# Did this warrant Lights and Sirens?



## Medic29 (Jun 18, 2012)

I work for a BLS transport company only. We got an emergency call to go to a nursing home. If you're familiar with the Denver area it's in the area of Federal and Arkansas. C/C was fever. In my rig I get a set of vitals. 

BP 150/60
Resp 28
Pulse 144
BGL 448
Temp 107.6 (That's right 107.6)

I double check, then check again, and then again and each time I got 107.x. Ok so my thermometer is F*cked cause the NH reported a temp of 102. We start going normal. I check my temp it's 97.6. I check his again 107.4.

I tell my driver to go faster. We're going to St. Anthony's Medical Center off of Alameda and 2nd. We're driving on Alameda about 1730. It's rush hour still in Denver. 

Besides the BP, everything is wrong for this patient (I'm used to working in nursing homes and I see patients with this BP everyday with hypertension).

I had my driver go lights and sirens because even if the resp were normal and the pulse was lower, the temp alone is enough to fry the brain. Some people have told me I did good, others said lights and sirens were not appropriate just drive fast.

Interventions: Undress and turn on air. I'm from SD so I don't yet have my IV cert to cool with fluids and being I'm still new, I forgot to use the ice packs I have available (something I'll be sure to do different next time).

What do you think?


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## bigbaldguy (Jun 18, 2012)

I would have run it with lights. Was the patient conscious? At 107 he/she should have been at the very least unconscious if not dead. Did you double check the thermometer? I would have taken my own temp just to make sure it wasn't reading wacky. Ice packs would have been a good idea. You would want to treat this as hyperthermia.

Diabetic hyperglycemic hyperosmolar syndrome?


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## Medic29 (Jun 18, 2012)

Pt AAOx2 baseline 2. Was like that the whole trip. Understood what I was doing and where he was going.

In the hospital he was still at x2. 
Pt is diabetic. Nurse reports no insulin given at time of pickup.



I did check my own temp. It was 97.6 (normal for me).

*Edit* After getting his temp down to 104 upon arrival the hospital, ED reported a temp of 105.


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## Aidey (Jun 18, 2012)

Who exactly triaged this as BLS?


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## bstone (Jun 18, 2012)

Yes to L/S.


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## Medic29 (Jun 18, 2012)

Aidey said:


> Who exactly triaged this as BLS?



We are BLS transport company only. We run only minor emergencies. No 911 calls at all. We do not operate under 911 dispatch centers. I don't know exactly how the dispatch system works. All I know is the nursing homes call the ambulance who provides the transportation services and then our boss calls us to go get them.


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## TransportJockey (Jun 18, 2012)

I know exactly which snf you're talking about... and yea that's a code three transport. I'd've possibly considered als too


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## Medic29 (Jun 18, 2012)

TransportJockey said:


> I know exactly which snf you're talking about... and yea that's a code three transport. I'd've possibly considered als too



It's not the first time I've taken a possible sepsis patient from this home. Not even a week ago I had another one from there go to St. Anthony's at 3am with a fever of 102.


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## Anonymous (Jun 18, 2012)

I would have... and/or called 911 depending on how far out you were.


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## TransportJockey (Jun 18, 2012)

Medic29 said:


> It's not the first time I've taken a possible sepsis patient from this home. Not even a week ago I had another one from there go to St. Anthony's at 3am with a fever of 102.



That's why some services up there (including the one I worked for at that time, ACA,) carried serum lactate meters... I don't know if they still do though


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## Aidey (Jun 18, 2012)

Medic29 said:


> We are BLS transport company only.* We run only minor emergencies.* No 911 calls at all. We do not operate under 911 dispatch centers. I don't know exactly how the dispatch system works. All I know is the nursing homes call the ambulance who provides the transportation services and then our boss calls us to go get them.



That is my point. This patient should have never been triaged as appropriate for a BLS transfer car.


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## Medic29 (Jun 18, 2012)

Aidey said:


> That is my point. This patient should have never been triaged as appropriate for a BLS transfer car.



That should come from the nursing home then. They're the ones who called my boss. The conditions for them to call us wasn't just with the temp (they tried to get one when we were there and it wasn't reading right) it was with the 77% O2 stats, the shaking, and the BGL. Why they didn't give the insulin I don't know.


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## JPINFV (Jun 18, 2012)

Aidey said:


> That is my point. This patient should have never been triaged as appropriate for a BLS transfer car.



I think the anger is misplaced. I get a dispatch on pager, I go run a call. If I think I need medics, I call medics (you won't ever catch me calling dispatch to ask about medics, I need medics, I pick up the phone and call 911). I need lights and sirens, I use lights and sirens. It's not the crew's fault that they got paged to a call they had no business being dispatched too. The only thing that's important from the crew's standpoint is if they handled it appropriately.


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## JPINFV (Jun 18, 2012)

Medic29 said:


> Why they didn't give the insulin I don't know.



Type 1 DM or type 2?


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## TransportJockey (Jun 18, 2012)

JPINFV said:


> I think the anger is misplaced. I get a dispatch on pager, I go run a call. If I think I need medics, I call medics (you won't ever catch me calling dispatch to ask about medics, I need medics, I pick up the phone and call 911). I need lights and sirens, I use lights and sirens. It's not the crew's fault that they got paged to a call they had no business being dispatched too. The only thing that's important from the crew's standpoint is if they handled it appropriately.



This. This nursing home also has a poor reputation.


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## Medic29 (Jun 18, 2012)

JPINFV said:


> Type 1 DM or type 2?



DM with neurological manifestations, Type II


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## Handsome Robb (Jun 18, 2012)

In traffic like it is at 1730 in Denver a code 3 transport of this patient is absolutely necessary. I'd personally lean towards it anyways, the guy is frying his brain.  I'm surprised they maintained their mentation. 

I do have a question and will play the devil's advocate though, did your partner have the IV cert? I'm guessing no but if they did I think they probably should have taken the call because this guy needs fluids along with a host of other things but that's just me. 

