In response to Graybeard's comment on my post about job prospects in the EMS field:
Yes, fraud is running rampant. In 2002, Medicare reimbursement for ambulances was less than $1 billion. In 2009, it had more than doubled, despite the fact that the amounts paid for each trip had not changed. I can tell you that the linked article's claim that 80% of interfacility ambulance rides are fraudulent doesn't surprise me one bit. I think that number is spot on.
The Feds are cracking down on this, but they are not even catching a fraction of the fraud. As the Affordable Care Act is implemented, it will only get worse.
Showing posts with label EMS. Show all posts
Showing posts with label EMS. Show all posts
Tuesday, July 30, 2013
Friday, July 26, 2013
A warning to youngsters
People signing up for EMT and Paramedic schools are at an all time high. The economy is so bad, that people are trying to gain job skills to be employable. Employers are taking advantage of this, and things are getting tight. In the peninsula of Florida, there are a few choices for EMT or Paramedic jobs:
1- Fire Department. This is a decent job with good pay, but the hours are long. You go to EMT school, and then Fire school. This takes about 7 months to complete. You take a certifying exam for both, and then start looking for work. Paramedic takes an additional year. Starting pay is $10-12 an hour for a Firefighter-EMT with no experience. Paramedics get around $13-16 an hour. Firefighters work 48-56 hours a week on average, so take home starts near $30,000 a year for EMTs, and $40,000 for Paramedics. Pensions are nor what they once were, but they are still better than most other professions. The real downside is that the competition is fierce. Even a "stepping stone" department, where many new firefighters get a job, earn experience, and them move on has a lot of applicants. Departments with a job opening are getting 200-300 applicants for each position. For that reason, there are so many unemployed people with firefighter certifications, that the state has largely shut down funding for the training of new firefighters. Unless you have experience or are a minority, getting a job as a firefighter is a long shot.
2- Hospitals, Doctor's offices, and clinics: These usually have decent hours, good working conditions, and pay varies widely. Hospitals pay well, and you usually work the Emergency Department in 3-12 hour shifts per week. Starting pay is usually $12 for EMTs and $16-$17 for Paramedics. Again, hard to come by, but not as hard as firefighter or theme park spots. You are restricted in what you can do by many places, so the work is not very exciting or challenging.
3- Theme parks: Even more difficult to get into than a firefighting spot, but the hours are great and flexible, and the starting pay is $14-16 an hour. Benefits are outstanding, if you can get a full time spot, but those are becoming as rare as unicorn sightings.
4- So you are then left with private ambulances. In this area, all these companies do is haul non-emergency medical patients between nursing homes, hospitals, and dialysis clinics. No 911 or emergency calls. In fact, in many counties, if the patient is emergent the ambulance is REQUIRED to pull over and wait for a 911 unit from the fire department to take over the patient. Starting pay is $9-10 for EMTs, and $13-14 for paramedics. Benefits are poor. Shifts are long, normally 12-14 hours each. You do not get a station to sit in on those times where you wait for your next call. You sit in the truck and wait. No reading, eating, sleeping, watching movies on your electronic devices, no texting, no phone use, and no drinking of anything except water. (Not even coffee) These jobs are easy to get, but turnover is high, and most people don't stay for long, using this place to get experience and move on. A person that stays at one of these places for more than 2 years becomes unemployable anywhere else, because many employers assume that you are stuck there for a reason.
One manager at a private ambulance company told me that his crews were not allowed to eat during shift, because he doesn't pay them to eat. Another told me that patient care is secondary to keeping the customer (nursing home, hospital, etc) happy, and that the patient was just cargo, and no one cares what cargo thinks. One of my former EMT students was told by an employer when he complained about working conditions, that for every EMT that was working there, there were 7 more looking for a job, and if he didn't like it, he could be replaced tomorrow.
Compare that to other jobs in the area: Fast food pays $8.50-9 an hour, or about as much as an EMT, and without the exposure to diseases that comes with EMT. Paramedic jobs that started at $14 an hour ten years ago are starting at $13.23 now. In comparison, my son went to nursing school after only three years as a paramedic, and his pay is now $32 an hour. Nursing school is the same length as paramedic, but more than double the pay.
There is a reason why the average EMT or paramedic spends less than 5 years in this job: injuries, poor working conditions, a lack of appreciation for hard work, and low pay all too frequently make the best and most talented leave. My advice to people that are thinking about a career in this field changed about two years ago: stay away.
1- Fire Department. This is a decent job with good pay, but the hours are long. You go to EMT school, and then Fire school. This takes about 7 months to complete. You take a certifying exam for both, and then start looking for work. Paramedic takes an additional year. Starting pay is $10-12 an hour for a Firefighter-EMT with no experience. Paramedics get around $13-16 an hour. Firefighters work 48-56 hours a week on average, so take home starts near $30,000 a year for EMTs, and $40,000 for Paramedics. Pensions are nor what they once were, but they are still better than most other professions. The real downside is that the competition is fierce. Even a "stepping stone" department, where many new firefighters get a job, earn experience, and them move on has a lot of applicants. Departments with a job opening are getting 200-300 applicants for each position. For that reason, there are so many unemployed people with firefighter certifications, that the state has largely shut down funding for the training of new firefighters. Unless you have experience or are a minority, getting a job as a firefighter is a long shot.
2- Hospitals, Doctor's offices, and clinics: These usually have decent hours, good working conditions, and pay varies widely. Hospitals pay well, and you usually work the Emergency Department in 3-12 hour shifts per week. Starting pay is usually $12 for EMTs and $16-$17 for Paramedics. Again, hard to come by, but not as hard as firefighter or theme park spots. You are restricted in what you can do by many places, so the work is not very exciting or challenging.
3- Theme parks: Even more difficult to get into than a firefighting spot, but the hours are great and flexible, and the starting pay is $14-16 an hour. Benefits are outstanding, if you can get a full time spot, but those are becoming as rare as unicorn sightings.
4- So you are then left with private ambulances. In this area, all these companies do is haul non-emergency medical patients between nursing homes, hospitals, and dialysis clinics. No 911 or emergency calls. In fact, in many counties, if the patient is emergent the ambulance is REQUIRED to pull over and wait for a 911 unit from the fire department to take over the patient. Starting pay is $9-10 for EMTs, and $13-14 for paramedics. Benefits are poor. Shifts are long, normally 12-14 hours each. You do not get a station to sit in on those times where you wait for your next call. You sit in the truck and wait. No reading, eating, sleeping, watching movies on your electronic devices, no texting, no phone use, and no drinking of anything except water. (Not even coffee) These jobs are easy to get, but turnover is high, and most people don't stay for long, using this place to get experience and move on. A person that stays at one of these places for more than 2 years becomes unemployable anywhere else, because many employers assume that you are stuck there for a reason.
