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Noobs

338 comments

Rookie Partner and I have a student, and because it is a female student she is “technically” under the control of RP. Not that I have any fears about RP not being able to do this. She’s smart. She’s good. But she’s sooooo impressionable. If I’m grouchy and want to do something wrong soon after, you’ll see RP doing the same thing! Screwing with drunk people! You bet! Asking dumb questions to obvious fakers…. she all over it. I’m corrupted her….

So what will happen with poor, no idea what in the hell-is-going-on-in-this-truck noob girl gets thrown into the masses? Well, we will see? We’ve given her a week of riding along, doing whatever. But next week the cord is cut. Time to run from mommy and be a medic!

Posted by on April 24, 2012 • Filed under: EMS Dispatch, ems-health-safety, ems-topics, partner, patient-management, Training, training-development

Damn it, Jim!

1,106 comments

Starting a story with a misquotation is likely a serious faux pas, but alas, I did it. Get over it.

We were called to Jim’s house by a 3rd party. Actually a fourth party. Jim had missed a lot of work so his boss called his next of kin–and estranged daughter–she called a neighbor and between the neighbor and his boss, made the decision to call the ambulance.

I was greeted on the rickety steps by a confused looking gentleman I learned to be Jim’s boss. As I walk past him he tells me Jim had fallen and was on the ground all night. Jim says he’s not hurt. He says he is fine. Every word he speaks is enunciated in booze. The fruity smell of cheap vodka and cheaper beer permeate through his pores. Even the feces he has all over himself smell of sweet, cheap alcohol.

But Jim is adamant that he isn’t hurt. He knows where he is, he knows what day it is, but he just can’t admit that he is hurt. He just can’t admit that he needs help.

See months earlier Jim lost his mother and sister in a week or two. Jim, already an alcoholic took these double crosses and stumbled back to the ropes. He bowed out and lost control. Now the alcohol has control.

See, Jim isn’t fine. You can see the cellulitis has eaten at his legs. He’s not eating. Not bathing. Not doing anything other than getting delivered in cheap booze. Intentional or not, he’s killing himself. He’s of sound, if not sane, mind. He by law, can make decisions for himself. People are allowed to let themselves die here.

But after I’ve spent a considerable amount of time trying to get Jim to go to the hospital today, with me in the ambulance, his family arrives. His estranged daughter, her husband, and the granddaughter he hasn’t seen in a year. I try to “prep” them for what they are going to see. This isn’t going to be the “dad” you’re use to. But she walks right by.

And the crying, and the begging, and fighting begin. PD tells me they have no grounds to hold him. No threat to self or others. See, Jim insists he’s in contact with his lawyer, who is going to take him to the doctor on monday. The problem is, he can’t tell me his lawyers name. If you ask Jim how much he’s been drinking he changes the subject. If you ask Jim to stand(knowing he can’t) he changes the subject again.

Jim wants to stay home and drink another day. I think he knows that if he manages to stay home and drink enough days his body will finally give in to his mind and end this all.

But just because someone thinks they want to die a miserable death doesn’t mean we SHOULD stand idly by. I had walked out, as the city around me is imploding with 911 calls and transfers, I’d given up. Nothing was working. I waked out, got my signatures and was getting into the truck when the daughter came up to me.

“Please help me”. I don’t want him to die here. I don’t want him to die alone”. I try to explain how little there is I can do. I’ll be honest, I don’t expend a great deal of energy trying to get people to go to the hospital. If people say they don’t want or need me, I send them on their way.

But not this time. I’d already spent 50 minutes on scene, a few more won’t hurt. I walked back inside, daughter trailing behind me. We walk past an unopened box of “Omaha Steaks” with a postmark before Christmas. What kind of man leaves a box of meat–tasty meat–on their front stoop?

Inside the front door Jim’s son-in-law and granddaughter are sitting there. Granddaughter is crying. I walked up to Jim and said flatly…. “if you can stand, I will leave you alone forever”. So he tries to stand up. And flails and fails miserably. Sad, but in a way, what everyone needed to see.