This guy needs active cooling fast but don't stress yourself about missing the cold packs, you still got his temp down 2.x degrees. I'd say you did a good job with what you had to work with. Bet you'll never forget cold packs again though


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## Aidey (Jun 18, 2012)

Medic29 said:


> That should come from the nursing home then.  They're the ones who called my boss. The conditions for them to call us  wasn't just with the temp (they tried to get one when we were there and  it wasn't reading right) it was with the 77% O2 stats, the shaking, and  the BGL. Why they didn't give the insulin I don't know.



I really would hope that your service has criteria that cause them to transfer the run to an ALS agency. What happens if a nursing home calls and says they have a patient with crushing chest pain and a BP Of 70/p? 



JPINFV said:


> I think the anger is misplaced. I get a dispatch on pager, I go run a call. If I think I need medics, I call medics (you won't ever catch me calling dispatch to ask about medics, I need medics, I pick up the phone and call 911). I need lights and sirens, I use lights and sirens. It's not the crew's fault that they got paged to a call they had no business being dispatched too. The only thing that's important from the crew's standpoint is if they handled it appropriately.



I don't blame the crew one bit, I blame whoever screwed it up before they ever got on scene. This is analogous to calling for a BLS transfer for an active MI patient.


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## Medic29 (Jun 18, 2012)

NVRob said:


> In traffic like it is at 1730 in Denver a code 3 transport of this patient is absolutely necessary. I'd personally lean towards it anyways, the guy is frying his brain.  I'm surprised they maintained their mentation.
> 
> I do have a question and will play the devil's advocate though, did your partner have the IV cert? I'm guessing no but if they did I think they probably should have taken the call because this guy needs fluids along with a host of other things but that's just me.
> 
> This guy needs active cooling fast but don't stress yourself about missing the cold packs, you still got his temp down 2.x degrees. I'd say you did a good job with what you had to work with. Bet you'll never forget cold packs again though



With my company (and soon as I type what I'm about to people in this area will know the company) we don't always run EMT/EMT. In my situation today, I was with a driver only. He's not an EMT so I was the only one there.


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## Medic29 (Jun 18, 2012)

Aidey said:


> I really would hope that your service has criteria that cause them to transfer the run to an ALS agency. What happens if a nursing home calls and says they have a patient with crushing chest pain and a BP Of 70/p?



Under the Denver/Metro EMS protocols, we're not equipped for a call like that. If they called us (which they better not if they're worthy of being a nurse), our boss would still send us and on scene, I'd have to call for an ALS unit.


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## TransportJockey (Jun 18, 2012)

Medic29 said:


> With my company (and soon as I type what I'm about to people in this area will know the company) we don't always run EMT/EMT. In my situation today, I was with a driver only. He's not an EMT so I was the only one there.



Wait... Do you work for Capitol? They are the only agency in the metro I can think of that doesn't run EMT/EMT all the time as a minimum

EDIT: And I might be wrong, but I thought to do a CBG, you had to have your IV cert?


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## JPINFV (Jun 18, 2012)

Medic29 said:


> DM with neurological manifestations, Type II



[Socratic method, engaged]

What's the basic pathophysiology behind type 2 DM?


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## Aidey (Jun 18, 2012)

Medic29 said:


> Under the Denver/Metro EMS protocols, we're not equipped for a call like that. If they called us (which they better not if they're worthy of being a nurse), our boss would still send us and on scene, I'd have to call for an ALS unit.



No one worthy of being called a nurse should have called for a BLS transfer for this patient. Even though the facility didn't get a temp as high as you did this patient is very sick. I'm not kidding when I said this is analogous to calling for a BLS transfer for an active MI. Sepsis, and specifically septic shock, have very high mortality rates.


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## JPINFV (Jun 18, 2012)

TransportJockey said:


> EDIT: And I might be wrong, but I thought to do a CBG, you had to have your IV cert?



It could be the, "Hi Mrs. Nurse, could you get an updated BGL for the ED please while we get the patient packaged?" game.


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## Medic29 (Jun 18, 2012)

TransportJockey said:


> Wait... Do you work for Capitol? They are the only agency in the metro I can think of that doesn't run EMT/EMT all the time as a minimum
> 
> EDIT: And I might be wrong, but I thought to do a CBG, you had to have your IV cert?



I do lol...I'm looking for an out atm but so hard being so new to Colorado. So I'm getting my BLS experience that I can take elsewhere with me. Like I put in a post about them not too long ago down this category, I'm not gonna let a company with a bad rep destroy me. I'm going to do what I'm trained and make a name for myself. I'm taking this company as a learning experience. 

If by CBG you mean a blood glucose, now you got me wondering too. Cause in SD as an EMT I could and I haven't heard otherwise out here. So now I gotta look before I did my self into a hole I'm gonna regret.


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## FLdoc2011 (Jun 18, 2012)

Did you get any followup on the case?


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## Medic29 (Jun 18, 2012)

FLdoc2011 said:


> Did you get any followup on the case?



I can't get a hold of the EMS coordinators at St. Anthony's atm so I will try again later if not tomorrow morning and I'll place my update here.


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## Medic29 (Jun 18, 2012)

JPINFV said:


> [Socratic method, engaged]
> 
> What's the basic pathophysiology behind type 2 DM?



I wasn't sure so I had to look it up:

The pathophysiology of Type 2 diabetes mellitus is characterized by peripheral insulin resistance (insulin insensitivity), cell damage, impaired regulation of hepatic glucose production, and later on: declining beta (ß) cell function, eventually leading to  possible ß-cell failure.

Taken from http://www.deathtodiabetes.com/Diabetes_-_Pathology.html


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## TransportJockey (Jun 18, 2012)

Medic29 said:


> I do lol...I'm looking for an out atm but so hard being so new to Colorado. So I'm getting my BLS experience that I can take elsewhere with me. Like I put in a post about them not too long ago down this category, I'm not gonna let a company with a bad rep destroy me. I'm going to do what I'm trained and make a name for myself. I'm taking this company as a learning experience.
> 
> If by CBG you mean a blood glucose, now you got me wondering too. Cause in SD as an EMT I could and I haven't heard otherwise out here. So now I gotta look before I did my self into a hole I'm gonna regret.



