fiznat

You're never in the wrong if you feel "something isn't right" and you want a medic. ...Especially on a 45 minute transport, a lot can happen in that time. I sometimes get frustrated when EMTs make similar decisions around here, but I work in a city and any ambulance can usually make it to the hospital within 10 minutes. That's a different situation. A medic probably isn't going to do much for this patient as you described it, but hey if he lost his airway or coded enroute it would be a different story entirely, right? And again, 45 minutes is a long time to sit on it if you aren't feeling good about the patient. Trust your instincts. You made a good choice.

We can't do complete rule-outs in the field. We have neither the equipment nor the education to do such a thing, which is why nobody but the very few with extremely liberal protocols can do it. I don't tell ANYBODY that they don't need to go to the hospital. I tell them I haven't personally found anything, but that doesn't mean much because I only have so much training and so many resources at hand. I don't care how experienced you are, paramedics don't have the ability to tell someone they are not sick. That doesn't mean I won't take an AMA refusal on anyone though, provided they are alert and oriented and I am satisfied that I have made them aware of the risk.

Jesus Christ. THAT is why this argument is so freaking infuriating. NOBODY, nobody nobody nobody is advocating at ALL that EMS providers EVER EVER EVER "talk a patient out of going to the hospital." Case closed period dot end. Stop even saying that sentence because that is freaking noooot what we are talking about! Damn!

Another article evaluating the accuracy of BP cuffs. They tested 645 of them, which I think is a pretty decent sample size. http://www.scielo.br/pdf/abc/v74n1/2202.pdf And another: http://ccn.aacnjournals.org/cgi/content/full/22/2/123 Even if we HEAR the sounds absolutely perfectly (which we dont, and I imagine this has an even higher margin of error), we are looking at a difference of four to eight points in blood pressure simply due to the CUFF. Add in user error, ambient noise, and stethoscope problems, and I guarantee we're looking at at least 10-15 points in error. People ought to realize that noninvasive blood pressures are estimations only.

No I agree with you JPINFV. Even if odd numbers are unacceptable (which is a ridiculous premise in the first place), it doesn't matter anyways because the cuffs have a margin of error that far exceeds the degrees we are discussing. And so, my original comment stands: the thread is crap. This is mostly true btw, even though ATLS still uses palpable pulses as a guideline for BP measurements. I don't disagree that clinical signs can sometimes give us a good idea about the blood pressure, but the exact "it must be over 80 if I feel a radial" is bunk. Some science to back it up: http://www.bmj.com/cgi/content/full/321/7262/673

This thread? http://www.emtcity.com/phpBB2/viewtopic.php?t=7470& Most of it is a steaming pile of crap imho... It doesn't matter whether BP readings are odd or even because either are within the range of SIGNIFICANCE on the instrument.

^^ Except the OP specifically said that they dont. If the "just add that skill to the current level" argument works, then why not use it for everything else, as well? Proper 12 lead interpretation requires a certain amount of skill and practice, not to mention a strong foundation in the physiology behind it. There is a reason lower level providers don't do it.

Sorry just to help us US folk understand, what can the "advanced" paramedics do that the current level cannot? From what you've typed so far, looks like early 12 lead with cath lab activation by EMS might be one of your major selling points. This (the activation part) was just introduced in our system and we are already seeing major changes in door to balloon times. I feel it is one of the most substantial things we do out in the field to reduce morbidity and mortality. Opiate pain control might be another big deal, especially considering how pain control is getting more attention these days in the medical field. This is another area that I think EMS can have a real impact on their patients, and something your current system seems to be lacking.

I'm still not totally sure I understand the situation here, but my opinion is that you should not have pulled the ambulance over. You are delaying care of the patient on your stretcher so that you can evaluate a second patient for which you weren't available in the first place. Even if you HAD to stop the ambulance for some reason (which you didn't), there is no reason BOTH you you needed to get out and assess this second patient. We don't pick up every sick person we see on the way to the hospital just because we're driving an ambulance. There is such a thing as available and not available. Unless the situation is extreme or unusually urgent, these other people can simply call 911 as the patient on your cot did. An ambulance will come. In the meantime, your responsibility is the patient you have in the back. Thats it. By the way this isn't an MCI. The definition states that the demand must exceed the resources of the SYSTEM, not a single crew.

Well it kinda depends. I've got five people together now, and like I said in my last post in order to maximize the discount ($100 per person) we need to have seperate groups of five (or ten). Are there five people on this forum (not including me) looking to go?

"Too fast for conditions" is such a BS term in my opinion. Its a label thats always applied after an accident has already occurred, for the specific purpose of assigning blame to an event that we did not actually witness. Just because there was an accident or something happened doesn't mean that there was driver error, or that the specific error was speeding.

Fired? Why? It isn't apparent at all that they were screwing around or trying to spin the truck on purpose. We drive hundreds, sometimes thousands of miles per month in our ambulances. Mistakes happen. These employees probably need a refresher and a wake up call about driving safety, but firing them? Calling them idiots? Thats a bit extreme.

I know it's off topic, but I have to say Ventmedic that's twice today I've been extremely impressed with your replies on this forum. I had no idea you've been in EMS so long and had such experience that you could (and do) pass on on to the rest of the community here. People of your kind don't get it often here so I'd like to offer my sincere thank you. Bravo.