One manager at a private ambulance company told me that his crews were not allowed to eat during shift, because he doesn't pay them to eat. Another told me that patient care is secondary to keeping the customer (nursing home, hospital, etc) happy, and that the patient was just cargo, and no one cares what cargo thinks. One of my former EMT students was told by an employer when he complained about working conditions, that for every EMT that was working there, there were 7 more looking for a job, and if he didn't like it, he could be replaced tomorrow.
Compare that to other jobs in the area: Fast food pays $8.50-9 an hour, or about as much as an EMT, and without the exposure to diseases that comes with EMT. Paramedic jobs that started at $14 an hour ten years ago are starting at $13.23 now. In comparison, my son went to nursing school after only three years as a paramedic, and his pay is now $32 an hour. Nursing school is the same length as paramedic, but more than double the pay.
There is a reason why the average EMT or paramedic spends less than 5 years in this job: injuries, poor working conditions, a lack of appreciation for hard work, and low pay all too frequently make the best and most talented leave. My advice to people that are thinking about a career in this field changed about two years ago: stay away.
Thursday, June 27, 2013
Duty
There is an interesting case in New York involving an EMT and a pregnant woman with asthma. The asthma patient had been seen earlier in the day by paramedics for her condition and had refused to be transported for evaluation. The EMT, who was working in dispatch for FDNY, was on a coffee break when the woman nearby began having an asthma attack. Bystanders, frantically looking for help, saw the dispatcher in uniform and asked her for help. The dispatcher called 911, but refused to get up and evaluate the patient. The women died.
FDNY Was sued by the dead woman's family, and the EMT was charged with the crime of negligence. To protect itself from the lawsuit, the FDNY claimed that dispatchers on break do not have a duty to act, and asked that criminal charges against the EMT be dropped.
My personal feeling is that when you are on the clock and in uniform, you do your job, even if you are on a coffee break. This EMT should have tried to do something. Even without equipment, she could have performed CPR.
Off the clock, I agree that you don't have a duty to act. Heck, I quit stopping at car accidents about ten years ago when a paramedic in Central Florida who stopped at a car accident was struck and killed by oncoming traffic, and the State of Florida refused to pay the widow his death benefits
because he was not on duty.
In this case, this EMT got lucky that her employer needed to avoid legal liability more than they wanted to prosecute her.
FDNY Was sued by the dead woman's family, and the EMT was charged with the crime of negligence. To protect itself from the lawsuit, the FDNY claimed that dispatchers on break do not have a duty to act, and asked that criminal charges against the EMT be dropped.
My personal feeling is that when you are on the clock and in uniform, you do your job, even if you are on a coffee break. This EMT should have tried to do something. Even without equipment, she could have performed CPR.
Off the clock, I agree that you don't have a duty to act. Heck, I quit stopping at car accidents about ten years ago when a paramedic in Central Florida who stopped at a car accident was struck and killed by oncoming traffic, and the State of Florida refused to pay the widow his death benefits
because he was not on duty.
In this case, this EMT got lucky that her employer needed to avoid legal liability more than they wanted to prosecute her.
Friday, January 13, 2012
Nice Try
There are many people who abuse 911 for various reasons. Some because they are whiney people with minor complaints that want to be seen now instead of in the morning, some because they want a free meal or to get high, some because they are simply stupid, and many because they are mentally ill.
There is a woman who falls into the latter category and is known throughout several states for faking seizures in order to get attention. This woman is well known by nearly every medic in the state of Florida who has more than a couple of years on the job. Chances are, if you are a paramedic in the state of Florida, you have or will run on this woman.
I have met paramedics all over Florida, Georgia, and even as far north as Maryland who have run on this woman. She has been seen on shows like Paramedics and Trauma: life in the ER. More than a few medics have given this woman Valium without realizing who she was. She is very good at faking.
So came the day that we ran on her at 2:30 in the A.M one early morning. Tired of running stupid calls, those of us who were there chipped in and paid her bus fare to Orlando, which was 20 miles away, put her on the bus, and patted ourselves on the back for ridding ourselves of the problem. (Come to think of it, this may explain why she has traveled so extensively.)
Two weeks later, I ran on her again. During the call, she handed me an envelope and told me that the Orlando firefighters had asked her to give it to me the next time she saw me. I opened the envelope, and in it was a note. It read simply:
Nice Try.
That, my readers, is a true story.
There is a woman who falls into the latter category and is known throughout several states for faking seizures in order to get attention. This woman is well known by nearly every medic in the state of Florida who has more than a couple of years on the job. Chances are, if you are a paramedic in the state of Florida, you have or will run on this woman.
I have met paramedics all over Florida, Georgia, and even as far north as Maryland who have run on this woman. She has been seen on shows like Paramedics and Trauma: life in the ER. More than a few medics have given this woman Valium without realizing who she was. She is very good at faking.
So came the day that we ran on her at 2:30 in the A.M one early morning. Tired of running stupid calls, those of us who were there chipped in and paid her bus fare to Orlando, which was 20 miles away, put her on the bus, and patted ourselves on the back for ridding ourselves of the problem. (Come to think of it, this may explain why she has traveled so extensively.)
Two weeks later, I ran on her again. During the call, she handed me an envelope and told me that the Orlando firefighters had asked her to give it to me the next time she saw me. I opened the envelope, and in it was a note. It read simply:
Nice Try.
That, my readers, is a true story.
Monday, August 8, 2011
There are incompetents everywhere
I work a second job at a large central Florida theme park. (There are only a few, you can guess which one.) During my last shift there, I was called to evaluate a man who was "having a seizure." When I arrived, I found a 59 year old man who was sitting upright in a chair and only verbally responsive. He has a history of cardiac, HTN, hyperlipidemia, and diabetes. A local hospital owned ambulance service was called. While waiting for them to arrive, we got the following vitals: HR 88, BP 92/54, RR 18, Temp 97.8, BGL 140. It was over 100 degrees in the park, and the patient's skin was flushed. We initiated active cooling, and he was again responsive within ten minutes.
The unit arrived, and in walks the EMT. Alone. Then he began talking the patient into signing a refusal. The medic never even got out of the truck. They took no vitals and did not even put him on the monitor. I pitched a fit and threatened to call their supervisor. The medic came in, ran a strip and they collected their refusal and left. Here are my questions:
How does the medic know that this was not a seizure?
How does the medic know that this was not a cardiac problem?