I kneeled down to his now low level. Firmly, but compassionately I said…

“Jim, look. Look around this room. These are all people that care about you. Your daughter. Your granddaughter. Your boss. Your neighbor. Even me and my partner. If we didn’t care, the easy way out presented itself 100 times or more. But we didn’t take it. I stuck around. WE all stuck around. Because I’m scared that we’re going to come back tomorrow morning and pick you up in a different way. In a black bag and instead of going to the emergency room we’l have to go to the morgue. I’m terrified that I’ll have to look at this little girl over here and tell her that her grandpa is dead because we couldn’t convince him to go to the hospital to take care of some moderate medical problems. I’m scared that I won’t be able to sleep if I don’t do right by you. You have a chance to go out with some pride. Go out on your own, not be drug out of area against your will or in a body bag. Do this for your pride, if nothing else. Your pride is going to kill you”

and all he said to me:

“Well I don’t wanna hurt your beauty sleep. You need all you can get. Lets go”

And so we went. Quietly and calmly. At first he was defeated, but then the relief swept over him and the fear faded away.

In my longest scene time ever(1 hour, 48 minutes) I actually did something. More than I do on every major trauma or code or stroke I go on.

When the powers that be wanted to talk to me about the scene time delays I told them to read the narrative. I wasn’t going to justify it any other way. I wasn’t going to say sorry. I got a sick person to go to the hospital.

THAT is my job.

Damn it, Jim.

Posted by on April 11, 2012 • Filed under: Crazy Calls, ems-health-safety, ems-topics, fire-rescue-topics, funding-staffing, Good Stuff, patient-management, Psych

Booze in the Nose.

1,771 comments

of “alcohol on her breath”. I’ve started a lot of charts like this. Seen PD run reports that said the same. I’ve seen it testified to in court….  And it is pretty interesting, in part because you can’t smell alcohol. Sure, you can smell booze–the other crap in the alcoholic beverage. But nope, you can’t smell “alcohol” on someones breath.

 

Smell of alcohol on the breath. There is a very poor correlation between the strength of the smell of alcohol on the breath and the BAC. Pure alcohol has very little smell. It is the metabolism of other substances in alcoholic beverages that produces most of the smell. This explains why a person who drinks large amounts of high-proof vodka (a more pure form of alcohol) may have only a faint smell of alcohol on the breath. On the other hand, a person who drinks a modest amount of beer may have a strong smell of alcohol on the breath.

 

This is hammered on by DUI lawyers, with mixed results:

“I Smelled a Strong Odor of Alcohol on the Suspect’s Breath”

Posted by Lawrence Taylor on June 23rd, 2006

You will never see a DUI case where the officer does not report an odor of alcohol on the suspect’s breath. Never. The officer expects to smell it and it is a psychological fact that we see, hear and smell what we expect to see, hear and smell. In fact, most police DUI reports are formatted for the usual symptoms: there will be a box for “odor of alcohol”, which the officer checks off. There are often three boxes, labelled “strong”, “moderate” and “weak”; there is no box for “none”, so that is not an option for the officer.  The ”strong” box is almost always checked.  Presumably, the stronger the odor of alcohol, the more intoxicated the person arrested.

There is only one problem with this:  alcohol in a beverage has no odor.

Assuming the officer actually does smell an odor on the breath, what he is smelling is not ethyl alcohol but the flavoring in the beverage. And the flavoring can be deceptive as to the strength or amount consumed. Beer and wine, for example, are the least intoxicating drinks but will cause the strongest odor. A much stronger drink, such as scotch, will have a weaker odor. And vodka leaves virtually no odor at all.

Consider a simple experiment. Have a friend drink a can of “near beer” — the stuff that looks, smells and tastes like beer but has no alcohol in it. Then smell his breath. You will smell an “odor of alcohol” — and maybe a strong one.

And, of course, there can be any number of causes of an “odor of alcohol” on a person’s breath: mouth wash, throat spray, cough syrup. Illness, indigestion or simple bad breath has been the cause of more than one officer’s trigger-quick conclusion that the suspect has an “odor of alcohol on his breath”.