Yep Cap Blood Glucose. And I just looked at Rule 500, it's service discretion for non-IV basics to do it. I know ACA only let IV-Basics do it


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## JPINFV (Jun 18, 2012)

Aidey said:


> No one worthy of being called a nurse should have called for a BLS transfer for this patient. Even though the facility didn't get a temp as high as you did this patient is very sick. I'm not kidding when I said this is analogous to calling for a BLS transfer for an active MI. Sepsis, and specifically septic shock, have very high mortality rates.



I've been dispatched on chest pain calls when I worked in So. Cal, but my threshold for calling 911 for medics is very low. I agree that it's wrong to dispatch an EMT crew to something like that, but unless the local government regulation agency (be it state or regional) places limitations on what levels can accept what calls, you aren't going to see it go away.


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## FLdoc2011 (Jun 18, 2012)

But I agree with the others above.  Either at the nursing home level or the company's dispatch end someone should've intervened for an ALS/911 transport.  

Especially with the temp you found during transport, that introduces several other serious conditions into the differential.   

How was the physical exam...  Diaphoretic?  Muscle rigidity?  Rash/mottling?  Bleeding? 

On any psych meds?

EKG? Just sinus tach?


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## Medic29 (Jun 18, 2012)

TransportJockey said:


> Yep Cap Blood Glucose. And I just looked at Rule 500, it's service discretion for non-IV basics to do it. I know ACA only let IV-Basics do it



I'll check with my EMS coordinator then. Cause all our rigs are stocked with it and only a few of us can do IVs. My trainer (who now works for ACA) told me it was ok for me to do during the first emergency I ran while under her care. Granted, listening to her doesn't make up for not checking with my coordinator, it was a trust thing and that's where I could be wrong. 

Man I've got so many things I have to re-learn again since my scope is much different than in SD.


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## JPINFV (Jun 18, 2012)

FLdoc2011 said:


> Especially with the temp you found during transport, that introduces several other serious conditions into the differential.



The problem is once you get there it also becomes a question about ETA. However if I decided that I needed to go L/S, then every action after that involved moving towards the ambulance. If I don't have a full set of vitals before I reach the hospital, then so be it, they weren't going to change anything at the EMT level anyways (provided, of course, that the vitals are present). I've had one call where my on scene (not even patient contact) time to arrival at the hospital was 7 minutes with a 0.25 mile transport (funky DNR wording, patient expired a few hours later).


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## Aidey (Jun 18, 2012)

JPINFV said:


> I've been dispatched on chest pain calls when I worked in So. Cal, but my threshold for calling 911 for medics is very low. I agree that it's wrong to dispatch an EMT crew to something like that, but unless the local government regulation agency (be it state or regional) places limitations on what levels can accept what calls, you aren't going to see it go away.



I know, I'm just in a mood and not very tolerant of crappy decision making right now.



FLdoc2011 said:


> But I agree with the others above.  Either at the nursing home level or the company's dispatch end someone should've intervened for an ALS/911 transport.
> 
> Especially with the temp you found during transport, that introduces several other serious conditions into the differential.
> 
> ...



I doubt they got an EKG...as a BLS agency they probably only carry an AED.


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## JPINFV (Jun 18, 2012)

Aidey said:


> I doubt they got an EKG...as a BLS agency they probably only carry an AED.



There's always what the hospital got on the monitor.


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## Medic29 (Jun 18, 2012)

FLdoc2011 said:


> But I agree with the others above.  Either at the nursing home level or the company's dispatch end someone should've intervened for an ALS/911 transport.
> 
> Especially with the temp you found during transport, that introduces several other serious conditions into the differential.
> 
> ...



Nothing other than his BGL, respirations, and pulse (outside of his temp) were abnormal. He has a solid normal skin color, full control of muscles, no rash nothing. No bleeding. Normal pupil response. Clear lungs on both sides. It was very odd. The call we had this morning (that my normal partner ran) was a sepsis call from a personal residence and had a temp of 10x and vitals were unstable. This guy went unconsious during transport to Porter. They were close enough to the hospital that at his judgment it would have taken longer for an ALS unit to get there than it would for him to just go. We had complete opposite patients.


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## FLdoc2011 (Jun 18, 2012)

JPINFV said:


> The problem is once you get there it also becomes a question about ETA. However if I decided that I needed to go L/S, then every action after that involved moving towards the ambulance. If I don't have a full set of vitals before I reach the hospital, then so be it, they weren't going to change anything at the EMT level anyways (provided, of course, that the vitals are present). I've had one call where my on scene (not even patient contact) time to arrival at the hospital was 7 minutes with a 0.25 mile transport (funky DNR wording, patient expired a few hours later).



I agree.  He was already there and what was done was done.   I am also not an EMS expert and the current system here in my county is basically a single tier all ALS systems so that's what I'm more familiar with.


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## the_negro_puppy (Jun 18, 2012)

Do we know what medications this patient was on?


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## Achilles (Jun 18, 2012)

Where you take a temp at? Oral or axilary or rectum  ???


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## Medic29 (Jun 18, 2012)

the_negro_puppy said:


> Do we know what medications this patient was on?



The list the nursing home gave me I left with the hospital. I don't need to put them in any of my reports so I don't keep them. I only keep for my report purposes are a list of allergies.


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## Medic29 (Jun 18, 2012)

Achilles said:


> Where you take a temp at? Oral or axilary or rectum  ???



Temperal thermometer. Right behind the ear.


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## Aidey (Jun 18, 2012)

Medic29 said:


> The list the nursing home gave me I left with the hospital. I don't need to put them in any of my reports so I don't keep them. I only keep for my report purposes are a list of allergies.



...................

For the other people around who do BLS transfers, is this normal?


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## Medic29 (Jun 18, 2012)

Aidey said:


> ...................
> 
> For the other people around who do BLS transfers, is this normal?