Why did the medic send his EMT in to get a refusal without even evaluating the patient?
Why do some medics still insist that medics who work for EMS only agencies are automatically better than fire based medics? Is it possible that my position, that it doesn't matter who signs the paychecks, it is what lies in the heart of the medic that counts, is the correct one?
I think the real problem is that some medics are unable to get a fire medic job for a variety of reasons (too fat, out of shape, can't pass the test, whatever) and spend their time bashing the fire department. I do everything that an EMS only paramedic does, and I fight fires and perform rescues as well.
The unit arrived, and in walks the EMT. Alone. Then he began talking the patient into signing a refusal. The medic never even got out of the truck. They took no vitals and did not even put him on the monitor. I pitched a fit and threatened to call their supervisor. The medic came in, ran a strip and they collected their refusal and left. Here are my questions:
How does the medic know that this was not a seizure?
How does the medic know that this was not a cardiac problem?
Why did the medic send his EMT in to get a refusal without even evaluating the patient?
Why do some medics still insist that medics who work for EMS only agencies are automatically better than fire based medics? Is it possible that my position, that it doesn't matter who signs the paychecks, it is what lies in the heart of the medic that counts, is the correct one?
I think the real problem is that some medics are unable to get a fire medic job for a variety of reasons (too fat, out of shape, can't pass the test, whatever) and spend their time bashing the fire department. I do everything that an EMS only paramedic does, and I fight fires and perform rescues as well.
Saturday, July 9, 2011
Obama Care and the future of medicine
I was at Clincon yesterday, and one of the lectures was about trends in medicine. One of the topics was Obamacare. When Obamacare takes effect in eight months or so, some provisions will change the way that medicine is paid for in this country, and not for the better.
The hospital will be paid a flat rate for a patient with a given problem, no matter how long the patient is in the hospital. For example, all patients who present to the hospital with congestive heart failure (CHF) will earn the hospital a set price, regardless of how many days that the patient stays in the hospital. This means that the hospital has an incentive to get you out of the hospital in a minimum amount of time, whether you are cured or not, and has the added incentive of diagnosing you with every ailment that they can think of, from halitosis to athlete's foot.
To correct this problem, the geniuses in the government have devised a solution: If the patient must be admitted for the same condition within 6 months of discharge, the hospital gets nothing for the subsequent visits. So that CHF patient doesn't follow his discharge instructions, and gets readmitted. The hospital eats it. It is only a matter of time before the hospitals are forced to find ways to keep frequent flyers away.
This is a real mess. I am not sure of everything that is coming, but I do know that it will create real problems in the health care field.
The hospital will be paid a flat rate for a patient with a given problem, no matter how long the patient is in the hospital. For example, all patients who present to the hospital with congestive heart failure (CHF) will earn the hospital a set price, regardless of how many days that the patient stays in the hospital. This means that the hospital has an incentive to get you out of the hospital in a minimum amount of time, whether you are cured or not, and has the added incentive of diagnosing you with every ailment that they can think of, from halitosis to athlete's foot.
To correct this problem, the geniuses in the government have devised a solution: If the patient must be admitted for the same condition within 6 months of discharge, the hospital gets nothing for the subsequent visits. So that CHF patient doesn't follow his discharge instructions, and gets readmitted. The hospital eats it. It is only a matter of time before the hospitals are forced to find ways to keep frequent flyers away.
This is a real mess. I am not sure of everything that is coming, but I do know that it will create real problems in the health care field.
Sunday, June 12, 2011
Know your toolbox
A 69 year old male with an implantable defibrillator calls EMS because it shocked him. A medic who was on the call with me was assuming that the defibrillator was malfunctioning. That is usually not the case. In fact, I cannot think of a single time when an implantable defibrillator shocked a patient unnecessarily. This patient told me that he got lightheaded at about the same time as he was shocked, so I was running off the assumption that the patient had been in Ventricular Tachycardia, and the ICD shocked him. We put the patient on the monitor, and the patient was in a first degree AV block with frequent (15 per minute or so) PVCs.
The best treatment for PVCs is oxygen, so we started the patient on 4 liters, and obtained IV access. By this time, the patient was in ventricular trigeminy, and it wasn't long before we started seeing couplets. Vitals: HR 88, BP 152/88, RR 18, SaO2 100%, EtCO2 34, and he weighs 193 pounds. Of the five of us on scene, there were three medics, and the other two medics wanted to give him a cordarone drip.
I told them to give 100mg of lidocaine, and follow that with a maintenance drip of 2mg/ minute. The PVCs were almost completely resolved (less than 4 per minute) within 3 minutes, and we took our ride to the hospital.
When we returned to quarters, we had a discussion on the benefits of lidocaine versus cordarone, and turned it into a training session. I must admit that other medics may have different feelings on this, but here are the reasons why I prefer lidocaine over amiodarone for conscious patients:
1. Amiodarone causes too much hypotension for my comfort
2. Amiodarone frequently causes bradycardia
3. Amiodarone has a long half-life, so in the event that 1 or 2 occurs, the patient is going to be screwed for a long time
4. Although lidocaine toxicity is theoretically a worry, I have never seen it on any of my patients.
So that is why I go with lidocaine. Any other readers have different opinions? If so, why?
The best treatment for PVCs is oxygen, so we started the patient on 4 liters, and obtained IV access. By this time, the patient was in ventricular trigeminy, and it wasn't long before we started seeing couplets. Vitals: HR 88, BP 152/88, RR 18, SaO2 100%, EtCO2 34, and he weighs 193 pounds. Of the five of us on scene, there were three medics, and the other two medics wanted to give him a cordarone drip.
I told them to give 100mg of lidocaine, and follow that with a maintenance drip of 2mg/ minute. The PVCs were almost completely resolved (less than 4 per minute) within 3 minutes, and we took our ride to the hospital.
When we returned to quarters, we had a discussion on the benefits of lidocaine versus cordarone, and turned it into a training session. I must admit that other medics may have different feelings on this, but here are the reasons why I prefer lidocaine over amiodarone for conscious patients:
1. Amiodarone causes too much hypotension for my comfort
2. Amiodarone frequently causes bradycardia
3. Amiodarone has a long half-life, so in the event that 1 or 2 occurs, the patient is going to be screwed for a long time
4. Although lidocaine toxicity is theoretically a worry, I have never seen it on any of my patients.
So that is why I go with lidocaine. Any other readers have different opinions? If so, why?
Friday, June 10, 2011
Stupid humans
Yesterday at work, I was flagged down by a woman who wanted to report an alligator in the middle of the road. Not an unusual occurrence in alligator country, but not as common as it once was. At four or five feet, the alligator was not a large one, but there was a group of about 10 people who were stopped in the middle of the road, out of their cars trying to get pictures of the animal, some of them as close as 10-12 feet away.
