bigj1130

I only glanced over the topic so if I am beating the proverbial horse I apologize. 1. If in doubt don't push it... If you only have 10cc Flushes, walk back to the unit and get a bag to hang. 2 If in doubt and you can't even hope for access, Drill them An IO needle can be removed pre-hospital, just like an IV can be removed. I would try my best to convince that person that an ED visit is in order but most Diabetics I have dealt with in the last 10 years are not too keen on going to the hospital after being woke up. Also just because d50 is preloaded as 25Grams, do we necessarilly have to give all 25 grams? Why not just titrate to effect wake them up and give them food, make them a peanut butter sandwich or help them prepare a meal. We are clinicians not just a call and a haul. 3. In regards to ED docs altering a Diabetic's med doses... If that is the case in your areas, you are a much luckier person than I am. Our ED docs will draw essential labs and tell the patient to follow up with their PCP. I know that is the case in other areas as well. What is stopping us from helping that patient get an appointment with their endocrinologist or PCP who has all of their records right there and has been the one altering those dosages for a lot longer than an ED doc who just met them. Please do not take this as trying to get a refusal on every diabetic out there. I will try as much as I can spending untold amounts of time on scene to convince somebody to go, but I am not going to purposely load them in the unit wake them up during transport and just drop them off at the hospital because it just makes my job easier. If my patients do not want to go to the hospital I do everything I can to make sure their Blood Glucose Levels are maintained prior to me leaving and that they have appointments with their doctor or have at least spoke to their doctor before I will get out the refusal form.

My department, Austin EMS, voted for a wage freeze for several reasons. Yes we are a public safety department but we do not have civil service protection. Texas historically is not a pro organized labor state. For us not to vote it down would have been political suicide. Something we as a department can't really afford to do. We voted for a wage freeze in good faith. I would have loved to get my 2.75% money in my pocket is good money. There was really not a threat of layoffs but the potential of layoffs is always there in an at-will state union or not. The city of Austin had an approxiamtely $30 million gap to eliminate we did what we as a department felt was right. Our money comes out of the general fund just like libraries and parks and water and energy. All those departments had to take their cuts as well. Yes our call volume has gone up and our paramedics are busier Yes our costs for service have also gone up. during a recession we raised the rates on our service to the public. As of last week the city manager was recommending furloughs for non uniformed staff in all departments. While we as employees would have loved our increase, My wife and I are still working and we are still getting paid to work. Plus my overtime is almost non existant. We have multiple float positions to cover vacation and sick call and more often than not floaters are unassigned and putting an extra unit on the street. We are as a department as close to being completely staffed as it has ever been. Oh yeah and we potentially funded more positions by holding off on our raise. I hope your union gets your situation under control. I hope the outcome is satisfactory to all involved I certainly hope you continue to have no interruptions in service. good luck with all of it I have to go to work.

Announced today that The City Of Austin/ County of Travis EMS system has named Dr. Paul Hinchey of Wake County EMS as our new Medical Director. No Info as to his start date yet.

Well I just got back from the panel discussions. We were able to meet the final three candidates and they are; Dr. Hinchey From WCEMS, Dr. Freese From FDNY, and Dr. Locasto from Cincinatti. They were given 3 minutes to introduce themselves, we had 25 minutes of Q&A, then they were able to make a quick summation. All in all about a half an hour per candidate.In my opinion, I think the FD and county ESD's will recommend Freese, He seems the most Fire oriented. I think the EMS contigent will recommend Dr. Hinchey because he is the most pro EMS and because of his vision for the delivery of EMS well into the Future. Dr. Locasto is kinda a dark horse to me, He may be the most balanced candidate having to deal with what he has in Cincinatti. All three are very bright men and have a good vision for healthcare delivery in Austin and Travis County. Locasto and Hinchey are very pro public health, i.e. advanced practice paramedics, PAs or Nurse Practicioners that can bring healthcare to the masses better than living room to ED, and they want to make us better. One of the good things I really liked about Dr. Freese is that he still wants to practice medicine, Hinchey as well. They want to be in the EDs when we deliver patients so they can see what it is we do. I didn't really get that vibe from Locasto, though it was not directly asked of him. I don't feel we got lip service from any of the three. My thoughts are Hinchey, Locasto then Freese. I think Hinchey wants to do the most for EMS and public health. Locasto about the same my only concern with Dr. Locasto is That we might be too big too soon for him. I only rank Dr. Freese third because our system is very much not FDNY. I am not knocking FDNY ems or NYC EMS at all. Dr. Freese is just used to a lot of On-line things and our system is very much not an On-line system, for better or worse. Either of these three doctors will be good medical directors for any system. Hopefully they fit well for us and can lead us for many years to come and put us back at the forefront of prehospital medicine.