The point of all this is that the odor of alcohol has very little relevence in a drunk driving case. It may or may not indicate that the person has consumed alcohol. It has absolutely no evidentiary value on the much more important question of how much the person has consumed — orwhat he had to drink, or when. Depending upon circumstances, a person with a single drink can have a “strong odor of alcohol on his breath”, and an extremely inebriated person can have a “weak” odor. And an experienced and honest DUI officer will readily admit this….if he is ever asked.

Unfortunately, evidence of the odor of alcohol on a person�s breath can have a significant impact on a DUI case. This is because most officers who pull a driver over for some driving irregularity at night are looking for further signs of drunk driving. When the officer approaches the driver’s window and smells alcohol, that confirms his suspicions. Since few can pass the “field sobriety tests”, particularly under the conditons in which they are given, an arrest is likely.

Are there any scientific studies to back up my claim that breath alcohol odor is largely irrelevant yet disproportionately weighted as “evidence” of intoxication?

In 1999, the same scientists whose federally-contracted studies became the basis of the so-called “standardized” battery of field sobriety tests conducted another study on the effectiveness of alcohol odor in detecting intoxication. These researchers used 20 experienced officers working with 14 subjects who were tested at blood-alcohol concentrations (BACs) ranging from zero to .13 percent. Over a four-hour period, the officers smelled the subject’s breath odor under optimal conditions, with the subjects hidden from view.

The conclusions of the study: Odor strength estimates were unrelated to BAC levels. In fact, estimates of BAC levels failed to rise above random guesses. Further, officers were unable to recognize whether the alcohol beverage was beer, wine, bourbon or vodka. According to the scientists, these results demonstrate that even under the best of conditions, breath odor detection is unreliable. Moscowittz, Burns & Furgeson, “Police Officers’ Detection of Breath Odors from Alcohol Ingestion”, 31(3) Accident Analysis and Prevention 175 (May 1999).

 

So the moral of the story is that we need to examine how we chart suspected intoxicated patients. Being highly suspicious of all medical conditions that could cause these symptoms is important too:

http://www.monkeydoit.com/medical-act-drunk.php

DIABETES
Symptoms of diabetes may make a person appear drunk or intoxicated.
A person with diabetes may exhibit abnormal behavior as a result of the many different signs or symptoms associated with the disease. The signs and symptoms listed here only relate to symptoms that mimic drunk or intoxicated behavior. Generally, these are warning signs that a person needs immediate medical attention and should be treated as a medical emergency. Police dealing with suspects often times mistake diabetes for drug or alcohol use during field sobriety exercises. 

Signs & Symptoms of Diabetes
-- The smell of acetone on the person's breath
-- A distinctive fruity odor on the breath (Police Officers often mistake the smell as alcohol during a field sobriety tests)
-- Dizzy, has trouble keeping balance
-- Altered states of consciousness
-- Arousal such as hostility or mania
-- Apprehensive with no obvious reason
-- Unusual nervousness
-- Disoriented in place or time
-- Confused when asked simple questions or confused in general about circumstances
-- Sweaty with clammy perspiration
-- Inability to concentrate on what you are telling them or on the tasks at hand
-- Sudden mood changes
EPILEPSY
Epileptic seizures generally happen without warning for most people. A seizure is a brain disorder of abnormal electrical activity in the brain. Seizures may be either partial or generalized and will present signs and symptoms that very among individuals. 
Signs & Symptoms of Epilepsy
-- May appear detached from reality
-- The person might be in a dreamy state 
-- Dizzy, unable to maintain balance
-- Falls down
-- Staring spells
-- Unresponsive
-- Walks away during a conversation
-- The person may have pupillary dilation
-- Sweating
-- Problems speaking
-- They may display an inability to answer questions
-- Contorted posture / limbs appear twisted
-- Flushing
-- Memory and time distortion (they may not remember what just happened)
-- May appear unrealistically fearful
-- May exhibit emotional signs of heightened pleasure
-- May exhibit emotional signs of displeasure
-- May appear aggressive or angry
-- Complete loss of consciousness
BRAIN INJURY
Brain injures will generally have signs and symptoms that relate directly to what part of the brain was injured. Here are just a few symptoms that someone could easily mistake as the person being drunk or intoxicated. These will vary among individuals and to what extent the brain was injured.