The alligator was facing them, mouth open, and hissing at them. For those of you who do not recognize the behavior of an animal that feels threatened, this posture is alligator speak for "Leave me alone, or I will maul your ass with these huge teeth I've got here." When an apex predator such as an alligator, or any animal, takes this sort of an aggressive posture, it behooves you to pay attention to the message and move away slowly without turning your back on it, lest you trigger a pursuit response from the predator. When the nice firefighter tells you to get in your car and leave before you get eaten, you should probably do so.
Of course, that is not the behavior of the people in my area. Instead, they want to argue with you about how they only want a picture, and how you can't order them around. Hey, I am not going to argue with you, go ahead and get your pictures. Once you get bitten, though, don't file a complaint against me when I laugh at you.
The alligator was facing them, mouth open, and hissing at them. For those of you who do not recognize the behavior of an animal that feels threatened, this posture is alligator speak for "Leave me alone, or I will maul your ass with these huge teeth I've got here." When an apex predator such as an alligator, or any animal, takes this sort of an aggressive posture, it behooves you to pay attention to the message and move away slowly without turning your back on it, lest you trigger a pursuit response from the predator. When the nice firefighter tells you to get in your car and leave before you get eaten, you should probably do so.
Of course, that is not the behavior of the people in my area. Instead, they want to argue with you about how they only want a picture, and how you can't order them around. Hey, I am not going to argue with you, go ahead and get your pictures. Once you get bitten, though, don't file a complaint against me when I laugh at you.
Saturday, April 30, 2011
Spinal Immobilization is not always what is best
This is another one of those EMS related posts. For those of you who are not in the medical field, I am sorry if this post makes your eyes glaze over a bit.
We have been taught to backboard every trauma patient. My protocols have us routinely backboarding patients who have been in car accidents, falls, penetrating trauma to the neck or torso, and a host of other accidents. Even when there is no sign of damage to the spine, we backboard. This is a result of the practice of defensive medicine. That is, we do this under the theory that we could be sued by the ambulance chasing "if I don't get you a big payoff, I don't collect a fee" lawyers that are always on the television during the day. The belief goes that if the patient needed to be immobilized and wasn't, there is a chance we could lose, but throwing someone who isn't really injured on a backboard doesn't hurt the patient, so we cover our collective butts by doing it to everyone.
Studies are starting to show that immobilizing patients is not a benign treatment. In fact, this 2010 study of over 45,000 trauma patients shows that patients who are victims of penetrating trauma to the torso, but do not present with any specific neurological deficit, experience a higher mortality rate when immobilized than similar patients who are not immobilized. We need to cease backboarding everyone. We are killing people. The lawyers are killing people. This needs to stop.
We have been taught to backboard every trauma patient. My protocols have us routinely backboarding patients who have been in car accidents, falls, penetrating trauma to the neck or torso, and a host of other accidents. Even when there is no sign of damage to the spine, we backboard. This is a result of the practice of defensive medicine. That is, we do this under the theory that we could be sued by the ambulance chasing "if I don't get you a big payoff, I don't collect a fee" lawyers that are always on the television during the day. The belief goes that if the patient needed to be immobilized and wasn't, there is a chance we could lose, but throwing someone who isn't really injured on a backboard doesn't hurt the patient, so we cover our collective butts by doing it to everyone.
Studies are starting to show that immobilizing patients is not a benign treatment. In fact, this 2010 study of over 45,000 trauma patients shows that patients who are victims of penetrating trauma to the torso, but do not present with any specific neurological deficit, experience a higher mortality rate when immobilized than similar patients who are not immobilized. We need to cease backboarding everyone. We are killing people. The lawyers are killing people. This needs to stop.
Monday, March 21, 2011
My rant
Yesterday, I was a witness to a homicide. I watched a doctor kill a patient. This was one of the worst performances that I have ever witnessed from a physician. Her ego, lack of medical skill, and lack of caring were all contributing factors in the death of this patient. Lots of medic stuff to follow. I will try to link to explanations where I can.
So we had a call for an unresponsive 91 year old female. I checked her radial pulse, and it was weak at 30 beats per minute. We put her on the monitor, and she was in a narrow complex bradycardic rhythm with no discernible P waves, so we began pacing her. That is exactly what the American Heart Association says is the appropriate for an unresponsive patient with bradycardia.
Her initial vitals: HR 70(paced), BP 87/63, RR:19, EtCO2 23 and square, SpO2 93%. There was a little expiratory wheezing, but her capnogram didn't show any obstructive pattern, and the EtCO2 of 23 indicated that this was a cardiac output problem, not a hypoventilation or respiratory problem. We decided that her problem was decompensated cardiogenic shock. We started a Dopamine infusion at 7 mcg/kg/minute.
We arrived at the hospital 15 minutes later. Her vitals were now: HR70(paced), BP 133/108, RR 19, EtCO2 26 and square, SpO2 94% (on NRB at ten liters). This was a significant improvement.
The Doctor's first question, even before I was done with my turnover: "Is she a DNR?" When I said no, and that the family was in the waiting room, her reply was "I am going to talk to them about a DNR." This doctor then removed the pacing pads, discontinued the dopamine, and ordered atropine. Whatever, you are the doctor, even if you are taking a treatment that is working and changing course.
Five minutes later, the patient's HR was 36, and her BP was 39/23. What did the doctor do? She ordered an albuterol updraft.At this point, I went over and politely showed her the capnogram, and pointed out that the lack of an obstructive pattern indicated that the beta agonist would not work. That is where she came unglued. She told me that she was giving it for wheezes, and I responded by telling her that wheezes do not always mean bronchospasm.
Then she got personal. She told me, "When you go to doctor school, you come back and we will fucking have this conversation." What followed was not my most shining moment.
I told her: "If I were you, I would go back to my doctor school and demand a refund, if what they taught you was to give an updraft to a patient in cardiogenic shock with adequate respiration, just because you heard some wheezes."
The good news is that my department and the medical director are standing behind me on this one.
So we had a call for an unresponsive 91 year old female. I checked her radial pulse, and it was weak at 30 beats per minute. We put her on the monitor, and she was in a narrow complex bradycardic rhythm with no discernible P waves, so we began pacing her. That is exactly what the American Heart Association says is the appropriate for an unresponsive patient with bradycardia.
