seems a bit over the top that you would go as far as to resign to make your point about it. Turning in an official complaint to the state at this point seems to me like sour grapes.

The fact that you work for the fire department of NY really has no relevance here whatsoever, but if you feel that gives you some credibility then have at it. I understand that it is important for providers to grasp at least on some level what it is they're dealing with on the ambulance, but I think it is also good practice in the presence of an illusive, idiopathic problem, to simply make sure that the basics are covered. There is nothing wrong with not knowing what exactly is wrong with your patient. In fact, any reasonably humble EMS provider should be well versed in the feeling. If you read what I said, I simply gave the advice that the poster make sure that the BLS is solid before going zebra hunting. And oh, its a bit of a pet peeve of mine. We're not diagnosing anything in the field. We build a clinical impression and develop a treatment plan based on that impression. It is a dangerous thing to start getting into the mindset that we, with our level of education and training, understand pathology on the level that a physician might. Not that it isn't a good thing to follow up with patients and work to stay sharp. It is. ...But a little knowledge is - and will always be - a dangerous thing.

Perhaps, but the patient would still be breathing................................................... dot dot dot

Honestly being that you've had this experience twice with the same patient following an ED examination, it seems more and more likely that the symptoms are probably psych related or connected to the progressing dementia. Still, the danger of course exists with these types of patients that THIS TIME it isn't psych but rather some other malignant problem. Some things to keep in mind: 1. Hypertension like that and altered mental status should make you start thinking about CVAs. You should do a good look for focal neuro deficits, not just hand grasps if you can. Get serial blood pressure readings and verify that an outstanding reading like that is legitimate. 2. Acute altered mental status in diabetic patients should always prompt a BGL check. There is no excuse for not doing it. In fact, if it comes up normal and there are no other good explanations for the AMS, do it again. Sometimes you can get a bad read. 3. The most important feature to know about with AMS patients is BASELINE mental status. Spend some time learning from the family how this patient normally behaves so you can clearly articulate what is different *today.* Sometimes it takes multiple good questions to really pull the information you need from a family member. Along the same lines, ask about previous episodes or issues relating to the incident at hand. 4. Remember your AEIOU-TIPS, and go through it in your mind when you've exhausted the obvious stuff. Alcohol, Epilepsy, Insulin, Overdose, Uremia, Trauma, Infection, Psychosis, Stroke. 5. Forget about obtaining the 3 lead ECG. It is a complete waste of time if you can't read it, and even if you can you would know that a 3 lead tells us very little anyways. The hospital doesn't care about your strip. Your time can be better spent elsewhere. 6. Lastly, remember that you don't always need to "figure out what exactly is going on." Especially at the BLS level. Make sure you protect the c-spine if necessary, keep her airway open, give oxygen, understand the story, and monitor for changes in vital signs. That is pretty much your job. Make sure you at the minimum do that stuff well, and save the zebra hunting until after.

I called the first red because I'm not sure of his volume status. Two long bone fractures and borderline hypotensive with tachycardia sounds like compensated shock to me. I could see calling it yellow also, though. Second was green. This is an MCI and she's got good vitals and a minor lac. Pretty sure you don't get bumped to yellow just because you are pregnant. Third is clearly red until she codes.

In the November 2008 issue of the Annals of Emergency Medicine, there was an article entitled "Code of Ethics for Emergency Physicians." The article was written based on the premise that, in addition to the oaths taken by all physicians, emergency physicians accept "specific ethical obligations that arise out of the special features of emergency medical practice." I thought this concept was interesting, and that perhaps we can look at these obligations and see how they might apply to our practice as prehospital providers. Here they are: 1.Embrace patient welfare as their primary professional responsibility. 2.Respond promptly and expertly, without prejudice or partiality, to the need for emergency medical care. 3.Respect the rights and strive to protect the best interests of their patients, particularly the most vulnerable and those unable to make treatment choices due to diminished decisionmaking capacity. 4.Communicate truthfully with patients and secure their informed consent for treatment, unless the urgency of the patient's condition demands an immediate response. 5.Respect patient privacy and disclose confidential information only with consent of the patient or when required by an overriding duty such as the duty to protect others or to obey the law. 6.Deal fairly and honestly with colleagues and take appropriate action to protect patients from health care providers who are impaired or incompetent, or who engage in fraud or deception. 7.Work cooperatively with others who care for, and about, emergency patients. 8.Engage in continuing study to maintain the knowledge and skills necessary to provide high quality care for emergency patients. 9.Act as responsible stewards of the health care resources entrusted to them. 10.Support societal efforts to improve public health and safety, reduce the effects of injury and illness, and secure access to emergency and other basic health care for all. As EMS providers, which of these do you think we excel at, and where do we need work? Do they all apply to us as equally as they do to physicians? The original article: http://www.annemergmed.com/article/S0196-0...1577-1/fulltext

Welcome to the boards! I'm not to familiar with what is required of EMTs across the pond... would you mind letting us know what kind of training was involved and what kind of stuff you do? Not that I'd be able to directly answer your question even with that info, but I'm interested to hear. It might do you well to give the National Registry a call and see what options are open for reciprocity, if any. Surely you are not the first person to try this, there must be a way besides completely starting over.

Did your pedi meet the size requirements for the IO? I know they say we shouldn't be putting them in patients under 3kg.

Ah, does a stretcher count as part of the 6 items? haha If not, PPE BP Cuff Stethoscope Gauze LP 12 BVM

I typed up a different explanation in this thread: http://www.emtcity.com/index.php?showtopic=14597 In there is also a link to a really good flash movie that helps explain it all.

Yeah this is definitely a good point. This sounds like a problematic situation to begin with. I see no reason to get yourself tangled up in it.