Signs & Symptoms of Brain Injury
-- The person may exhibit tremors
-- Dizzy, unable to maintain balance
-- Unable to make simple movements of various body parts
-- Inability to perform a sequence of complex movements
-- Unable to focus on tasks
-- Sudden mood changes
-- Inability to focus attention visually
-- Difficulties with hand and eye coordination
-- The person may suffer from hallucinations or visual illusions
-- They may have difficulty in understanding spoken words
-- They may show signs of aggressive behavior
-- The person may slur their speech 


Brain Picture -EpilepsyALZHEIMER'S
Alzheimer's or dementia is unique for every individual. Alzheimer’s is a progressive and fatal brain disease and the most common form of dementia. The signs and symptoms like the other medical conditions listed here may mimic impairment or drunkenness.

Signs & Symptoms of Alzheimer's
-- The person may show signs of paranoia
-- There may be drastic changes in mood
-- Confusion is quite common with people suffering from Alzheimers or dementia
-- They may have problems speaking
-- The person may exhibit aggressive behavior
-- It's common that there will be problems with remembering things
Posted by on November 13, 2011 • Filed under: administration-leadership, Changes, Code 3, Code 4, command-leadership, Crazy Calls, Dispatch, ems-health-safety, ems-topics, Failure, fire-rescue-topics, firefighter-safety-health, funding-staffing, hipaa, in-the-line-of-duty, news, patient-management, Pediatric, Protocol, special-operations, training-development, Wow.

The Mendoza Line

1 comment

Do you ever feel like we’re playing a losing game?

The other day I went through my cardiac arrest statistics. Dispatched to 91 cardiac arrests since I became a medic. ~30/year. I have worked approximately 50% of those. I have EXACTLY 1 cardiac arrest save.

ONE!.

If this were baseball, I’d have a batting average of 0.01098901098901099.  OOOH! If we call all of the no start calls “sacrifices” I’d have an average of 0.021739130434782608. If we only say that the ~45ish times I’ve actually worked an arrest count as “at bats”, then I have an amazing 0.022222222222222223.

In baseball the record for lowest career batting average for a player with more than 2,500 at-bats belongs to Bill Bergen, a catcher who played from 1901 to 1911 and recorded a .170 average in 3,028 career at-bats. I’m well below the “Mendoza Line”

What is YOUR batting average?

 

 

 

 

Posted by on October 25, 2011 • Filed under: administration-leadership, Coping, ems-health-safety, ems-topics, Failure, fire-rescue-topics, news, patient-management, rescues, special-operations, technology-communications, technology-communications-ems-topics, training-development, training-fire-rescue-topics, Uncategorized

Ambien made me post this…

2,073 comments

Seriously. It did. I take ambien for sleep(12.5mg XR), as the chances of me sleeping on my own are not so good. But if I am awake past that first 40 minutes it makes me do crazy crap. Like post on my blog. Or clean out the fridge. OR trim, cut and cure 40 lbs of deer meat for Jerky slices. I’ve rearranged my 75 gallon aquarium and not remembered. I’ve don a LOT of things and not remembered.

It is mildly terrifying to know how much can happen with so little control. MY wife sure like the cleaning version of me though, so I doubt I’ll be changing over soon.

Do any of you have first hand experience of the crazy things meds made you do?  We hear stories all the time from patients and coworkers, but I’d like to hear your own stories.

ON a clinical note, what do we need to look for with these odd situations? Can a patient sedated with ambien be reliable?

Drop me a line!

 

Ambien Side Effects

Ambien Dosage:

Dosage in adults

The recommended dose for adults is 10 mg once daily immediately before bedtime. The total Ambien dose should not exceed 10 mg per day.