There is a combination of things that did go wrong... Wrong lane in the booth. the lugs of the ambulance only clear that particular lane by 9 inches. which means even if the operator cleared that nine inches,4.5 inches on each side, the mirrors would not have cleared the cameras that are at the curbs of the booths. The toll plazas have wide load lane for semis fire apparatus etc. and this was not it... Inexperience, while I will not make any comments on the operator of the vehicle I will say, that a lack of operational expertise involving our medium duty ambulances was probably a factor. including bad fender judgement. Speed, After looking up some things speed did come in to play though I will not comment on the extent. Rumors going around is that the total expense for this incident could total up to about 350-400K. This is a bad wreck but we have had several in the past year. I think that is fueling the arguement from city management to get us out of medium duties to F350s or F450s. But I will not comment on that either

While I agree with p3medic that he has a massive blunt traumatic injury, and in my system that is an indication to field pronounce off-line, there are still some considerations. PEA- rate? first responders say they had pulses. We all know this is not always reliable and maybe they were feeling their own pulse. However, I would be wrong to not suspect a pulse if the rate that was "felt" was awfully close to the PEA. Other tools to determine a ROSC- Was ETCO2 available? More often ETCO2 is a better indicator of return of perfusion than a palpable pulse. A perfusing body is not a dead body. While you may not be able to feel a pulse, if there is a spike in ETCO2 with that PEA, you might well feel pulses soon enough. H's and T's- while this is a blunt traumatic injury is this patient in arrest due to an H or T? If so Early intervention and aggressive treatment can make a difference. A tamponade or tension pneumo or hypoxia perhaps? Protocol- From a system standpoint, It might be a standing order to transport a cardiac arrest or traumatic arrest in public to the closest appropriate facility. If we, as a system can not obstruct the view of the public or if it is an obvious crime scene with obvious signs of death then we have to transport. It is also possible that this system doesn't pronounce blunt traumatic arrest in the field at all. Confidence of the provider- While we all like to think that every medic out there is competent and confident, maybe this provider wasn't confident in what he or she was seeing or finding is his/her assessment in relation to the patients injuries. It is possible that a mistake was made and he/she could not put the pieces of the puzzle together. High speed collision with minimal exterior trauma but in arrest? The possibility of second guessing oneself could be pretty high in a provier that hasn't seen this before or doesn't see it often enough. It might be feasible to think that this s a MEDICAL arrest and the trauma happened because of the medical event. Based on the description of the call that is highly unlikely but I don't know I wasn't there. So to answer the question based on the information I have in the post and my protocols and guidelines, Yes I would work the Arrest, Especially without 100% certainty of the presence of a pulse. If I had my little toys with me, ETCO2 etc. and I don't have a good reading or waveform and the PEA is a confirmed PEA after assessment and a quick r/o of H's and T's, I still think I would work the Arrest even with such a low success rate.

Some do Do your research Check with Trace, Vandenberg, Med Ex, ATI, Bud's, Superior. All of Those are in the City in some sense, Kurtz, A-tec, Advanced, Alverno, Rescue 8 if it is still in business, First Care, Precise, Lifeline, and RMT are all mainly suburbs. It's been over three years since I have lived in Chicago, so some of these companies might have new names or merged etc. You have plenty of choices call around and good luck

I will be going to the panel discussion on the 28th to meet these 6 physicians and see what potential path my career might take. I say 6 because I have not met Dr. Kempema as of yet. Not that that is necessarily a bad thing. I hope Our penny pinching city Manager allows for a little more inoput than just him and the Good Judge but we shall see.

I've seen quite a few of the ones already mentioned, The rubbing alcohol and the coining I've also seen the root on the chest although I can not remember its name. I have also seen cupping. That's where they took the cups and created a suction on the person's back. Needless to say it generated a call to child services, but I found out it is a common Eastern Practice to "suck out" the toxins. I have also seen people super glue lacs prior to our arrival.