I'm kinda glad we don't. Most of the people we get calls for are nursing home patients with a grocery list of medications that never fit on our paper reports. Our paperwork consists of the information about the transport as well as the patients diagnosis which we do chart on. Meds aren't one of them. It's a :censored::censored::censored::censored:ty company in the way they operate I understand that. If I could change a few things about it, believe me I would.


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## Akulahawk (Jun 19, 2012)

JPINFV said:


> I've been dispatched on chest pain calls when I worked in So. Cal, but my threshold for calling 911 for medics is very low. I agree that it's wrong to dispatch an EMT crew to something like that, but unless the local government regulation agency (be it state or regional) places limitations on what levels can accept what calls, you aren't going to see it go away.


JP, over the years, when I was working as a basic, I have been dispatched to many calls where 911 was refused. A lot of the time it was because they don't want all the commotion that comes along with a 911 call. Some of the nursing homes are very good at playing the "we want BLS" game. So they'd call us with complaints such as "weakness and lethargy" or other similar complaint that supposedly wouldn't make our dispatchers ears perk up...  Of course, we all knew and we'd bet each other what the complaint would really be. 

I don't have a low threshold for calling for paramedics, I have a low threshold for wanting to get the patient to definitive care as soon as possible in the most appropriate manner. Once I decide that my patient needs to go to the hospital emergently, it becomes all about ETA. Specifically, that means ETA to some kind of advanced level care. Ultimately it boils down to I get the patient to the ED faster than I can get a paramedic to the patient.


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## TransportJockey (Jun 19, 2012)

Aidey said:


> ...................
> 
> For the other people around who do BLS transfers, is this normal?



Not at all. Ever. If it's a long list, I either type in the pertinent meds and scan the page and put 'see sheet for rest of medications' or hand write the pertinent meds and make a copy of the sheet and staple it to my PCR. You *NEED* to have the meds documented, IMHO.


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## Medic29 (Jun 19, 2012)

I can start doing it I guess. My company doesn't ever ask for it and I was never trained to do it. 

Hopefully they won't complain about all the extra paperwork. Crappy thing about Capital is that everything is paper. They don't do nothing computers and that really blows!!


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## the_negro_puppy (Jun 19, 2012)

After doing a bit of reading:

Wikipedia: Hyperpyrexia is a fever with an extreme elevation of body temperature greater than or equal to 41.5 °C (106.7 °F) The most common cause is an intracranial hemorrhage.

Could this patient be having a stroke/CVA?


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## FourLoko (Jun 19, 2012)

Why wouldn't you check temp before even putting the patient on the gurney? Especially if they actually admitted to a fever.

On Saturday we had the opposite, hypothermia. PT temp was 94.1 and supposedly was 91 earlier that day. We went outside and called the FD.


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## bstone (Jun 19, 2012)

FourLoko said:


> Why wouldn't you check temp before even putting the patient on the gurney? Especially if they actually admitted to a fever.
> 
> On Saturday we had the opposite, hypothermia. PT temp was 94.1 and supposedly was 91 earlier that day. We went outside and called the FD.



Our BLS and ALS buses don't carry thermometers, tho I am uncertain why. Why did you call the FD for a hypothermia PT?


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## JPINFV (Jun 19, 2012)

Akulahawk said:


> JP, over the years, when I was working as a basic, I have been dispatched to many calls where 911 was refused. A lot of the time it was because they don't want all the commotion that comes along with a 911 call. Some of the nursing homes are very good at playing the "we want BLS" game. So they'd call us with complaints such as "weakness and lethargy" or other similar complaint that supposedly wouldn't make our dispatchers ears perk up...  Of course, we all knew and we'd bet each other what the complaint would really be.



The problem is that when a "lethargy and weakness" call is, "Our patient has a pulse of 26 because he's in a 3rd degree heart block," than something needs to happen to keep that from being BLS. That's also why the Riverside County BLS call protocol includes some of the key phrases. 



> I don't have a low threshold for calling for paramedics, I have a low threshold for wanting to get the patient to definitive care as soon as possible in the most appropriate manner. Once I decide that my patient needs to go to the hospital emergently, it becomes all about ETA. Specifically, that means ETA to some kind of advanced level care. Ultimately it boils down to I get the patient to the ED faster than I can get a paramedic to the patient.



I worded that poorly and your wording is what I was going for. Also, my bar wasn't nothing and I was comfortable with some patients that others weren't. I also had no trouble going toe to toe with ED nurses who weren't happy that I didn't call paramedics ("No, I'm not going to call paramedics for the patient with chest pain at the SNF down the side street from you. There's a stop sign and anyone responding would have to pass the hospital to get there. Here's a copy of the county protocol, enjoy.") I also never, for what it counts, called for paramedics and had them retriage back to BLS. 

However we get posters all the time on here who say something like, "Well, I called dispatch and they just told me to take the patient and not call paramedics," but I'm of the opinion that the buck always stops at the crew.


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## Meursault (Jun 19, 2012)

Aidey said:


> ...................
> 
> For the other people around who do BLS transfers, is this normal?



I don't keep anything from the sending facility, but I do document meds and history, and when time permits, I'll spend an extra minute or five hunting them down before I leave. Occasionally, I'll get a call that's both very close to the ED and time-sensitive; I'll reconstruct some info from memory and scrawled notes afterward. 

Knowing history and medications plays into my delusion of providing medical care and spares me the scorn of ED nurses. It's also required for our documentation. 



Akulahawk said:


> Some of the nursing homes are very good at playing the "we want BLS" game. So they'd call us with complaints such as "weakness and lethargy" or other similar complaint that supposedly wouldn't make our dispatchers ears perk up...  Of course, we all knew and we'd bet each other what the complaint would really be.


We have exactly the same problem. I don't know whether the primary cause is incompetent call triage, 911-averse SNF staff, or management prioritizing facility relations over patient care. My best guess is all three to varying degrees.


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## Akulahawk (Jun 19, 2012)

JPINFV said:


> The problem is that when a "lethargy and weakness" call is, "Our patient has a pulse of 26 because he's in a 3rd degree heart block," than something needs to happen to keep that from being BLS. That's also why the Riverside County BLS call protocol includes some of the key phrases.