Special populations

Elderly or debilitated patients may be especially sensitive to the effects of zolpidem tartrate. Patients with hepatic insufficiency do not clear the drug as rapidly as normal subjects. The recommended dose of Ambien in both of these patient populations is 5 mg once daily immediately before bedtime [see Warnings and Precautions (5.6)].

Use with CNS depressants

Dosage adjustment may be necessary when Ambien is combined with other CNS depressant drugs because of the potentially additive effects [see Warnings and Precautions (5.5)].

Administration

The effect of Ambien may be slowed by ingestion with or immediately after a meal.

Posted by on October 5, 2011 • Filed under: ems-health-safety, ems-topics, father, firefighter-safety-health, HELP, Home, husband, medic, news, patient-management, Uncategorized, videos

Mostly it’s the getting by thing…

2,117 comments

We all joke in ways our families, friends and patients don’t understand. See around the 3:20 mark of this video:

Godspeed, friends!

Posted by on October 5, 2011 • Filed under: administration-leadership, command-leadership, ems-health-safety, ems-topics, Failure, father, firefighting-operations, funding-staffing, Heart Strings, partner, patient-management, sleep, special-operations, TV

Dropping a patient…

2,090 comments

doesn’t seem so bad now:

You could drop them from a moving ambulance.

Posted by on September 14, 2011 • Filed under: crazy, ems-health-safety, ems-topics, fire-rescue-topics, news, patient-management, training-fire-rescue-topics, videos

Still in there…

4,845 comments

One of the most common, and hardest patient encounters for me as a medic is that of someone who has lost their ability to do things. They still have all of their cognitive function…. they are just unable to do the things that you and I take for granted every day. Things like opening the milk, buttoning our pants, or driving the car. All gone, in what seems like a flash.

All of the sudden we are thrust into a moment where our patients are exposed for their weakness: they can no longer care for themselves. They KNOW they can do these things…. they just can’t actually complete the task. Our brain tells us we can do the things we’ve done countless times over our lives… but our bodies just don’t cooperate.

Today we had a patient at a local retail store. Found by staff in the bathroom. On the floor, covered in feces. He seemed alert, but was too weak to stand. To weak to grasp, to move. We arrived on scene found him sitting in a power chair, running into the wall… then the sink. Repeat.

It was obvious we were in one of these dreaded moments. Where it had to be explained to him that he needed help. Perhaps family has tried. Or maybe they haven’t. Maybe they’ve left this up to a stranger. To me.

As I explain to the man, who just knows he can take care of himself that I can’t let him drive. That I think we should take him in to get checked out–even though I don’t think he actually needs an emergency room–I see that look in his eyes. I see that he knows that he can’t do this anymore.

But he can’t let go. When he lets go of this he knows the rest is soon to come. That every piece of independence he loses is another piece of his dignity, all but forgotten.

While these patients can be frustrating, because it should seem like common sense that grandpa can’t drive, or grandma can’t climb the stairs anymore… families are in a hard place… taking the dignity from their elders. So take the time, the compassion to try to approach things delicately. Remember that some day, someone is going to have to tell you that you too are unable to do the things you’ve done all of your life. That you know you can do.

Despite being slower, weaker, and unable to complete seemingly simple tasks…. they are still in there. There is a soul in there still needing our compassion.

Posted by on September 1, 2011 • Filed under: ems-topics, medic, patient-management

We’ve all been there….

2,231 comments

Sad as it may be, many medics spend a great deal of time trying to get out of doing their jobs. We’ve all been there: annoyed, over tired, and over worked. We don’t get paid any more to transport, so sometimes we seem to think that maybe the patient doesn’t really need an ambulance….

I can see how it plaid out in my head. I really can… and that is what scares me the most. In 2008, 39 year old Edward Givens died shortly after EMS saw him at his home. The medic that day told Mr Givens he was just having acid reflux and recommended Pepto Bismol. Two hours later Mr Givens was dead.