Her initial vitals: HR 70(paced), BP 87/63, RR:19, EtCO2 23 and square, SpO2 93%. There was a little expiratory wheezing, but her capnogram didn't show any obstructive pattern, and the EtCO2 of 23 indicated that this was a cardiac output problem, not a hypoventilation or respiratory problem. We decided that her problem was decompensated cardiogenic shock. We started a Dopamine infusion at 7 mcg/kg/minute.
We arrived at the hospital 15 minutes later. Her vitals were now: HR70(paced), BP 133/108, RR 19, EtCO2 26 and square, SpO2 94% (on NRB at ten liters). This was a significant improvement.
The Doctor's first question, even before I was done with my turnover: "Is she a DNR?" When I said no, and that the family was in the waiting room, her reply was "I am going to talk to them about a DNR." This doctor then removed the pacing pads, discontinued the dopamine, and ordered atropine. Whatever, you are the doctor, even if you are taking a treatment that is working and changing course.
Five minutes later, the patient's HR was 36, and her BP was 39/23. What did the doctor do? She ordered an albuterol updraft.At this point, I went over and politely showed her the capnogram, and pointed out that the lack of an obstructive pattern indicated that the beta agonist would not work. That is where she came unglued. She told me that she was giving it for wheezes, and I responded by telling her that wheezes do not always mean bronchospasm.
Then she got personal. She told me, "When you go to doctor school, you come back and we will fucking have this conversation." What followed was not my most shining moment.
I told her: "If I were you, I would go back to my doctor school and demand a refund, if what they taught you was to give an updraft to a patient in cardiogenic shock with adequate respiration, just because you heard some wheezes."
The good news is that my department and the medical director are standing behind me on this one.
Thursday, February 17, 2011
Capnography for ROSC patients
There was a case recently where a paramedic was working a code on a patient in PEA. During the code, the EtCO2 of the patient rose from 12mm to 27. The medic correctly assumed that his patient was a ROSC patient. He stated so to the ED staff when he turned the patient over to them. The doctor ignored the medic, and stated that the increased EtCO2 meant nothing, and declared the patient dead. Some time later, when the staff went in to prepare the patient's body for delivery to the morgue, they noticed the patient trying to breathe. The code was resumed, with the result that the patient finally expired several days later. Lawsuits are pending.
The evidence is overwhelming, capnography is a reliable predictor of ROSC in an arrest patient. Here are some studies to prove my point:
Analysis of the Efficacy of Waveform Capnography Monitoring Using Bag-Valve-Mask Ventilation. Wales, RA. Society for Technology in Anesthesia 2011.
End Tidal Carbon Dioxide Levels Predict Cardiac Arrest. Manyam H. Society for Technology in Anesthesia 2011.
End Tidal Carbon Dioxide Predicts Cardiac Arrest. Manyam H, Thiagarajah P, Patel G, French R, Chaluvadi S, Balaan M. American Heart Association Resuscitation Science Symposium
Analysis of the Efficacy of Waveform Capnography Monitoring Using Bag-Valve-Mask Ventilation. Wales RA, Dyott W. Prehospital Emergency Care (NAEMSP). January 2010; Volume 14, (Suppl 1), 48-49.
Capnography as a Survival Predictor in Cardiopulmonary Resuscitation.Farinha LF. Resuscitation, Volume 81, Issue 2, Supplement 1, December 2010, Page S57.Sleep and Pulmonary Rehab
Partial Pressure of End-tidal Carbon Dioxide – Reliable Criteria for Termination of Non-traumatic Cardiac Arrest Resuscitative Efforts in the Field. Grmec et al. Resuscitation, Volume 81, Issue 2, Supplement 1, December 2010, Page S26.
Capnography during CPR in SUMMA 112: Preliminary Study. Diez-Picazo LD, et al. Congreso Nacional SEMES 2009. June 2009.
The evidence is overwhelming, capnography is a reliable predictor of ROSC in an arrest patient. Here are some studies to prove my point:
Analysis of the Efficacy of Waveform Capnography Monitoring Using Bag-Valve-Mask Ventilation. Wales, RA. Society for Technology in Anesthesia 2011.
End Tidal Carbon Dioxide Levels Predict Cardiac Arrest. Manyam H. Society for Technology in Anesthesia 2011.
End Tidal Carbon Dioxide Predicts Cardiac Arrest. Manyam H, Thiagarajah P, Patel G, French R, Chaluvadi S, Balaan M. American Heart Association Resuscitation Science Symposium
Analysis of the Efficacy of Waveform Capnography Monitoring Using Bag-Valve-Mask Ventilation. Wales RA, Dyott W. Prehospital Emergency Care (NAEMSP). January 2010; Volume 14, (Suppl 1), 48-49.
Capnography as a Survival Predictor in Cardiopulmonary Resuscitation.Farinha LF. Resuscitation, Volume 81, Issue 2, Supplement 1, December 2010, Page S57.Sleep and Pulmonary Rehab
Partial Pressure of End-tidal Carbon Dioxide – Reliable Criteria for Termination of Non-traumatic Cardiac Arrest Resuscitative Efforts in the Field. Grmec et al. Resuscitation, Volume 81, Issue 2, Supplement 1, December 2010, Page S26.
Capnography during CPR in SUMMA 112: Preliminary Study. Diez-Picazo LD, et al. Congreso Nacional SEMES 2009. June 2009.
Saturday, February 12, 2011
Drug lethality
Of the drugs that Americans routinely abuse, many of them are quite toxic. Take a look at this:
The median lethal doses for different substances in a 100kg male:
nicotine 5 g
Cocaine 9.5 g
aspirin 20 g
THC (main ingredient of marijuana) 127g
alcohol: 180 g
caffeine 192 g
acetaminophen (Tylenol): 200 g
table salt: 300 g
Sucrose (table sugar): 2900 g
The issue here is not so much the total lethal dose, but how close you must be to the lethal dose in order to get the effect you are looking for. The largest cluster of substances has a lethal dose that is 10 to 20 times the effective dose: These include cocaine, MDMA (often called "ecstasy") and alcohol. A less toxic group of substances, requiring 20 to 80 times the effective dose to cause death, include Rohypnol (flunitrazepam or "roofies") and mescaline (peyote cactus). The least physiologically toxic substances, those requiring 100 to 1,000 times the effective dose to cause death, include psilocybin mushrooms and marijuana, when ingested. I've found no published cases in the that document deaths from smoked marijuana, so the actual lethal dose is a mystery. My guess is that smoking marijuana is more risky than eating it, but still safer than alcohol.
Alcohol ranks at the dangerous end of the toxicity spectrum. So despite the fact that about 75 percent of all adults in the United States enjoy an occasional drink, it must be remembered that alcohol is toxic. This makes me wonder why we spend so much money on the drug war. Nevermind, the answer is profit.
