cekuriger

Haha this is an impressive undertaking, you're a stronger one than me for doing it. Great idea, and thank you for doing it! I work in a busy urban service. We'll get between 50 and 70 thousand calls per year with 13 ALS units on during the day, 3 BLS units on from 0700-2300, and 10 ALS units at night. I'm not one to gripe about dumb calls, I appreciate the easy tripsheets, but the level of EMS abuse we see is astronomical. i.e: Tooth Pain, Broken Toes, my kid has a cough and fever, and we were at the hospital today, and it's still there and I want him checked out again. Everyone deals with this stuff, I get it. In an 8 hour shift, it's not unlikely for us to get 6-7 calls for just my ambulance (what a lot of services get in 24 hours for 2 ambulances), and there are days were that's all of our calls, forcing our also high number of truly truly ill patients to wait another 15 minutes for one of our other ambulances to get there. This is some thing, very obviously, NOT specific to my service, but shows a serious lack of education on what's ED appropriate and what's not, and when I try to explain that there's not much the ED can do, they get mad, tell me I'm lazy, blah, blah, blah, totally unaware of how much they are clogging up the system and hurting sick people. I think it would be cool to develop an app with common non-emergency complaints, and the person can select it, and be given more appropriate solutions, or, at what point with them (if there is any) that the patient should go to the hospital. The only big issue I see here, is I'm sure a lot of investors could be cautious with the liability aspect...but it never hurts to throw it out!!!

That was well-put, good job!

Well, it should never be advanced airway management vs providing ventilation...Unless, what you meant was, intubate, or just do BLS airways. This question isn't really a one word answer, and can get kind of complicated. Text book answers say, Intubation is the Gold Standard. Reason being, you can prevent gastric insufflation, which as we all know could lead to an airway disaster, and just general aspiration of secretions, and the text books are very correct in saying that. But. Text books, again, as I'm sure you know (I'm not trying to be condescending), often ignore the reality of the streets; it's not uncommon that the situation simply doesn't allow you to. Also, you need to look at the cause of arrest. Was it primarily airway related? Then, yes, do everything you freaking can to get that tube. Or, do we suspect it's more cardiac in nature, where you still have some O2 reserve to play around with? Either way, if you can't get a tube for some reason, there's no reason why an ALS provider shouldn't at least have a king airway (or whatever ALS Adjunct is preferred in whatever state). Most adjuncts have SOME degree of airway protection. Very little, and close to none, but it's better than just "hoping for the best". A king airway takes basically no skill, and there's no reason why it can't be in every state's BLS Scope of Practice. If for some reason, I see an ALS provider only doing BLS airways on an arrest...they aren't technically wrong, but I'll still stand there and roll my eyes unless they have a VERY good reason why

ALS is great, when it's used appropriately. This is an excellent situation that our (ALS-Only) Service beats into our heads, patients who are critically-ill, and this patient was, as soon as you saw respiratory distress. Granted, now that CPAP is BLS everywhere (is there anyone reading this where their state is CPAP is only ALS?), it's possible that something like this could have gone BLS, if no ALS was closely available, but that shouldn't be an easy choice to make. I don't believe this was accelerated junctional, at 164, it sounds like a rhythm that worked its way to a lethal one that should have been managed. Bicarb was likely given, because the medics were just freaking out, or don't really know much science, or as you mentioned with the low potassium, the confused that with High Potassium, which is absurd, but not unthinkable that freaking out providers would confuse the two. The reality is, this patient, prior to extrication, needed CPAP, a 12 lead, and (capable) pharmacological rhythm management, I didn't see much along the lines of medical history, I may have overlooked it, but without a significant cardiac history, the patient probably also needed IM Epi, and breathing treatments on top of the CPAP (which is probably a BLS skill in your state, but I obviously can't say that for sure, because I don't know where you are), Fluids and Mag (like I said, I don't know much about the medical history, so that blanket respiratory distress would need to be catered to this specific patient) The old mentality of "everyone need diesel fuel RIGHT NOW" is wrong, that's true to traumas, but sick medicals, need time on scene, with effort put into it. This has been proven in studies, and when we implemented it in the field where I work, the amount of cardiac arrests we've had in our care was literally cut by 60%. So, your theory of doing nothing, and just driving, while it COULD be appropriate in some situations, is lethal in quite a few others, and there's now science to back that up, as opposed to how someone "feels". This call supports this statement. Short scene times are not always your best friend. As for the code of silence, there is none. I don't care "how it works" where you are. There is none. This patient was improperly managed, it led to his death, there is no code. That's one of the few things I write people up for on calls. Shame on them, and shame on you for not going above their heads on this after the call. I do agree, once ALS care has taken over, your hands are tied, because if you say anything too contrary on scene, you could create a hostile scene (which is an awful mentality on the medics' part), but once the call is over, this call needed a serious QA by management, and I have a feeling that likely didn't happen on this one. This sounded like a catastrophe all around, and maybe it couldn't have been avoided, but no one can say that, because no one practiced to their full scope. Basically, this call was a bunch of ambulance drivers, and I bet everyone on this call would be the first to be all up in arms about being calls that, even when that's what they've proven themselves to be, and it's embarassing to the profession.

There's no downfall to mixing Epi and Bicarb, there's a downfall to pushing Bicarb and Calcium in the same line.

It's hard to accelerate a course that's already only a semester long. I usually don't take people too seriously when they start asking about accelerations, because that tells me their education isn't that important to them. EMT class is too short, as it is at the moment, and paramedic school is even worse; so take the semester-long course, and soak up EVERY bit of information squeezed into it.

I think that's totally irrelevant to this website, and politics are best left off of here.

Well, based on science, there are precious few situations where the decision to move the patient in an active arrest is a decision that says someone cares about the patient. The only good that does is mitigating the clinician's need to feel like they've done everything, or showing a lack of basic science. Like I said, there are just a few situations where it's appropriate, but the majority of arrests....it's not.

So, no critical patient should be moved prior to treatment. If you have to be on scene for 40 minutes, do it. The service I work for has done significant research on this, and the results are staggering (both local and nationwide). As for doing CPR, I hate to sound like I'm being rude, but it's almost a silly question. Yes. The extrication should be immediately aborted, and the code should be worked where you are (or wherever is the closest feasible area). Even if you start compressions during extrication, you cannot effectively transfer a patient while doing chest compressions, causing a second, and ultimately (usually) the final blow to the brain that will destroy any chances of neurological return. Typically, it's not effective to transport an active arrest. It's dangerous for the crews, and patients tend to do worse. Some, less scrupulous services will tell you to transport all arrests, because they can bill for it if you transport, and that's just wrong, those companies don't care about their employees.

So, I don't think law enforcement will help, because they don't deal with HIPAA violations. I think this is a super gray area, that wouldn't be easily fought, but I do agree that this was an inappropriate post. Unless you can definitively prove it's from a specific company, it's going to be REALLY hard to get a company to admit one of their people did this because no one will want to deal with the repercussions of a possible HIPAA violation. It's wrong, but it's reality. I'm not sure there's anything you can do unless, like I said, you can definitively prove that it was directly from their company. Ghettomedic is not very good about accepting any kind of criticism, it's kind of sad. Anyone who disagrees with them gets instantly blocked. -C