fiznat

Sounds like the medics in PA are going to be expected to take on more work, more responsibility, and more liability than they were before this protocol change. Is anyone planning on compensating them for these additions?

Nothing in the mail yet!

Wow, uh, thanks for digging up this old thread to let us all know that you "heard" an ambulance was late to "a" (singular) call. Sour grapes much?

hahaha this is awesome. I'm going to start doing this!!!

Dwayne, I know I expressed this to you over PM as well but please know that I am truly honored you would think of me for something like this. "The soul of EMT city" is a heavy title, but like I said before I really do believe that it is the COMMUNITY here that makes this place as good as it is. Everyone contributes their part, which is why I think it is such an excellent idea that we keep this going as an annual or biannual thing. There are some really good people on that list there. Each and every one of them is absolutely deserves some recognition, and I think you were right to mention that there are so many others who were in the running as well. Again Dwayne, thank you so much.

The pulse ox, alone, is meaningless. We don't throw patients on oxygen (or start any other treatment for that matter) on the basis of a single measurement. If you were concerned about this patient's oxygenation, why didn't you perform an respiratory assessment? It seems you had the opportunity, since you had already tried looking for an IV site. Careful about how critical you choose to be about your instructors and preceptors. Utilize them for their knowledge, and don't feel bad about asking questions. If you want to know why this medic didn't think it was important to put the patient on oxygen, ASK him. Take the information you receive however you like, but the only way to truly understand how that decision was made is to ask the person who made it. Who knows, maybe you'll find out that there was more to it than you thought.

My favorite quote from Moby Dick: "I will have no man in my boat," said Starbuck, "who is not afraid of the whale." By this, he seemed to mean, not only that the most reliable and useful courage was that which arises from the fair estimation of the encountered peril, but that an utterly fearless man is a far more dangerous comrade than a coward. That said, "fearless paramedicine" means to me: -Never be afraid to make mistakes, as long as you admit and learn from them. -Never be afraid to report abusive behavior. -Never be afraid to stand up for your patient when everyone else wants to cut corners. Never be afraid to do the right thing. -Never be afraid to challenge yourself to learn more. To ask questions from the people you respect, to follow up on what you don't know. Never be afraid to go back to school.

Yeah probably. It's not just about a better understanding in the field, though. We should study physics (among other things) to raise the intellectual and educational standard of our providers. I think that setting higher educational standards (like requiring college-level science) would have a profound, positive effect on our profession.

Great idea Dwayne! There are a lot of amazing folks on this forum who deserve to be recognized, and I think passing forward your good fortune is an excellent way to do that. Maybe they can be engraved without too much additional cost?

Well what are you suggesting you should have done differently? Sometimes fractures are not obvious in the field, and clinical presentation can change with time and position. Your case wasn't the first that seemed to present differently in the ED. Don't forget that a "hip" fracture is usually a proximal femur fracture anyways, so the end result wasn't really all that different from what you had originally suspected. I haven't found that the "reverse KED trick" does all that great of a job for hip fractures. If I suspect a hip fracture I usually stabilize with pillows, use pain control, and get some extra help to move the patient gently. It sounds like you guys did pretty much the same thing.

We have a Hindu temple nearby that we respond to every once in a while. They have it set up with a curtain down the middle of the room- all the women on one side and all the men on the other side. They tried to tell us that only my partner (a female) could go in and see the female patient, and also that we had to remove our shoes. Mind you, this was for an unresponsive patient. We were as respectful as possible, but we told them that both of us need to see the patient and that we would not be removing our shoes. After explaining (for longer than I would have liked) that this was important, and "proving" that our shoes were "clean," they allowed us to do what we needed.

We can do epi drips for bradycardia and hypotension, but they are way down towards the bottom of the guidelines. IM epinephrine works *extremely* well for anaphylaxis and severe asthma, and we will usually repeat those before we fiddle with a drip. We also use racemic epinephrine for inhalation. Epi is a versatile drug!

Okay, fair enough. Just don't lose sight of the fact that we are not independent practitioners. We will never, and nor should we, completely sever our connection with the physicians who direct and oversee our medicine. It is my opinion that you should view your medical directors as allies in this process rather than a hindrance. Utilize that resource! Here is a link to our local protocols. I think they are pretty comprehensive, and organized in a thoughtful and accessible manner: http://www.northcentralctems.org/documents/June%202%202009%20NCCEMS%20EMS%20Guidelines%20g.pdf And a list of meds we use: Acetaminophen Activated Charcoal Adenosine Albuterol Amiodarone ASA Atropine Benzocaine Spray Bumetanide Calcium Chloride Dextrose 50% Diazepam Diltiazem Benadryl Dopamine Epinephrine 1:10k and 1:1k Fentanyl Lasix Glucagon Haldol Atrovent Toradol Lidocane Ativan Magnesium Sulfate Solu-Medrol Reglan Metoprolol Versed Morphine Narcan NTG Zofran Neo-Senephrine Procanimide Phenergan Sodium Bicarbonate Tetricane Vasopressin

This seems just bizarre to me. Why don't you have your medical director writing your protocols? Around here, protocols are written by a panel of doctors and are reviewed annually to keep up with the latest research. These kinds of decisions need to be based on science and come from a background of experience and education. I don't mean to say anything negative about you specifically, but it seems to me that there is *no way* a single paramedic should be given this kind of responsibility.