You can see it now, can’t you? Maybe the patient is being overly dramatic, or maybe it is the family. You’ve been working for 20 hours and this is your 30th call. You’re 8 charts deep and know that another refusal or no ambulance needed is less work than the transport…

But here is the problem…. it is our job to transport people to the hospital. It isn’t our job to determine whether they need an ambulance or not. If someone wants to go, we take them. Regardless of whether you think they are sick or not. We don’t diagnose. We don’t cure. We are in the business of transporting patients.

I don’t know what really happened that day in 2008, but I do know that we’ve all been there before. We’ve all spent a considerable amount of energy on not transporting someone. Maybe you’ve even had a close call. A stroke you thought was a diabetic…  or an AMI that you thought had reflux… But until now you’ve skated by.

Well stop. Stop expending so much energy trying to get out of doing your job. If you’re no longer interested in transporting patients, find a new line of work. When it comes down to it, is it worth risking someones life, your job, and your family’s livelihood on it? The medics in question here were not found to have violated any policies or procedures by their employer…. but do YOU want to live with that on your shoulders?

Posted by on March 3, 2011 • Filed under: administration-leadership, command-leadership, ems-health-safety, ems-topics, major-incidents, news, partner, patient-management, training-development

The Speech

30 comments

“Mr Thompson…. Today when we arrived your wife was not breathing, her heart was not beating. We began CPR and hooked her up to our cardiac monitor. The monitor showed that your wife’s heart had stopped. It had no electrical activity.

At that time we continued CPR while administering heart-starting medications and inserting a breathing tube. After nearly 20 minutes, nothing has changed.  Her heart is still not beating. She is still not breathing.

I give you my most sincere condolences, but she is deceased and there is nothing more we can do. I’m very sorry sorry for your loss. ”

This is how it plays out in my head. Well put, accurate, somewhat concise…

But it never comes out as well and they never let you get that far. It is even harder in untimely deaths.

What do YOU tell people when their loved ones have died?

Posted by on February 19, 2011 • Filed under: ems-health-safety, ems-topics, Failure, Heart Strings, patient-management

“Service”

29 comments

Are we “service” professionals? Do you view patients as “customers”?

I work for a corporate system and I am having a hard time wrapping my head around some of corporate nonsense they are using in employee publications as of late.

What do you think of calling “patients” “customers”?

My first impression…. I was under the impression “customers” “bought” things…. not took them for free?

Posted by on November 5, 2010 • Filed under: ems-health-safety, ems-topics, medic, patient-management

Why you do not NEED an ambulance:

2 comments
  • You are running around the house trying to gather your cellphone, charger, makeup, purse, keys, underwear, kitchen sink, and other miscellaneous ”essential”.
  • You continue to cut me off, tell me I’m wrong, and insist that you must have some sort of cancer(unrelated to the 3 pack a day habit you have).
  • Are mad I am not going to carry you to the ambulance after you have been running around the house(up and down stairs, too!).
  • Are made that I will not give you morphine for this mysterious leg pain that just started when we got into the ambulance.

Reasons I don’t care:

  • I only work one day this week.
  • I haven’t listened to anything you’ve said.
  • I’m dreaming of a nap.
  • You smell something like a mix of cigarette smoke, old cheese, and pot roast.

Sincerly,

m3

Posted by on October 7, 2010 • Filed under: ems-topics, patient-management, Uncategorized, wtf

Reality Check

1,638 comments

As usual, the EMS blogosphere has found itself in yet another little tiff. This time Timothy Clemans and Medic22 are in a bit of disagreement about proper use of ALS, among other things.

Timothy seems to believe that ALS skills are wasted on patients that are not in risk of losing life or limb. While Medic22′s way of responding to him might be over the top, I can TOTALLY understand how and why that would happen. See here and here. We all take this pretty damn seriously, so I understand the frustration.

Because I agree with Medic22′s thought process on this, I thought I would chime in a little bit.

