scubanurse Posted July 29, 2013 Posted July 29, 2013 correction: FDNY is only one of the many EMS agencies here in NYC. in NYC there are only two levels of prehospital care. the EMT-B and the PARAMEDIC. anything under paramedic is working at the basic level. ERDOC has his opinions on how a person should appreciate or feel or care etc etc.. that's fine, I don't mind the right to free speech. "not wanting to see people die" means you are emotional, not necessarily good, certainly do not mean you are competent. Competent is competent, Cowboy? there are no cowboys in NYC thus I don't understand what you mean. EMTs are not doctors, Paramedics are not doctors. Our goal here is to get the patient to the doctor in no worse condition than we found them. Please do tell me, what special things you are going to do for this patient that I was not going to do ? it is BLS, there isn't a lot to do ! we all have the same national standards, so please do tell me what it is that isn't already in the protocols that you want to see be done for this patient ? ( dont answer that, its for you to think about) Not scared, because that's not my job, but the medic will come put in a tube. not scary, no nightmares. if the tube wont go in down the throat, then the medic can do the cricothyrotomy. I guess when you know what you are doing and trust your fellow EMS to do their jobs well, there is no place for scary panicky nightmares. Im done with this topic, be safe out there people ! So because I don't want my patients to die, I'm emotional and incompetent??? Not wanting people to die is a very basic human desire. Being sad when someone dies is a very basic human emotion...what are you? a robot? I hope you never have to feel the emotions that come with loosing someone very close to you, or loosing a child. You sound like a heartless bastard and that would make you a very incompetent and piss poor EMS provider. 1
MariB Posted July 30, 2013 Posted July 30, 2013 I'm well aware of the levels in NYC and have worked with many EMTs and Medics on LI who also worked in NYC. Again, you failed to answer the question. Do you work for FDNY, a hospital based service or one of the privates? You know exactly what I mean when I say cowboy. Should I use the term buff? I know you understand that. I also know full well that EMTs and medics are not doctors. I did EMS in NY, not NYC, for 10 years and know the systems from Staten Island to Montauk pretty well. When we say scared, you know we do not mean it literally. However, the fact that you cannot do anything more and cannot properly provide the care the pt needs because of the standards in NYS and the fact that you are an EMT should literally scare you. People are dying because of the dismal state of EMS in NY but that is for another thread. So what are you going to do when this guy goes unconscious because his SBP is 70 and you can't bag him and your ALS backup is tied up on another call and you have to take care of the pt. You are right, there is nothing you can do but watch him die. The fact that that doesn't bother you makes you a piss poor provider in any system. yes he works for FDNY. A simple search on him came up with his real name and his occupation. He also states he is an ems instructor. He also does pot runs 1
ERDoc Posted July 30, 2013 Posted July 30, 2013 (edited) It's interesting how we are saying the same thing to him that others on that other website said to him a year ago when he got his EMT card: "I am beginning to think this is a troll...and maybe I shouldn't feed it. FDNY isn't even the best EMS provider in the City, so lets bring that noise down a notch. Your FDNY provided training will in no way make you an experienced provider. Unless I'm not aware, there isn't a huge difference between how FDNY THEORETICALLY does EMS and any other agency does. The medicine is all the same.This kind of attitude will not endear you to other providers in the City, hospital staff, ect, some of which you will have to deal with and are very good. It also may aggravate your co-workers" It's funny how they mentioned this website in there. Oh wait, maybe they meant New York City. EDIT: He also referred to pts as "just packages" and pretty much got the same response he did here. Edited July 30, 2013 by ERDoc 1
island emt Posted July 30, 2013 Posted July 30, 2013 Gotta agree with Doc: The scary thing is that he has no idea of what he doesn't know. 40 years ago we gave this pt air & a chair and a ride to the hospital. I'd hate to think that the state of prehospital care in NYC hasn't advanced any further than that in the past 4 decades. glad I don't live in the city.
ERDoc Posted July 30, 2013 Posted July 30, 2013 So, back to the OP. How do you manage this guy at the BLS and ALS level when you have more than a 30 second ride to the hospital?
DartmouthDave Posted July 30, 2013 Author Posted July 30, 2013 (edited) Hello, ALS and BLS are on scene. The patient is very weak and will wake briefly to voice. His lungs are course and decreased to the bases. You feel some subcutaneous air on his upper chest. A #20 IV is inserted and a NRB is applied. Newest set of VS: GCS 14 HR 130 BP 70/30 Resp 40's SpOs 87% on NRB The EKG shows Sinus Tachycardia with St elevations in II, III and AVF I saw a post above talk of a cricothyrotomy. A cricothyrotomy and tracheobronchial malacia is not a great idea. Cheers Edited July 30, 2013 by DartmouthDave
ERDoc Posted July 30, 2013 Posted July 30, 2013 Can the mother tell you anything else about the stent? What kind, where it was placed, etc? Does she have a card for the device or a way of getting in touch with the surgeon? In the meantime we still need to manage this guy and I don't think we've made it past the A in ABC. He has an unstable airway that is going to be a potential disaster to manage. Who wants to RSI him? Who wants to do something else?
scubanurse Posted July 30, 2013 Posted July 30, 2013 Old school but maybe a NPA? And we can bag him as well... I feel hesitant to RSI since he's likely a difficult tube and he's tanking so fast... Large bore IV's, fluid bolus, EKG continuous monitoring, capnography if we have it, keep patient calm and alert receiving facility...
MariB Posted July 30, 2013 Posted July 30, 2013 How long of a transfer? 87% on a nrb? This is a patient I wouldn't hesitate to use lights and sirens on.
paramedicmike Posted July 30, 2013 Posted July 30, 2013 Subcutaneous air indicates a perforated trachea. Combine this with his low sats, tachypnea and raging sepsis and this guy is gonna need an airway at some point. He will be a difficult tube. I'd try something simple like positive pressure ventilations or CPAP to start and hope I don't have to tube him. If/when it gets to the point that a tube becomes necessary I would not paralyze him in an effort to preserve what little native respiratory drive he has left. Etomidate only would be an option. Otherwise it'll be a crash airway when he crumps. A single 20 gauge IV isn't going to cut it. He needs at least two large bore IVs with fluids running. If his vascular status won't allow IV access then go IO.
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