No kidding. Unfortunately, the various facilities were pretty darned sneaky about that stuff. We got pretty darned good at quickly determining whether or not our patient had to go right NOW, and we got even better when the County changed the utilization for BLS to 10 minutes at scene to ED times if your patient needed to be transported code 3. It also meant that the facilities had no control over those 911 calls from BLS units, so they learned to call 911 because it was going to happen anyway - it was just who was going to call, not "if" anymore. After that, BLS transfers to the ED became far more "routine" and less emergent. The facilities hated it though because they had to log more 911 calls... but they could at least "blame" it on local protocol change. 




JPINFV said:


> I worded that poorly and your wording is what I was going for. Also, my bar wasn't nothing and I was comfortable with some patients that others weren't. I also had no trouble going toe to toe with ED nurses who weren't happy that I didn't call paramedics ("No, I'm not going to call paramedics for the patient with chest pain at the SNF down the side street from you. There's a stop sign and anyone responding would have to pass the hospital to get there. Here's a copy of the county protocol, enjoy.") I also never, for what it counts, called for paramedics and had them retriage back to BLS.
> 
> However we get posters all the time on here who say something like, "Well, I called dispatch and they just told me to take the patient and not call paramedics," but I'm of the opinion that the buck always stops at the crew.


When it's my patient, the buck stops with me. I won't do anything that jeopardizes my cert/license. If I was told to take the patient by dispatch (or management), I'd have simply packaged, placed the patient in my ambulance and turned the patient over to ALS. Fortunately, I worked for a guy that understood that it was far better to do the turnover to ALS outside the facility than to get into a peeing match with the facility staff. It's just as fast and gets the patient where they need to go.


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## Bullets (Jun 19, 2012)

I wouldnt have called for ALS, but in my town my transport time is 10 minutes or less. If they werent dispatched originally then im going to beat them to the hospital.

Welcome to NJ, were BLS goes to every call, and ALS is by request only


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## johnrsemt (Jun 19, 2012)

From the OP I don't see much that makes this patient ALS.
  High Temperature,  BLS:   strip/AC--he did that,  Ice packs--he didn't do that.
  High HR (144), BLS:  due to the elevated temperature.
  High BGL: (448):  ALS is going to do much in less than 2-3 hours with IV's;  doubt that Denver ALS carries insulin.
  B/P:  (150/90)  BLS.
    Run fast (lights/sirens) to the hospital:  BLS.


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## usalsfyre (Jun 19, 2012)

johnrsemt said:


> From the OP I don't see much that makes this patient ALS.
> High Temperature,  BLS:   strip/AC--he did that,  Ice packs--he didn't do that.
> High HR (144), BLS:  due to the elevated temperature.
> High BGL: (448):  ALS is going to do much in less than 2-3 hours with IV's;  doubt that Denver ALS carries insulin.
> ...









The patient was septic, they needed fluid resus and from what it sounds like an airway. I have no idea how a medic could get BLS from this.


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## Veneficus (Jun 19, 2012)

I am of the mind that because of the risks involved and the very few times it makes a difference, no call is worthy of lights and sirens.

The only reason it still exists is public expectation and tradition.


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## systemet (Jun 19, 2012)

usalsfyre said:


> The patient was septic, they needed fluid resus and from what it sounds like an airway. I have no idea how a medic could get BLS from this.



Agree 100%.


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## Medic29 (Jun 19, 2012)

I just got my patient follow up from St. Anthony's. 

My pt is septic from a UTI. Not enough to warrant ICU. They have him on Med/Surge pushing fluids and antibotics. Seems he is doing ok.


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## Handsome Robb (Jun 19, 2012)

usalsfyre said:


> The patient was septic, they needed fluid resus and from what it sounds like an airway. I have no idea how a medic could get BLS from this.





systemet said:


> Agree 100%.



I'll third that.


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## NYMedic828 (Jun 19, 2012)

johnrsemt said:


> From the OP I don't see much that makes this patient ALS.
> High Temperature,  BLS:   strip/AC--he did that,  Ice packs--he didn't do that.
> High HR (144), BLS:  due to the elevated temperature.
> High BGL: (448):  *ALS is going to do much in less than 2-3 hours with IV's;  doubt that Denver ALS carries insulin.*
> ...



Granted we now know the cause was sepsis 2nd to a UTI, fluid resuscitation is fluid resuscitation.

Yes the ER is better suited and educated to do it properly than we are, but we can absolutely start the process a decent period ahead of time if the situation warrants it. Septic patients can require a massive amount of fluids if vasodilatory/distributive shock sets in. Why would you want to delay that process? If by some miracle you managed to establish two 14g IVs, you could potentially give this patient 600ccs of fluid per minute. (My numbers may be off, I forget)

I'm not sure what your insulin comment is about. Insulin resistance 2nd to sepsis is a result of MOD as far as I know. I can't imagine the first thing a doctor is going to do for this patient is hit them with an insulin drip. Treat the underlying cause that is inevitably going to kill them and quite rapidly at that. They will die to other complications before hyperglycemia takes them down.


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## Christopher (Jun 19, 2012)

Medic29 said:


> I work for a BLS transport company only. We got an emergency call to go to a nursing home. If you're familiar with the Denver area it's in the area of Federal and Arkansas. C/C was fever. In my rig I get a set of vitals.
> 
> BP 150/60
> Resp 28
> ...



Emergent transport has not been proven to decrease mortality of septic or febrile patients. Recognition of these conditions, however, has been.

Routine is fine for anything not proven to be time sensitive. Even trauma hasn't been shown to benefit from L&S.

Nice and easy ride always wins.


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## Christopher (Jun 19, 2012)

usalsfyre said:


> The patient was septic, they needed fluid resus and from what it sounds like an airway. I have no idea how a medic could get BLS from this.



Agreed that the patient requires ALS.

I don't think, however, that if ALS in unavailable in this patient that it warrants an emergent transport. Even if ALS could be available, they would simply be starting Early Goal Directed Therapy (IV's and fluids), which hasn't necessarily been shown to be effective when started in the field without confirmation of sepsis.