The median lethal doses for different substances in a 100kg male:
nicotine 5 g
Cocaine 9.5 g
aspirin 20 g
THC (main ingredient of marijuana) 127g
alcohol: 180 g
caffeine 192 g
acetaminophen (Tylenol): 200 g
table salt: 300 g
Sucrose (table sugar): 2900 g
The issue here is not so much the total lethal dose, but how close you must be to the lethal dose in order to get the effect you are looking for. The largest cluster of substances has a lethal dose that is 10 to 20 times the effective dose: These include cocaine, MDMA (often called "ecstasy") and alcohol. A less toxic group of substances, requiring 20 to 80 times the effective dose to cause death, include Rohypnol (flunitrazepam or "roofies") and mescaline (peyote cactus). The least physiologically toxic substances, those requiring 100 to 1,000 times the effective dose to cause death, include psilocybin mushrooms and marijuana, when ingested. I've found no published cases in the that document deaths from smoked marijuana, so the actual lethal dose is a mystery. My guess is that smoking marijuana is more risky than eating it, but still safer than alcohol.
Alcohol ranks at the dangerous end of the toxicity spectrum. So despite the fact that about 75 percent of all adults in the United States enjoy an occasional drink, it must be remembered that alcohol is toxic. This makes me wonder why we spend so much money on the drug war. Nevermind, the answer is profit.
Wednesday, January 26, 2011
Using Capnography in ACLS
You have a patient in SVT. (for more on SVT, see this post) How do you decide whether to cardiovert or use drugs? The ACLS classes recommend that you look for signs of poor perfusion, such as altered mental status or a systolic blood pressure below 90mmHg. The problem with waiting for these signs is that they are relatively late signs of cardiogenic shock.
A person with altered mental status or an SBP below 90mmHg is already decompensating, and is into the third (or possibly fourth) stage of shock. The blood pressure and mental status changes indicate that the brain and other vital organs are not being oxygenated, and as we all know, this leads to acidosis and cell death.
If only there were a way that we could determine that our patient's SVT is reducing cardiac output due to Starling's Law. Wish no more, here is your answer:
As cardiac output decreases, so does venous return to the lungs and heart. This lower blood flow results in less CO2 making it to the lungs to be exhaled. If your SVT patient is placed on capnography, and the CO2 is less than 37mmHg, you need to start thinking that your patient is having a bit of trouble perfusing, most likely to reduced cardiac output. This is the beginning of our patient's journey to decompensation city. It is time to begin leaning towards cardioverting our patient before we reach the point where our patient has deteriorated so severely that he has begun to lose brain cells.
Don't fall behind the curve. Be proactive, and you will do yourself and your patients a true service by catching problems earlier rather than later.
A person with altered mental status or an SBP below 90mmHg is already decompensating, and is into the third (or possibly fourth) stage of shock. The blood pressure and mental status changes indicate that the brain and other vital organs are not being oxygenated, and as we all know, this leads to acidosis and cell death.
If only there were a way that we could determine that our patient's SVT is reducing cardiac output due to Starling's Law. Wish no more, here is your answer:
As cardiac output decreases, so does venous return to the lungs and heart. This lower blood flow results in less CO2 making it to the lungs to be exhaled. If your SVT patient is placed on capnography, and the CO2 is less than 37mmHg, you need to start thinking that your patient is having a bit of trouble perfusing, most likely to reduced cardiac output. This is the beginning of our patient's journey to decompensation city. It is time to begin leaning towards cardioverting our patient before we reach the point where our patient has deteriorated so severely that he has begun to lose brain cells.
Don't fall behind the curve. Be proactive, and you will do yourself and your patients a true service by catching problems earlier rather than later.
Tuesday, January 4, 2011
This happened to me
I know the cartoon is funny, but something similar happened to me about five years ago. We were dispatched to a reported drug overdose at one of our local Hispanic night clubs. (For those who are unaware, more than 45% of the local population speaks Spanish as a primary language. There is no shortage of Spanish dance clubs around Central Florida.) A young lady had called 911 to report that she and her friend were in the restroom of the club, and her friend had overdosed on an unknown drug. When we arrived on scene in the rig with all of the emergency lights flashing, I got out and went to enter the club.
The bouncer at the door told me that I had to pay the cover charge in order to enter. Thinking that he was kidding, I laughed. He blocked the door. Pointing to my uniform, I told him that I was there on official business and brushed past him. No sooner did I enter the restroom, when I was jumped by four bouncers who carried me out through the club, with the patrons of the club shouting at me, "Get out Gringo," and yelling Spanish obscenities. The bouncers threw me out the door, and told me that whites were not allowed inside.
I called for Police backup, and got no fewer than 15 Deputies. We wound up treating our patient, and the Manager (and his bouncers) got a lecture from the cops. No arrests were made.
Wednesday, December 22, 2010
SVT revisited
What is Supra Ventricular Tachycardia? I think that I did a good job explaining it here. The problem that brings this up again is yet another nurse who thinks she needs to school the dumb paramedics.
I was recently training a new paramedic, and I showed him a picture of a Sinus Rhythm at a rate of 180 beats per minute. I told him that he was, for the purpose of this discussion, working at the first aid tent of a marathon, and that this was the presenting rhythm of a marathon runner who was complaining of dizziness. I use this scenario often as a training aid, and this medic, as new medics invariably do, identified the rhythm as PSVT and stated that it should be treated with 6mg of Adenosine. I asked why, and he told me that PSVT is any rhythm that has an origin above the ventricles, and a rate of over 150 beats per minute.
I pointed out to him that while SVT is technically any tachycardia that occurs above the ventricles in a purely literal sense, it is important for clinicians to recognize that what we refer to as PSVT is a dysrhythmia, and that there is not any set heart rate that separates Sinus Tachy from PSVT. The only way to tell the difference is to do a good patient assessment.
A nearby RN overheard, and attempted to tell me why I was wrong, and that 150 bpm is the standard for defining SVT.
I asked her why she felt I was incorrect in saying that the aforementioned marathon runner is probably in Sinus Tachy. This rhythm is a response to the normal metabolic demands of the runner's body. A person taking a stress test has similar responses. (After all, the target heart rate for a stress test is usually over 150 beats per minute)
Instead of answering, the RN tried to tell me that the AHA defines SVT as all tachycardias that originate above the ventricles and have a rate over 150. Sigh. Where does the AHA say that?
