[nurse educate]

Please remember (because most don't realize)- there is a difference between an EMT and a Paramedic...and It's a big difference!!

[poor.er.doc]

1. please give a full report of what you found at the scene, or what the nursing homes concern was in a patient who can't or is poorly able to give a history. You are our eyes and ears!!!

Context is everything! Hang out until you can say hello to the doc, unless the case is bogus.

2. Please quickly run down the interventions you did en route.

3. Ask the family the code status if you have any chance to, and bring in DNR papers and meds!

Thanks for all you do, you ARE appreciated!

[boulergirl]

Please remember (because most don't realize)- there is a difference between an EMT and a Paramedic...and It's a big difference!!

Good point! If any of you have read Jane Stern's book "Ambulance Girl", she talks about her experiences as an EMT-B. (And it's a fascinating read!) Although she can assist at the scene, she cannot do all that the paramedics can do--this requires special training. Anyway, the book gave me an insider's view of the world of medics and EMTs. They have a tough job.

[Medic2RN]

I'd like to comment on rn29306's post regarding tube movement.
I can offer some advice regarding intubation in the field. On most incidents you will have to move the patient from the floor to a backboard to the stretcher into the MICU, then take a (usually) bumpy ride to the hospital while running code, take the stretcher out of the MICU and then roll it into the ER. All the tube has to do is move a couple of millimeters and it is dislodged from the trachea. That's a LOT of movement and a very LITTLE distance!
When you intubate, visualize the cords, place an ETCO2 on the ET tube, note condensation in the tube while ventilating, secure the tube, note the reading on the tube at the patient's teeth and place a C-collar on the patient!! This will reduce any movement of the head during all that movement. ALWAYS check breath sounds, ETCO2 reading, the reading of the tube at the patient's teeth (sometimes people will push down while ventilating with a BVM and it will push the tube into the right mainstem) and tube condensation anytime the patient is moved. And always document all of those points in your report.
I have intubated patients sitting up in cars, on the side of the road in the rain at night - I haven't tubed one upside down yet but give it some time....and I have never lost a tube. I think the C Collar really helps.
Also, if you have access to mannikins, practice intubating every shift. I practice 5 tubes every morning at the beginning of the shift, so if I have to intubate or RSI that day - I'm already warmed up! I haven't "tubed the goose" yet and I contribute that to all the practice!
If you don't have an airway, you don't have a patient!

Hope this helps! Have fun out there!

[V. Nightingale]

Most of the EMTs/paramedics I work with are AWESOME. We tend to see the same guys bringing pts to the ER every week, and I try to maintain a good relationship with all of them -- after all, I've cared for some of these guys in the ER, and who knows when I may be calling them to my house!

That said, my biggest pet peeve is a lousy report, either because the medic doesn't know half of what was done or else they have made a determination based on a poor assessment (example: 40-something yo female brought in for c/o seizure. Medic tells me "She's faking it. It stops and starts, plus look at all the psych meds she's on." Hmm, I thought, you might be able to fake a seizure, but it's pretty hard to fake diaphoresis! Pt had been seizing for 45 min during transport and recieved no meds! Ohter example: 30 yo black male motorcyclist vs truck. "He's very stable," says EMS. "He's diaphoretic and has decreased breath sounds," says I. Final diagnosis was bilateral pneumothorax, fractured pelvis, and lacerated liver.).

The other thing that really bugs me is a lack of critical thinking. If a patient has COPD, please do not treat her shortness of breath with 15L O2 per NRB, or we will be intubating her upon arrival to the ER because she will be breathing about 2 times per minute! Sometimes you have to think outside the protocol.

[poor.er.doc]

Sometimes you have to think outside the protocol.

Aren't they discouraged from doing that?

[nurse educate]

Originally Posted by poor.er.doc

Aren't they discouraged from doing that?

I think in this case, it's the nurse who needs to think outside the protocol. Having been an EMT (not a Paramedic), it was a difficult concept to grasp, that low 02 is their drive to breathe. But when it means they are going to STOP breathing, you need to forget the rules. When they are baseline, thier drive to breathe is driven by low O2, but when they are in distress, I would think you would want to avoid intubation.

[V. Nightingale]

bonemarrowrn has it right, of course; keeping the patient breathing is pretty much the point. My main complaint (this really happened to a patient of mine) was that 15 liters O2 was the first thing EMS tried for a patient whose sats were something like mid to high 80's, when 4L per NC and a breathing treatment might have helped turn the corner. As it was, we intubated upon arrival to the ER because the patient was only breathing 2-4 times per minute. Protocol is a wonderful and useful tool, but so is critical thinking.

[nurse educate]

Originally Posted by V. Nightingale

bonemarrowrn has it right, of course; keeping the patient breathing is pretty much the point. My main complaint (this really happened to a patient of mine) was that 15 liters O2 was the first thing EMS tried for a patient whose sats were something like mid to high 80's, when 4L per NC and a breathing treatment might have helped turn the corner. As it was, we intubated upon arrival to the ER because the patient was only breathing 2-4 times per minute. Protocol is a wonderful and useful tool, but so is critical thinking.

Agreed. As my hubby (the paramedic) says, there are good medics and bsd medics (just like nurses)

[paraloco]

Originally Posted by Medic946RN

As a nurse that was (is) a practicing paramedic for the last 25 years. (I know, I'm old) I can tell you one of the best things to do is seek out the nursing staff or even the MD when you have one of those borderline calls that your not so sure about. Ask them, hey I felt this guy was a (add your feild diagnosis here) was I right, was my treatment appropriate. This goes miles. As long you're not doing it on every call. In the nursing profession it's collaborating. The RN's and Doc's will take you for Paramedic that concerned about his patients and improving his practice. You automatically set yourself up as part of health care team, which you are. (It's much nicer nowadays, I remember back in the Dark Ages of Paramedicine when nurses and medics were mortal enemies and the patient usally got the short end) Don't be afraid to ask questions and don't be afraid to check on your previous patients when you bring a new one in. Good luck and stay safe!

I was a private service medic for 6 years, and I do not remember those days with fondness. We had to be kiss-*ss sweet to all facility staff, regardless of whatever rudeness they felt like dishing out(and there were a few with soap-opera lives who liked to vent on a helpless target). The owner toadied up to these folks, because he owed his business on their good will. But, Ya know, ya can't really respect someone who kisses your *ss just to get along. We have a great relationship with our nurses, based on mutual respect and understanding.