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## bigbaldguy (Jun 19, 2012)

Veneficus said:


> I am of the mind that because of the risks involved and the very few times it makes a difference, no call is worthy of lights and sirens.
> 
> The only reason it still exists is public expectation and tradition.



There's a lot of truth to this. It does rarely make a difference and the risk generally doesn't balance out but I wouldn't go so far as to say it never makes a difference time wise.


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## medicdan (Jun 19, 2012)

Veneficus said:


> I am of the mind that because of the risks involved and the very few times it makes a difference, no call is worthy of lights and sirens.
> 
> The only reason it still exists is public expectation and tradition.



My rationalization for L&S often lies in an expectation that when I arrive at the hospital I will immediately be swarmed by nurses and doctors, or that a critical intervention is to be performed in the first 5 minutes.

It seems utterly pointless to haul a$$ then wait in triage for 10 and be directed to the waiting room or an ignored bed. If I've risks others lives on the transport, I'd better have a good reason.

Maybe my knowledge is limited, but while this patient seems urgent, not emergent, and I doubt a comfortable ride and delay of just a few minutes will make a considerable difference on outcome. I'm all for bringing treatment modalities to the field, but I also just don't like driving L&S unless absolutely necessary.


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## Aidey (Jun 19, 2012)

Christopher said:


> Agreed that the patient requires ALS.
> 
> I don't think, however, that if ALS in unavailable in this patient that it warrants an emergent transport. Even if ALS could be available, they would simply be starting Early Goal Directed Therapy (IV's and fluids), which hasn't necessarily been shown to be effective when started in the field without confirmation of sepsis.



How much confirmation do you need? The diagnosis pretty much danced a jig in a dress while yelling "Here's sepsis! "


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## Veneficus (Jun 19, 2012)

bigbaldguy said:


> There's a lot of truth to this. It does rarely make a difference and the risk generally doesn't balance out but I wouldn't go so far as to say it never makes a difference time wise.



I think I would describe it as acceptable losses.

The few times it makes a dfference in my mind does not warrant the risks when it doesn't. 

To lose a handful of time sensitive patients to stop reading about provider deaths and all the other side effects of lights and siren response and transport, makes perfect sense in my mind.

Particularly when considering the ED is not the definitive care needed, but further delays it.

MI, CVA, and a plethora of surgical emergencies are not helped by ED resuscitation attempts. It is an outdated and misunderstood concept to try to "resuscitate," "stabilize" etc prior to definitive intervention. The very definition of resuscitation is to restore homeostasis, not normalize a bunch of numbers with treatments that could normalize numbers on a corpse in a cadaver lab while delaying the intervention that addresses the reversible lethal pathology.


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## JeffDHMC (Jun 19, 2012)

Veneficus said:


> I am of the mind that because of the risks involved and the very few times it makes a difference, no call is worthy of lights and sirens.
> 
> The only reason it still exists is public expectation and tradition.



This.


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## Christopher (Jun 19, 2012)

Aidey said:


> How much confirmation do you need? The diagnosis pretty much danced a jig in a dress while yelling "Here's sepsis! "



I didn't mean that this patient wasn't septic, just sepsis patients in general are usually not caught by EMS.


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## bigbaldguy (Jun 19, 2012)

Veneficus said:


> I think I would describe it as acceptable losses.
> 
> The few times it makes a dfference in my mind does not warrant the risks when it doesn't.
> 
> ...



To many big words for me to understand the whole thing but this is what popped into my head when I tried.

Voilà! In view, a humble vaudevillian veteran, cast vicariously as both victim and villain by the vicissitudes of Fate. This visage, no mere veneer of vanity, is a vestige of the vox populi, now vacant, vanished. However, this valorous visitation of a by-gone vexation, stands vivified and has vowed to vanquish these venal and virulent vermin vanguarding vice and vouchsafing the violently vicious and voracious violation of volition.


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## Aidey (Jun 19, 2012)

In English, more people are hurt/killed in crashes related to lights and sirens then would die if they were never used.


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## JPINFV (Jun 19, 2012)

So number needed to treat is lower than the number needed to harm?


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## Aidey (Jun 19, 2012)

JPINFV said:


> So number needed to treat is lower than the number needed to harm?



Yup. But we have evidence saying the same thing about back boards and look how far that has collectively gotten us.


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## JPINFV (Jun 19, 2012)

Aidey said:


> Yup. But we have evidence saying the same thing about back boards and look how far that has collectively gotten us.




As a member of my Holy Trinity of EMS?


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## Aidey (Jun 19, 2012)

Back boards, oxygen and lights and sirens...


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## Anjel (Jun 19, 2012)

We have a couple nursing homes that call BLS for everything. Because if they call for ALS they have to call for the fire department. 

Unless it is a vent transfer or something like that. 

That being said. It is not unusual for us to get on scene and call for an ALS rig.

That is what I would of done. If your service doesn't have ALS, I would call 911 or ask my dispatcher to. 

I mean, the guy is alive, you didn't do anything to hurt him. So call it a good days work and move on.

Yes lights and sirens were warranted, but maybe not so much if you could of had ALS there. 

The combo of the temp, HR, and BGL would of made me call ALS. Especially since everything about this call screams sepsis. 

Did you happen to take another set of vitals? I am interested to see the trending for this patient. Did the HR or BP change at all?


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## Medic29 (Jun 20, 2012)

Anjel1030 said:


> ....
> 
> Did you happen to take another set of vitals? I am interested to see the trending for this patient. Did the HR or BP change at all?



I took vitals throughout the whole trip. Nothing really changed by anything more than a couple points on any vital. With the exception of getting the temp to 104.


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## Handsome Robb (Jun 20, 2012)

The biggest thing I see here is traffic in downtown Denver at rush hour. Sure the guy probably would have been ok but I've sat in that traffic and it can take forever to get anywhere. I'll play the devil's advocate and ask what happens if you transport this guy routine and he codes while you're sitting in traffic? The provider is going to get hung out to dry. It's a catch 22. I'm not a huge fan of transporting code 3. It's a pain to do from both a driving and a patient care standpoint not to mention the danger for everyone involved along with innocent bystanders and drivers. Unfortunately it's what is expected by the general public in situations like this so it will continue to happen. 