If it was up to me I would eliminate prehospital ALS except in cases where ALS care prevents the need for hospital/clinic care and in cases where evidence demonstrates that ALS saves lives. That said, Medic 22 did bring up an excellent point about prehospital pain management.

Is it really that simple? Simply put, I’m out of a job. All of us are. In a systemsign-realitycheck with 11,000 calls a year, we’d be able to pay one medic. Thats it. After the sob story of me being unemployed is over, we’ll address the real issue: why is it that you have to be dying to get compassionate, adequate, respectful care?

If you are sick or injured, but not dying, Timothy is saying that you should only get a taxi ride to the hospital(where you will wait in triage for an hour(or more) and then wait for a nurse to complete an assessment, then a doctor, then maybe get your treatment started).

Are there ALS skills that need to be reviewed? Absolutely, but until you have had to sit in a truck with patients puking their brains out(on your new, shiny boots) you will not understand the validity of our skills that are in between taxi driver and super hero. Pushing Zofran for that nausea not only helped to relieve the discomfort for that patient, it also helped prevent them from further dehydrating themselves (or like a patient a week ago… going into vfib every time she puked… Seriously).

Managing pain in patients is one of the best skill sets we offer(and either the most avoided due to paperwork or most abused by patients).  Allowing grandma some comfort for the 15 mile ride through my Wintry Mid-Western city riddled with potholes and ice chunks is the least I can do after she allowed my whiny ass to stay alive all this time.

I can’t agree more with you! I have been battling this topic for 7 years to no avail. At one point we had our agency MD on board yet the other program MDs in the county voted against it! Again, “nobody ever died of pain” was just one reason. Another was/is the potential abuse issue, especially with fentanyl compounded by the fear ketamine could be stolen off the trucks by youngsters for their Rave parties. Subsequently, our patients receive a proper induction via etomidate but very infrequently the administration of diazepam and morphine post intubation (only a few of us religiously use the agents). What you end up with is a patient who doesn’t remember undergoing paralysis and intubation but wakes up being paralyzed and intubated on a bumpy ride to the hospital.

All this says is that local MDs have zero faith in their medics. If you can’t secure your narcotics, you have no business being in this business. There are dozens of ways to secure them. This is simply an excuse for someone who is afraid to allow their medics the ability to treat.

Medic 22 a dehydrated girl with a low BP and tachycardia needs a line and a fluid blous. That’s ALS. Not an emergency… but something that a paramedic can, and SHOULD do.
Me: what’s the benefit of the prehospital als in that case? if it doesn’t save a life or shorten hospital stay what’s the point
Medic 22: It’s GOOD PATIENT CARE. Its what competent, caring prehospital care providers do.

If the care by paramedics could prevent the need for hospital then I’m all for it. Unfortunately in the case wouldn’t you just be delaying hospital care and doing something just to do it?

First of all, you are assuming we are delaying care. Like I said before:

My scene time consists of a brief primary assessment, possibly a 12 lead and loading the patient where I begin the rest of my treatment–unless the patient absolutely needs other interventions prior to departure. That being said, when I am 15 minutes away from the hospital with someone puking(and further dehydrating themselves) or someone who has moderate wheezes, why shouldn’t I begin treating them?

Again…. It seems that you assume there is some abundance of Life or Limb calls in EMS. Honestly, those exciting calls just don’t come all that much. What we get a lot of is sick baby boomers, indigents, drunks, and people who don’t know any better. Does that mean we shouldn’t treat them while we can?

It is our job to treat patients, and as long as I have time in the back of my truck, I am going to do everything I can to make them more comfortable, happier, and healthier–if at all possible.

Posted by on March 9, 2010 • Filed under: Blogroll, ems-health-safety, ems-topics, medic, patient-management, Protocol, training-development • Tagged:

False Hope.

262 comments

As EMS providers, we have a very limited scope of tools to help our patients. We are obligated to follow our protocols and treat was is evident from our assessment. This means your assessment is likely the most powerful tool you have in providing medical care. Ironically our most powerful tool, communication, is often completely forgotten by EMS providers.