While I am a union guy and I believe in the importance and utility of job actions like this, I have to admit that I have little faith they will work. For the reasons stated above and others, I really just can't see something like this coming together on a national scale, nevermind actually working to our advantage. I feel what we are missing is a national identity. EMS workers are spread out so thin over the various kinds of services, that the guy working in the city for a private company feels light years away from a fire/medic working out in the boonies. We all work under different protocols in different circumstances and worse, we all fight amongst ourselves who is better/more educated/has better equipment/is a better provider etc etc etc. The Nurses got respect (and with that, pay, educational standards and career advancement opportunities) though a national identity and a national lobby. As long as we continue to fight petty battles between ourselves and refuse to come together, I don't think we can ever hope to achieve what they have.

I still wouldn't turn him in. What the guy does on his own time is his own business as far as I am concerned. If he were high at work that is something else, but this is his private life and I personally believe that it is not my place to butt in. Furthermore, I think it would do EMS a disservice if it was believed that we were not only out to provide medical care, but to provide "moral policing" of the people we find. ...Even if we only police other healthcare workers under the auspices that we are securing our profession, what message does that send to the public? We only care about the welfare of our own? Our ethics only apply to some people and not others? Nah. In my opinion this is not only faulty logic, but ill advised.

I don't understand what this question is about. We have no responsibility to report illegal activity no matter who it is (save abused minors, in this state). That is the job of a police officer. Do people really still get these two roles confused? WE ARE NOT POLICE OFFICERS!

Heh it is a bit misleading to compare intubation to cardioversion, but I agree our protocol does sound a bit ridiculous on it's face. Then again, I can understand the reluctance of physicians to approve prehospital RSI on a large scale. The potential for abuse, misuse, and damage to the patient are pretty high, and the research isn't exactly supporting EMS intubation these days. It isn't like we sit there and do nothing for these patients. My medical control is fairly progressive in every other aspect, with standing orders for a wide array of treatments that I know a lot of other services have to call and ask for. Our docs are the type that if they start seeing research that definitively supports prehospital RSI and they feel they can upkeep the program, then we will have it. Until that day, though....

Ah, either not intubate them or wait till they become unresponsive enough to intubate. OPA, BVM, high flow O2, etc. Same that every other service does when they don't have RSI. The post-intubation versed is mostly for people who are barely conscious but still "bucking" the tube a little bit. The only time I ever used it was on a code save when the guy started actually regaining consciousness and tried to yank the tube.

We don't have RSI or any sort of premedication before intubation. ....Just the versed afterward if they start fighting the tube.

There are services surrounding mine that have either "sedated intubation" (etomidate) or full RSI with paralytics. It seems that the smaller (easier to QA/QI?) services are the ones with RSI while the larger services either have sedated intubation or nothing. My protocols allow me to give 5 of versed AFTER I intubate, but not before. I guess just to keep patients from "bucking the tube" such as in ROSC situations etc.

Alright so I found the information on their website, imagine that. Groups from 5 to 9 people will save $500 off the total bill on a 2 or 3 day ticket. Groups of 10+ will save $1000 off of the total bill on a 2 or 3 day ticket. They have it set up kinda silly. If your group is not a multiple of 5 or if you have more than 10 people then you don't save as much money as you could have. If we are going to do this here, we should make sure we divide the group up right so that we maximize the savings per individual. $100 off per person is a significant savings-- about 20-30% off depending on which package you want. Moderators, would you be against me starting a new thread to organize a group buy on these tickets? This thread is getting kinda long and cluttered.

Well hang on. We can get the group discount for sure. I've got 4 people interested, money in hand, right now. Surely we can make a group of five, or ten, out of this community of thousands? The savings at the five person group level is a hundred bucks per person so it's not insignificant.... Hold on to your money for a few more days. Let me give the conference a call and find out the exact numbers. I'm sure we can set this up so we can all save a few bucks at least.

This study seems a little odd to me. They're trying to isolate the effect of etomidate, and yet they are comparing treatment regimens that differ on more than on level. Group "E" got etomidate and suxx. Group "FM" got fentanyl, versed, and suxx. Aren't those two completely different paths of treatment? How can they say that the endpoint differences between the groups can be attributed to only the etomidate? Why cant they say it's because of the versed? Or the fentanyl? The groups differed in those drugs, as well. Seems to me there are a lot of confounding factors here, and statistical trickery can only go so far to eliminate them. I'm no stats whiz, but... Increasing the sample size (n) would of course increase the power of the study, but calculating the exact size necessary is a bit esoteric, and requires distribution knowledge about the population that I don't believe we have. What I also don't know is how sensitive this study really needs to be, as I'm not sure how fine the measurements of cortisol truly are. Are these lab levels normally highly variable or are they steady? The former would require a higher power (bigger sample) study, the latter could probably do with a smaller one. The p value is the percentage chance that the null hypothesis was rejected in error (a type I error). Basically, it is the percentage chance that the difference between the two groups is due to chance rather than the treatment. The smaller the sample size, the more likely these types of errors are to occur. Therefore, we must set our alpha level (the "cutoff" point for the p value) lower for smaller sample sizes. <0.01 would probably be more appropriate here.

^^ Thats sorta what I mean. A lot of the stuff that we see purported as "research" in magazines like JEMS and the like are not rigorous studies that hold meaning within the rest of the medical community. I'm talking about performing a real live prospective, randomized double-blind study that adheres to the scientific standards of peer-reviewed literature. Anyone here ever orchestrated something like that before?

I agree this is important. You need to understand the language of the field before you attempt to be a part of it. Personally I learned about this stuff in college and have direct experience with performing as well as evaluating scientific research. That was in a different field, though, and I've never been on "this side" of the fence: transforming an idea into an actual trial.