Have you done *anything* over the past year that could count as CME? Taught/assisted with any classes? Shadowed any doctors? Gone to any lectures? Read any books? Visited any presentations? Anything at all? A lot of time the powers that be where I work will grant CME for nontraditional learning experiences if they think the medic really benefited from them. Can you get any CME hours for ACLS, PALS, PEPP, or PHTLS refresher courses? Double check with your company (or whoever is doing the accounting) that all these on-line CME courses count. My medical control will only allow a certain number of online hours. Also if it gets down to the line, suck it up and ask for an extension for a week. I cant imagine it is worth it for the company to fire you rather than give you an extra week off to get everything handled.

Yes, this is the point I was trying to make. The patient could have filled out a DNI form, or a comprehensive list of advanced directives, but she chose not to. The only documentation of the patient's wishes we have is Do Not Resuscitate. Unless the family has a legitimate legal right to make decisions on the patient's behalf, what they would prefer, or what they think the patient might prefer, is of no consequence.

I believe this is the website Dwayne was referring to: ECG Wave-Maven It really is an excellent resource. Search by difficulty, diagnosis, or randomizer. Good explanations, too.

What is your legal responsibility in Ohio? Is there a separate DNI form that either accompanies or does not accompany the DNR? What are the state laws regarding power of attorney for unconscious patients? Does the hospital or your group have a policy? I understand that there are moral and ethical ideas that get mixed in here, but I wonder if might be in the doc's best interest to ignore all that and simply follow the law as written. DNR does not necessarily mean DNI, and unless the family has a explicit right to make decisions on the patient's behalf, it might be best to follow the patient's documented wishes to the letter. Intubate, do not resuscitate. How much good can the doctor do if he is sued or loses his job because he chose to make an independent, moral assumption about the patient's wishes? How many patients will he be unable to help then? It might not serve the greater good for the doc to risk his job over this single patient, and don't forget, intubation might actually be life saving!

DRAMA.......... If there is an issue with this paramedic's medicine, pass it on to his medical control and have it investigated officially. There is already too much that gets passed around as suspicion and rumor. If there is a problem, give it to the people who deal with problems. You will never know what effect 1 (or 3) doses of NTG would have on this *potential* stroke. It seems doubtful to me that it had any effect whatsoever, but I suppose there is some small possibility. NTG will decrease cardiac output, which will in turn reduce cerebral perfusion pressure.

It depends on the call. For this patient I chose to wait on scene, start a line and give the guy some analgesia before we attempted to move him. He didn't have a pressing medical problem other than his pain, and I didn't see a reason to rush to the hospital before making him comfortable. I do this with a lot of back pains, kidney stones, hip injuries, etc etc etc. If the patient isn't unstable, I have no problem taking as long as necessary to make the patient comfortable and pain-free before we start moving. Usually I am more a "load and go" kind of provider, but if there is something that the patient needs on scene, I'll give it on scene.

We just got fentanyl into our kits (in addition to morphine), and I actually used it today for the first time. 150 mcg for a guy with back pain from shoveling. With that amount of medication he went from unable to move to getting up out of his chair and taking a few steps to the stretcher. I understand that is about the equivalent of 15 mg of morphine, which seems about right. The difference was there was no hypotension, no nausea, no dirty side effects. The onset was quicker but seemed less overwhelming and uncomfortable for the patient. This was only my first time using it, and I know this isn't the kind of answer the OP is looking for, but I'm liking it so far. I've found morphine to be a very unpredictable drug and I never knew exactly how my patient would react with it. I'm hoping fentanyl proves to be a good substitute.

First let me complement you on your thorough and diligent assessment. A lot of people never realize that the "paramedic assessment" is *much* more about diligence than it is about diagnosis. As far as your questions: No. ST elevation means the condition is acute. With rare exception (like in the days following a CABG), there is no such thing as "old ST elevation." Keep your STEMI mimickers in mind (LBBB, BER, LVH, pacers, etc etc etc), but real ST elevation is something to be considered as cardiac injury. Depression can be a number of things, but "cardiac depression" is caused by ischemia or is a reflective change from injury. Consider it an acute problem. Whats the difference? What does a "cardiac" patient get that a GI patient does not? If you are worried about a AAA or some sort of GI bleed I would imagine you might be concerned about ASA (and I would too), but it seems you did the right thing by passing that decision on to on-line medical control. NTG as well. Other than that, both GI and cardiac patients get IV/Monitor/O2 and continued reassessment. Don't forget that this patient may have both a GI problem and a cardiac problem. It is not necessarily one or the other. You can't rule out cardiac because he has problems in his belly. Take heart, though. Our job is largely the same. Prepare for something worse to happen, consult on any meds you might want to give (if any), and reassess, reassess, reassess.

Why didn't the ED just put the patient on their external pacer? Seems silly they made you hang around for an hour. Duane, I assume by losing capture he meant that he wasn't getting electrical and mechanical response for every pacer spike. It is possible that you can have both initially, and then gradually (or quickly!) loose it. It would look the same as it does when you are trying to get initial capture, with an intermittent pacer response on the screen. Usually I set the current about 10 or 15 milliamps higher than the capture threshold to help this from happening.

Dude no problem at all, dont apologize! Lol I'd rather we fight about it than end up hugging and holding hands haha. Its more interesting that way. I think there are a lot of good people on here with lots of different opinions and backgrounds. Threads like this get a good mixture of responses which I think usually cover everything that needs to be said. The OP got everything he needed, which was "DUDE WTF" (from me), "and we're here to help, start here" (from you). I think he needed to hear both!

Hey Charles thank you! I'll be sending you an email.