The hardest part about our job is being honest with patients and their families. Often times we are present in end of life situations. These are difficult in controlled atmospheres–let alone the seemingly claustrophobic nature of EMS scenes. When a patient is dying we need to be honest with them and their loved ones. We need not be brutally honest, but most certainly we can not allow false hope.

False hope is a natural defense mechanism in the grieving process. Denial. Even as EMS providers we sometimes hold on to false hope in difficult calls to get by–but this is neither practical nor healthy in the end. Allowing and providing for false hope will create more shock when reality strikes. Death is a natural process–not always a pleasant process–but natural none the less.

As providers it is our duty to assist our patients and their families in understanding the reality of their situation. Does this mean saying “you’re going to die”? Not at all. But it does mean being clear that the patient is very ill, and you are doing all you can but 1) they need higher level of care 2) they may not make it to that higher level.

Does this make the process of dying easier? Absolutely not. For patients and their loved ones knowing their impending doom can be equally troubling. But it is still our duty to be truthful with our patients. Where I believe this honesty to provide an important relief to EMS is in the all to difficult cease or withholding of resuscitation talk we find ourselves in during these types of calls. Being honest with a patient and their family gives them more time, possibly only seconds, for reality to sink in.

When termination of resuscitation becomes part of the discussion, patients families are often unprepared. Giving them the truthful answers to questions about the reality of the condition of their loved ones will certainly help them to make the decisions to terminate care when necessary.

How do you handle these difficult moments in patient communication?

Posted by on December 11, 2009 • Filed under: Coping, ems-topics, medic, patient-management • Tagged:

Cause…

4 comments

I couldn’t have said it any better, I’ll just Let EPIJUNKY do it for me.

We should all follow her lead. I think this is really what we should focus EMS 2.0 on. If we can’t stand up for our patients, what business do we have THINKING for them…

Posted by on October 28, 2009 • Filed under: administration-leadership, ems-health-safety, ems-topics, medic, patient-management

Unspoken

73 comments

Often times on a call, it is what ISN’T said that is most important. As paramedics we are trained to ask a set of questions necessary for assessing our patients, but more often than not, we know the important answers. We know when our patients are sick. We know when they hurt. We know when they can’t breathe. Those things are usually obvious.

The hardest thing we often know without a word spoken… we know when our patients are ready to die. The look–or lack there of–in their eyes, their posture, their sound–they all tell the tale all too well.

no_evilThe trouble is that we are trained to prolong life. Little about our training prepares us for letting allowing watching someone die. We are trained to do everything possible to prolong life–whether that is what the patient wants or what is best for them. We are trained to give drugs, artificially ventilate, pace, defibrillate, and otherwise interfere in the dying process. We are not trained to let people die.

So what do we do when the ultimate time comes? Outside of a DNR most systems won’t allow you to cease rescussitation. My system takes the word of a family member very seriously–outside of suspicious circumstances, we honor the wishes of an immediate family member. We also take the time to educate them on what will happen either way. I find it important to make sure someone knows that even if we get them to the hospital alive, they very well might never wake up.

My job isn’t as cut and dry as most think. I rarely save lives. Most of what I do has little to do with medicine or emergencies. Most of my night is spent dodging drunks or other frequent fliers. In the last 6 weeks my partner and I had 4 or 5 really “exciting” calls. Maybe I’m sick/twisted/strange/gross, but the exciting calls are the ones that make you go “aw shit…”. Most of the time we are running call after call of No Ambulance Needed or PD to Transport. But every so often we actually run a “real” call. Every so often we come across a sick patient.

Every so often that patient has already made up their mind that theypain can’t fight anymore. Who are we to decide otherwise? Does what we do make a difference other than to prolong a life of pain and discomfort? Are we doing harm in interjecting in what is the obvious end of the dying process? Are we causing pain? Obviously we are bound by our protocols/guidelines. Obviously we are bound as medical professionals to follow the medical standard. But at what point are we doing MORE harm?

Posted by on October 26, 2009 • Filed under: Coping, ems-topics, Heart Strings, medic, patient-management