I was recently training a new paramedic, and I showed him a picture of a Sinus Rhythm at a rate of 180 beats per minute. I told him that he was, for the purpose of this discussion, working at the first aid tent of a marathon, and that this was the presenting rhythm of a marathon runner who was complaining of dizziness. I use this scenario often as a training aid, and this medic, as new medics invariably do, identified the rhythm as PSVT and stated that it should be treated with 6mg of Adenosine. I asked why, and he told me that PSVT is any rhythm that has an origin above the ventricles, and a rate of over 150 beats per minute.
I pointed out to him that while SVT is technically any tachycardia that occurs above the ventricles in a purely literal sense, it is important for clinicians to recognize that what we refer to as PSVT is a dysrhythmia, and that there is not any set heart rate that separates Sinus Tachy from PSVT. The only way to tell the difference is to do a good patient assessment.
A nearby RN overheard, and attempted to tell me why I was wrong, and that 150 bpm is the standard for defining SVT.
I asked her why she felt I was incorrect in saying that the aforementioned marathon runner is probably in Sinus Tachy. This rhythm is a response to the normal metabolic demands of the runner's body. A person taking a stress test has similar responses. (After all, the target heart rate for a stress test is usually over 150 beats per minute)
Instead of answering, the RN tried to tell me that the AHA defines SVT as all tachycardias that originate above the ventricles and have a rate over 150. Sigh. Where does the AHA say that?
Tuesday, September 28, 2010
The Big Red Taxi
Ask anyone who works in EMS, and they can tell you a hundred stories of people who abuse the EMS system. I have seen my share, and the stories have infinite variety:
The thermostat:
It was 2 o'clock in the morning when we went to this woman's house for a complaint of "difficulty breathing." When we got there, the "patient" didn't want to go to the hospital, she just wanted help. Having just moved into her house, she didn't know how to program her electronic thermostat and wanted us to show her how. It wsa 82 degrees in her house, nowhere near being a medical emergency.
Incarceritis:
People fake seizures, unconsciousness, chest pains, you name it, in the belief that they will not be arrested if they go to the hospital. The sad fact is that they are sometimes right. The officer sometimes doesn't want to sit around the hospital for several hours, waiting for his prisoner to be discharged for minor misdemeanors. Felony arrests? Forget it, you are going to jail as soon as the hospital is done with you.
A variation of this was one morning's call:
A man was required to be in court at 8 o'clock in the morning for a child support hearing. He walked from his home towards the courthouse 10 miles away. (Why he didn't take the bus is a mystery.) He made it about 3 miles, and then called 911 with reported shortness of breath and chest pain at about 10 after 7. When we arrived, he wanted to go to the hospital that, coincidentally, was two blocks from the courthouse. When we arrived and asked him what was going on, his first words were, "I am trying to get to court because my wife..."
We all knew that this was a fake call intended to get him to the hospital closest to the courthouse, so that he could walk out and be in court faster. Since there is no penalty for failure to pay for the ambulance ride OR the ER bill, this is the equivalent of a free taxi. We decided that the best thing for this patient was to go to a different hospital. Why? Well, if he really was having chest pain, the patient would be less likely to walk out of that one, opting instead to use the ER bill to show the court why he had a medical reason for missing court. IF he wasn't really having chest pains, then he didn't need to go anyhow. Besides, to reach the hospital he wanted, we would have had to pass another, closer one, and there was no medical reason to pass a perfectly good hospital to go to the other one.
Lest anyone think that we were being mean or lazy, he still got a complete workup. His vitals were: SaO2 98% on room air, 100% on 2 lpm of O2. HR 82, RR24, BP 142/94. Monitor showed SR, and 12 lead showed nothing important. He was hot and sweaty, but that is unsurprising considering that he was about 60 pounds overweight, and it was 82 degrees with 80% humidity. He still got 325 mg of aspirin, NTG spray x2, and transport to the closest hospital (rather than the one he wanted)
People abuse the system every day. This is why universal, "free" health care will never work.
The thermostat:
It was 2 o'clock in the morning when we went to this woman's house for a complaint of "difficulty breathing." When we got there, the "patient" didn't want to go to the hospital, she just wanted help. Having just moved into her house, she didn't know how to program her electronic thermostat and wanted us to show her how. It wsa 82 degrees in her house, nowhere near being a medical emergency.
Incarceritis:
People fake seizures, unconsciousness, chest pains, you name it, in the belief that they will not be arrested if they go to the hospital. The sad fact is that they are sometimes right. The officer sometimes doesn't want to sit around the hospital for several hours, waiting for his prisoner to be discharged for minor misdemeanors. Felony arrests? Forget it, you are going to jail as soon as the hospital is done with you.
A variation of this was one morning's call:
A man was required to be in court at 8 o'clock in the morning for a child support hearing. He walked from his home towards the courthouse 10 miles away. (Why he didn't take the bus is a mystery.) He made it about 3 miles, and then called 911 with reported shortness of breath and chest pain at about 10 after 7. When we arrived, he wanted to go to the hospital that, coincidentally, was two blocks from the courthouse. When we arrived and asked him what was going on, his first words were, "I am trying to get to court because my wife..."
We all knew that this was a fake call intended to get him to the hospital closest to the courthouse, so that he could walk out and be in court faster. Since there is no penalty for failure to pay for the ambulance ride OR the ER bill, this is the equivalent of a free taxi. We decided that the best thing for this patient was to go to a different hospital. Why? Well, if he really was having chest pain, the patient would be less likely to walk out of that one, opting instead to use the ER bill to show the court why he had a medical reason for missing court. IF he wasn't really having chest pains, then he didn't need to go anyhow. Besides, to reach the hospital he wanted, we would have had to pass another, closer one, and there was no medical reason to pass a perfectly good hospital to go to the other one.
Lest anyone think that we were being mean or lazy, he still got a complete workup. His vitals were: SaO2 98% on room air, 100% on 2 lpm of O2. HR 82, RR24, BP 142/94. Monitor showed SR, and 12 lead showed nothing important. He was hot and sweaty, but that is unsurprising considering that he was about 60 pounds overweight, and it was 82 degrees with 80% humidity. He still got 325 mg of aspirin, NTG spray x2, and transport to the closest hospital (rather than the one he wanted)
People abuse the system every day. This is why universal, "free" health care will never work.
Sunday, October 14, 2007
A lesson in cardiology
This post arises from a call I ran yesterday with a relatively new medic. Those of you in EMS know that new medics are pretty timid, and tend to have problems with calls that require them to think outside of the box we call protocol. This was one of those times that it is obvious that we need to do so. I hope any new medics that read this will learn an important lesson.
Our patient was a 58 year old man who was working at some light gardening when he began having pain between his shoulder blades, and began loudly burping, which relieved the pain. He went inside and took some gas medicine. His obviously intelligent wife called 911 and got him to take 2 baby aspirin.