Aidey said:


> How much confirmation do you need? The diagnosis pretty much danced a jig in a dress while yelling "Here's sepsis! "



:rofl: now that's funny!


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## johnrsemt (Jun 20, 2012)

I never said that the patient did not need ALS if they were there;  I was trying to say that the patient could have gone BLS if they were what was dispatched; and they were closer to the ED than to ALS.    

  Re reading my original post; you are all right it read like I was saying that the patient was not that sick  and didn't need ALS.    and everyone is perfectly justified in thinking that I am too dumb to be a medic

  I worked with many, many basics who would wait on scene for 15 minutes because they thought the patient should have gone ALS, when they could see the ED across the street.

  Yes this patient presented as a Septic patient;  but everyone is knocking the dispatchers for not turning it over to ALS, but no one is thinking that the nurse probably didn't give the dispatcher enough information to know that.  The OP noted that the nurses didn't believe their thermometer so they said the patient had a temp of 102.


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## Veneficus (Jun 20, 2012)

JPINFV said:


> So number needed to treat is lower than the number needed to harm?



I wouldn't say it this way.

The total number of patients needed to have one serious enough where the time saved makes a difference (treat) is very high.

But the amount of patients that are transported lights and sirens for the convenience of the providers than patient need is much higher than the population that would recieve medical benefit from it.

Provider or company convenience, is not reason enough in my opinion to justify the risks and negative incidents.

A BLS transfer between home or facilities that takes hours because of traffic is just the price of business. Everytime you add lights and sirens to it, you roll the dice. 

Perhaps nothing happens or providers don't realize the wake effects most of the time, but on the day you lose, it will be big.

If you take a gamble often enough, it is just a matter of time before you lose.


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## JPINFV (Jun 20, 2012)

johnrsemt said:


> I never said that the patient did not need ALS if they were there;  I was trying to say that the patient could have gone BLS if they were what was dispatched; and they were closer to the ED than to ALS.


There are very few patients that still have a pulse where it would be worth waiting for paramedics on scene instead of transporting when transport time is lower. Those are normally patients who need a specialty center and the closest hospital does not offer that specialty.


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## Uclabruin103 (Jun 21, 2012)

I don't know the true validity of this, but I have always been told that SNFs get so many times calling 911 a year before their ratings start to be affected.  To avoid this they'll call a BLS car, and if warranted the crew will be the ones that call for ALS.  

I've learned to never trust what SNFs tell me.  I always get a new set of VS on my own or watch them do things like SpO2, and BGL since we don't have that equipment.  Some of the SNFs in the LA area are truly the worst places on earth.  

My favorite SNF bs VS are when they gave us a BP of 110/70.  I get 60/P, so we expedite the guy the 0.2 miles to the hospital where we're greeted by a nice central line.

As far as L/S goes, I don't hesitate to turn them on if it'll help my patient.  I'm also a very conservative code 3 driver, so it's like I'm driving my normal snail pace anyway.  If we can respond to a stubbed toe in LA code, then I can transport my sepsis or hypotensive patient code.


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## Veneficus (Jun 21, 2012)

Uclabruin103 said:


> I don't know the true validity of this, but I have always been told that SNFs get so many times calling 911 a year before their ratings start to be affected.  To avoid this they'll call a BLS car, and if warranted the crew will be the ones that call for ALS.
> 
> I've learned to never trust what SNFs tell me.  I always get a new set of VS on my own or watch them do things like SpO2, and BGL since we don't have that equipment.  Some of the SNFs in the LA area are truly the worst places on earth.
> 
> ...



I think something important to remember is that a SNF is not like somebody's private residence.

These patients are there for a reason. 

As poor as the quality usually is, a SNF is part of the healthcare system. These patients are being managed by a physician at some level as well as an overworked RN staff. 

I agree from the EMS standpoint, the information received is often highly unusable or even misleading. 

But If a patient needed transport from one hospital unit to the other, it doesn't really require the person doing the trasport to work this up as a new patient.

The issues are known and being taken care of.

These facilities have become infamous over the years and with good reason. I have found ifyou dig alittle deeper (usually into the chart) you will get much more usable information. 

Providers at these facilities are often so focused on their day to day responsibilitiesthat the big picture often escapes them.

SNFs should not be routinely using the 911 system.


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## Anonymous (Jun 21, 2012)

Veneficus said:


> SNFs should not be routinely using the 911 system.



With a concentrated population of chronically ill patients I would say routine use of the 911 system is inevitable.


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## Meursault (Jun 21, 2012)

Veneficus said:


> SNFs should not be routinely using the 911 system.



Alright, but until their staff and their contract providers are able and willing to determine patient acuity and respond appropriately, I'd rather have over-triage and inappropriate system use than long delays in care.

I'm told that, once upon a time, a lot of routine procedures (G-tube and Foley replacement, FFS) were done within SNFs and urgent issues were usually evaluated by the physician before transport. If there were a way to return to that, we could avoid this whole problem and probably deliver better care. I suspect there are too many obstacles.


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## mommak90 (Jun 21, 2012)

considering the VS I would most definitely run lights and sirens. Depending on distance/traffic to the hospital I would've called for ALS intercept, but not waste any time just waiting for them. I've seen pts with BLG in the 400's go into DKA, plus that temp.... that temp is just horrid. And seeing as though you are not IV cert yet, I'd say you did a d*** good job and you did make the right decisions. I work for a 911 service now, but I used to work at a BLS only service and I had to make calls like that before.


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## Veneficus (Jun 21, 2012)

MrConspiracy said:


> Alright, but until their staff and their contract providers are able and willing to determine patient acuity and respond appropriately, I'd rather have over-triage and inappropriate system use than long delays in care.
> 
> I'm told that, once upon a time, a lot of routine procedures (G-tube and Foley replacement, FFS) were done within SNFs and urgent issues were usually evaluated by the physician before transport. If there were a way to return to that, we could avoid this whole problem and probably deliver better care. I suspect there are too many obstacles.