Nothing yet Dr. Kempema from Brackenridge has taken it on an interim basis. The system anticipates taking about a year to find our new medical director

Yes without a doubt... regardless of age risk factors family history etc. It takes 30 seconds to a minute to obtain a 12 lead. Personally I also think a b/p of 90/50 with a rate of 130 is a damn good reason to take a look at the heart regardless of age. Hyperemesis causes electrolyte imbalances. What more reason due you need? We also are aware that a tachycardiac heart has increased O2 demand and that O2 demand is not going to be met for very long with those vitals. Treat him/her as an ACS patient, no but still look at the heart.

Dust, You make very valid points about Wesley, Maggiore, Becker, and Bledsoe. I think that is why I personally only read the online content in JEMS. My subscription lapsed 2 years ago and I did not see a need to subscribe again as I found my dream career, I didn't want to work for Southwest Ambulance, and I wasn't going to buy a whole bunch of Geezer Squeezers ( Auto Pulse) so I just read those contributors online. I also will occasionally read Will Chapleau and his trauma articles but even he has gotten a little out there and really hasn't said anything new in a while. Now to comment on EMT-Bs loving this issue... WTF no more education but here you go have some drugs and IVs. Stepping back the profession 36 years IMO. Not to beat a dead horse... How bout more education and be better at your scope of practice. Let basics do BLS and Paramedics do BLS and ALS. Most Paramedics don't know why they give certain drugs... so lets give basics the same thing and they won't know why the administer the brown box when someone is in cardiac arrest. ](*,) :violent2:

Informed consent is a great thing. AAOx3 or 4 can only go so far. If that patient has become a threat to themselves or others we are well within our rights to chemically restrain with IM or IN Midazolam. A subject can be AAOx3 or 4 and still have evidence of a head injury. In that case do you consider your patient of sound mind and body and able to make their own healthcare decisions? I personally say no and transport them based on Implied consent. If I have to put them down to do it I will, but I always act in the best interest of my patient. I also have no qualms about restraining a patient for their safety and mine. Anthony to answer your question about your inebriated person, If I can't talk them down to the bed and he/she is to big for me to put down by myself I will enlist the help of PD or Fire. IF it is too unsafe for us to move him or her to the cot we will give them IM Midazolam and move them after they get a little drowsy. Lucky don't forget that we as healthcare providers still have to know law. You have to know your consent rules which in some states are law. What powers do we as healthcare providers have in terms of mental health evaluation. Does your state have committal laws? I know that where I work if a person directly says that they want to hurt themselves or others to either PD FD or Us that their right to refuse goes out the window regardless of mental status. I know what you are trying to say but leaving a suicidal patient at home is just as bad as poor medicine. Not trying to start something just saying.

Look into EMEDU. ORG I believe good 12 lead library Also Check Here http://www.ecglibrary.com/ecghome.html cut and paste apparently I can not rememebr how do to a hyperlink

Well when it comes to STARFlight, yes the county has taken control from EMS. However Us ground pounders, only know parts of the reason why and we just try to fill in the blanks ourselves. So here is what I heard, Starflight is going to be adding a 2nd Helicopter operatioal 24/7 that way they can do all the interfacility stuff they do as well as still be available for scene calls, which has been an issue over the last few years. If I ever had ambition to fly it would be with STARFlight, but that yearning is not there for me. To answer the question of a dream job I think I am happy and content right where I am at. Austin Travis County EMS as we all know is a fairly progressive system though maybe not as "cutting edge" as it used to be. We have good protocols, granting us the ability to be thinking medics. All ambulances are ALS with BLS first responders from the FDs. 32 units on the street. Good Ambulances, Wheeled Coach Customs, however our maintenance is lacking. Induced Hypothermia protocol post arrest, good, not great, opporotunity for advancement, and dapertment provided CEU's. Basically we get re assigned off of one of our shifts for 48hrs out of the year to do M & M case review, ACLS, AMLS, PHTLS PALs, etc. also STEMI Review protocol review and just basic assessment and treatment modality review. Some People may not think it is great but I got 23 possibly 24 years left and I am gonna ride it out, I love it here.