When we arrived, we found him seated on his couch, he was cool and covered in sweat. He states he has a history of hypertension, for which he takes no medicine. He states that his doctor feels like his blood sugar is too high, and wanted him tested for diabetes, but that was 6 months ago, and he hasn't been back since. When we stand him up to plpace him on the stretcher, his pulse becomes irregular. His vitals are: P- 88, BP 138/86, RR 20. In the truck, we start an IV, and find him to be in a normal sinus rhythm, his SaO2 is 99% on room air, blood sugar is 170. His 12 lead EKG is as follows:
(Click for a larger picture)
There are a few things that jump out at you here.
Sigh. This is one of my pet peeves. This man has risk factors- possible untreated diabetes AND high blood pressure. He is complaining of anginal equivalents- indigestion, and back pain. His irregular pulse on standing MAY be PVC's, and his 12 lead confirms a cardiac event.
I finally prevailed, and we alerted the hospital. The doctor sent him to the cath lab, and it turns out that he had a complete blockage of the distal end of the left anterior descending coronary artery. He was having a hearta ttack, but we caught it early, and he is now recovering.
Please, medics. Learn how to read the signs your patient is giving you, and learn to read and interpret the 12 lead EKG. Cardiology, diabetes, and drug overdoses are the three areas where medics save the most lives. Be the best you can be at this, lives depend on it.
Our patient was a 58 year old man who was working at some light gardening when he began having pain between his shoulder blades, and began loudly burping, which relieved the pain. He went inside and took some gas medicine. His obviously intelligent wife called 911 and got him to take 2 baby aspirin.
When we arrived, we found him seated on his couch, he was cool and covered in sweat. He states he has a history of hypertension, for which he takes no medicine. He states that his doctor feels like his blood sugar is too high, and wanted him tested for diabetes, but that was 6 months ago, and he hasn't been back since. When we stand him up to plpace him on the stretcher, his pulse becomes irregular. His vitals are: P- 88, BP 138/86, RR 20. In the truck, we start an IV, and find him to be in a normal sinus rhythm, his SaO2 is 99% on room air, blood sugar is 170. His 12 lead EKG is as follows:
(Click for a larger picture)There are a few things that jump out at you here.
- The 12mm height of the QRS in lead aVL indicates "voltage criteria" for left ventricular hypertrophy. This is likely caused by his history of uncontrolled high blood pressure.
- The length of his QRS (0.122 sec) could be considered a left bundle branch block, but I think this is probably due to the QRS widening caused by the LVH, since the EKG doesn't have that "LBBB look" to it.
- The poor R wave progression in leads V1 through V6
- The ST segment depression in Leads V3 and V4
Sigh. This is one of my pet peeves. This man has risk factors- possible untreated diabetes AND high blood pressure. He is complaining of anginal equivalents- indigestion, and back pain. His irregular pulse on standing MAY be PVC's, and his 12 lead confirms a cardiac event.
I finally prevailed, and we alerted the hospital. The doctor sent him to the cath lab, and it turns out that he had a complete blockage of the distal end of the left anterior descending coronary artery. He was having a hearta ttack, but we caught it early, and he is now recovering.
Please, medics. Learn how to read the signs your patient is giving you, and learn to read and interpret the 12 lead EKG. Cardiology, diabetes, and drug overdoses are the three areas where medics save the most lives. Be the best you can be at this, lives depend on it.
Saturday, September 29, 2007
Half Assed Medic
WARNING: Medical terminology to follow, but I will try and keep it to a minimum.
I was the first medic on scene to a 54 year old male, whose chief complaint was that he nearly passed out while he was lifting a heavy object from the back of his minivan. He had a History of insulin dependent diabetes, a heart bypass, high cholesterol, and high blood pressure. His vitals were as follows: HR 72, RR 20, BP 136/72. He takes lopressor, insulin, lipitor, and aspirin. His 12 lead showed nothing acute, except LVH. I was in the middle of finishing my assessment when the transport unit arrived.
The medic on that truck told the patient that the near syncope was probably due to stimulation of the vagus nerve that lifting the box caused. I pointed out to the patient that while the other medic was probably correct, due to his extensive history, it would probably be best to take him in, just to be sure. You see, diabetics frequently do not have the classic symptoms of a heart attack, and often the first sign that a diabetic has of a serious heart attack is fainting, nausea, or shortness of breath, and not chest pain. The patient agreed with me, and decided to go to the hospital.
Apparently, that angered the other medic, who had been hoping to talk the patient out of going to the hospital. After he dropped the patient off at the hospital, he decided to come talk to me about "taking over his patient." I pointed out to him that he is a new medic (less than a year on the street) and that patient refusals are not there for his personal comfort- paramedic inconvenience is not a reason to avoid transport.
If there is any piece of advice I can give you new medics out there, it is this:
If you are ever undecided as to the proper course of action, whichever option it is that causes you the most work is usually the correct one. Don't ever forget that we are the patient's advocate, and all of our decisions need to be in the best interests of the patient, not ourselves.
I was the first medic on scene to a 54 year old male, whose chief complaint was that he nearly passed out while he was lifting a heavy object from the back of his minivan. He had a History of insulin dependent diabetes, a heart bypass, high cholesterol, and high blood pressure. His vitals were as follows: HR 72, RR 20, BP 136/72. He takes lopressor, insulin, lipitor, and aspirin. His 12 lead showed nothing acute, except LVH. I was in the middle of finishing my assessment when the transport unit arrived.
The medic on that truck told the patient that the near syncope was probably due to stimulation of the vagus nerve that lifting the box caused. I pointed out to the patient that while the other medic was probably correct, due to his extensive history, it would probably be best to take him in, just to be sure. You see, diabetics frequently do not have the classic symptoms of a heart attack, and often the first sign that a diabetic has of a serious heart attack is fainting, nausea, or shortness of breath, and not chest pain. The patient agreed with me, and decided to go to the hospital.
Apparently, that angered the other medic, who had been hoping to talk the patient out of going to the hospital. After he dropped the patient off at the hospital, he decided to come talk to me about "taking over his patient." I pointed out to him that he is a new medic (less than a year on the street) and that patient refusals are not there for his personal comfort- paramedic inconvenience is not a reason to avoid transport.
If there is any piece of advice I can give you new medics out there, it is this:
If you are ever undecided as to the proper course of action, whichever option it is that causes you the most work is usually the correct one. Don't ever forget that we are the patient's advocate, and all of our decisions need to be in the best interests of the patient, not ourselves.
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