Just my opinion, but I think the only obstacle is reimbursement.

I remember the days when SNF did that stuff too. But I have also seen nursing start to return to a more limited role since then also.


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## rmabrey (Jun 21, 2012)

Im late to this game but yes, its obvious sepsis is whats going on. yes it needs to be ALS, No it does not warrant lights and sirens.


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## Tigger (Jun 21, 2012)

Veneficus said:


> SNFs should not be routinely using the 911 system.



Agreed, they are generally a burden on the municipally provided EMS service in terms of call volume. However, some change needs to happen within the private EMS world before this can really happen. If the private companies are using dispatchers that only send units to calls and can't EMD callers, that is an issue. Even if the company does not have in-house ALS, the dispatcher should be able to generally determine the acuity of the call. If the company is only BLS, the dispatchers need to have the ability to send or request ALS themselves rather than relying on a BLS ambulance to respond, arrive, and assess, only to say "too sick" and then spend time needlessly waiting for ALS (in any fashion including intercepts). Most of the time, if the patient needs a medic, they've needed one from the onset of the call and an effort should be made to provide it.


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## Akulahawk (Jun 21, 2012)

Patients can't normally be transported out of a SNF unless it's truly an emergency, thus 911... so the Nursing staff has to assess and refer to a physician who then writes an order for the transfer. This can take HOURS. So, what should have been a relatively easy, smooth, no-worries transfer ends up being a 911 call because the patient has started to decompensate or they get the order, call an ambulance for the transfer, and that crew is no longer appropriate because things changed and the info that generated the transfer hasn't been valid for a long time.


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## Cindigo (Jun 21, 2012)

Nice job. 

Also, validation that I am in no way ready to be on call with a driver that has no medical training and is difficult to understand. They've been pushing me ("Nothing gonna happen. You be fine") and I will continue to refuse.....unless of course you want to be on call with me.

I'm all for confidence and trial by fire but holy mother I've only had my state cert. for three weeks!


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## Medic29 (Jun 21, 2012)

Cindigo said:


> Nice job.
> 
> Also, validation that I am in no way ready to be on call with a driver that has no medical training and is difficult to understand. They've been pushing me ("Nothing gonna happen. You be fine") and I will continue to refuse.....unless of course you want to be on call with me.
> 
> I'm all for confidence and trial by fire but holy mother I've only had my state cert. for three weeks!



You just have to request to work with me. Completely understandable about the only driver part. Until you are confident you can run these "emergencies" on your own, keep telling him no unless he pairs you with an EMT instead a driver. Then take the opportunity to learn from us. It's amazing when we get these calls and we're an EMT/EMT crew. We both get in the back, help each other out before one of us gets out to go. Not that easy when you're in a Driver/EMT crew. We'll go over some things in the morning when we get to the office. 4am! Be ready!! lol


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## Cindigo (Jun 21, 2012)

Thanks dude. Hope I didn't come off as negative. I appreciate the opportunities it's just with my comfort zone being really pushed and the 5 million degree temperatures for the last two weeks I feel a little  overwhelmed.

I was talking to a long time RN that works at the VA at a get together I went to yesterday. She was saying that she never worries about the newbie nurses that are nervous and have their doubts, she's nervous about the ones that don't. The more I learn, the more I see that I have to learn. On calm days, that's exciting. On days that I don't sleep well or eat like crap or just get into my head too much....it doesn't seem all that exciting.

Probably text book normal


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## Medic29 (Jun 21, 2012)

Cindigo said:


> Thanks dude. Hope I didn't come off as negative. I appreciate the opportunities it's just with my comfort zone being really pushed and the 5 million degree temperatures for the last two weeks I feel a little  overwhelmed.
> 
> I was talking to a long time RN that works at the VA at a get together I went to yesterday. She was saying that she never worries about the newbie nurses that are nervous and have their doubts, she's nervous about the ones that don't. The more I learn, the more I see that I have to learn. On calm days, that's exciting. On days that I don't sleep well or eat like crap or just get into my head too much....it doesn't seem all that exciting.
> 
> Probably text book normal



If you piss me off tomorrow I'm gonna toss you out the back. I'll be nice and have you buckled to the cot! So eat breakfast and you're gonna nap after our first call lol. Make sure to bring lots of water also or I'll buy you a few at the gas station


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## JPINFV (Jun 22, 2012)

Medic29 said:


> If you piss me off tomorrow I'm gonna toss you out the back. I'll be nice and have you buckled to the cot! So eat breakfast and you're gonna nap after our first call lol. Make sure to bring lots of water also or I'll buy you a few at the gas station


[YOUTUBE]http://www.youtube.com/watch?v=MsQH7PFrI04[/YOUTUBE]


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## Tigger (Jun 22, 2012)

Akulahawk said:


> Patients can't normally be transported out of a SNF unless it's truly an emergency, thus 911... so the Nursing staff has to assess and refer to a physician who then writes an order for the transfer. This can take HOURS. So, what should have been a relatively easy, smooth, no-worries transfer ends up being a 911 call because the patient has started to decompensate or they get the order, call an ambulance for the transfer, and that crew is no longer appropriate because things changed and the info that generated the transfer hasn't been valid for a long time.



At least where I am we do non-physician ordered emergency transfers fairly frequently on both the ALS and BLS side. Our crews will respond to SNFs to work codes, though I am not sure if it's supposed to be taken that far. I'd still maintain that we provide a higher level of service than the city often does given dispatch's propensity to sending medics and quicker response times in many cases. This is company specific of course.


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## Cindigo (Jun 23, 2012)

Medic29 said:


> If you piss me off tomorrow I'm gonna toss you out the back. I'll be nice and have you buckled to the cot! So eat breakfast and you're gonna nap after our first call lol. Make sure to bring lots of water also or I'll buy you a few at the gas station





and I live to ride another day.


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