# 140/80 and you're calling for ALS intercept for hypertensive crisis?



## Hockey (Mar 12, 2012)

:rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl::rofl:


40 year old lady.  BP 140/80.  HR 82.  Complaining of stomach pain after eating taco bell (rated at 2/10)

BLS crew from another company called for ALS intercept for "hypertensive crisis"

They ignored my request to not go P-1 and said that I was too far out to stop and wait.

Met them at the hospital, and thats the explanation I got.  Talked to the patients RN at the ER and she started to get on me thinking I told them to roll it in hot.

They cleared before I got the chance to have a return chat with them.  Tomorrow should be good


----------



## mycrofft (Mar 12, 2012)

A co-worker woke a MD at 2AM because an inmate's blood glucose was 120 (over the standard normal 100)....


----------



## EFDUnit823 (Mar 12, 2012)

I don’t care who you are, that’s funny right there!


----------



## Amberlamps916 (Mar 12, 2012)

The more and more I work as an EMT,the more I get annoyed with fellow EMT's panicking when a BP is slightly elevated from the normal range. I don't know what it is, but it is becoming increasingly evident to me that some providers rush to make judgements based on numbers and not actually taking the patient's condition into consideration. I had a partner panic and wanted to refuse transport the other day because a patient who was being discharged had a bp of 156/72. The patient was completely stable with no signs of distress. He had a history of htn but refused his medication because he didn't want to have a headache during transport. Am I wrong in thinking that this patient was not having a "crisis"?


----------



## SoCal911 (Mar 12, 2012)

Is the patient going to die before or have permanent damage caused before you can drive to the hospital code 2? Than it's not a crisis. Systolic under 90 is not life sustaining per the receiving MD in my area so light it up. Over 200 is high, but if they have a Hx of htn and no obvious distress than its not a light it up transport. Now if it's a chest pain with cardiac Hx and a 230/120 then light it up. But use your brain - just because it varies from 120/80 does not make it an emergency - it makes you a moron.


----------



## mycrofft (Mar 12, 2012)

Some people need their Daily Drama.
Won't find many of us old Dinosaurs acting like that.


----------



## usalsfyre (Mar 12, 2012)

SoCal911 said:


> Systolic under 90 is not life sustaining per the receiving MD in my area so light it up....Now if it's a chest pain with cardiac Hx and a 230/120 then light it up.



:rofl::rofl::rofl::rofl:

Neither of these in isolation require emergent transport with a medic on board.

If I had a nickel for every ICU patient sitting at 75/40....


----------



## abckidsmom (Mar 12, 2012)

usalsfyre said:


> :rofl::rofl::rofl::rofl:
> 
> Neither of these in isolation require emergent transport with a medic on board.
> 
> If I had a nickel for every ICU patient sitting at 75/40....



I have noted an average diastolic for our clientele of about 100. Is anyone normotensive anymore?


----------



## Handsome Robb (Mar 12, 2012)

usalsfyre said:


> :rofl::rofl::rofl::rofl:
> 
> Neither of these in isolation require emergent transport with a medic on board.
> 
> If I had a nickel for every ICU patient sitting at 75/40....



I was just thinking the same thing...


----------



## Anjel (Mar 12, 2012)

Wow.... 

I hate basics. They give other basics a bad name. No wonder most medics dont trust us. 

Ive called for ALS twice, per med controls orders. 

Once was for hypotension,chest pain, and a confirmed AAA. 

And the other was syncopal episode with hypertension, and chest pain.


----------



## Shishkabob (Mar 12, 2012)

I have a better one for you, hockey.


When I was working IFT in Dallas, my ALS unit and an ILS unit were posted at the same hospital, when dispatch sent my ALS unit on a BLS transfer for a psych patient, right next door.  As we're coming out with the patient, we see the ILS truck leaving, and as I start driving with my EMT in the back, dispatch says when we get to the psych facility, to send me (the Paramedic) to meet up with the ILS unit due to a hypertensive issue.


So we get there, I leave my partner with the patient, and I go off to find the ILS crew.  As I walk in, the Intermediate is doing paperwork while the EMT is hanging out with the patient.  The Intermediate looks perturbed that I was there, saying "I can handle it, I don't know why they sent you".   I check out the patient anyhow.


BP of 260/140, nausea/vomiting, blurry vision, AMS.  And they were sitting there doing paperwork.  I told them to get the patient on the stretcher and out the door in the next 30 seconds or I'd be getting a supervisor involved.  They finally transport and the patient is whisked off to CT, where an intracranial bleed is noticed.



I had a talk with that intermediate afterward.  I made it quite clear he screwed up.


----------



## johnrsemt (Mar 12, 2012)

Basics that get worried/freak out due to HR of 140-160 while running a fever of 104F.   Oh wait that was me, until someone sat down and educated me about things like that.

   Speaking to the experienced providers out there;  All of us were new at one point,  most of us had something that worried us until we were taught or learned better.

   I have seen basics freak out because of HTN, htn, hi/lo BGL's, HR, fever induced HR (me), exercise induced HR.

   Had a basic that spent a weekend working with me;   we had multiple chest pains for some reason:  he and his BLS partner got waved down the next week for a person having chest pain at a ball park.  They called for ALS, me.   When I got there they had the patient on the truck, so I climbed in with them and my equipment.  They already had her on high flow O2, and had 4 Baby ASA that the patient was chewing on.    
   WHen I started evaluating the patient the basic got out the spray NTG and was getting ready to give it when I stopped him and told him it wasn't cardiac:   He got upset because as a medic "You can't diagnose patients, and can't make the call if it is cardiac or not".    She had already told him where she hurt and when it started.
   Patient was a fast ball softball pitcher that took a line drive directly to her ribcage, just under and slightly left of her left breast.    She was complaining of chest pain, only in that spot, and started approx 10 minutes earlier approx 2 seconds after she got hit.       
    Fentanyl did wonders for the pain; and it wasn't cardiac when we got her to the ED.

   That Basic is a good EMT;  and I sat him down and explained to him that we can and do diagnose patients in these situations.


   All of these 'new' and 'inexperienced' and 'lousy' basics that we complain about now, have the potential to be us in 5, 10 and 20 years.  If someone like us doesn't scare them away.


----------



## FourLoko (Mar 12, 2012)

If I had actual non-IFT experience and was encountering "normal" human beings I might be more "scared" about a "hypertensive" reading.

With IFT I'm happier to see a high blood pressure than anything borderline low. It's less scary actually because HTN seems to be in every HX I read.


----------



## Shishkabob (Mar 12, 2012)

FourLoko said:


> With IFT I'm happier to see a high blood pressure than anything borderline low. It's less scary actually because HTN seems to be in every HX I read.



I have many more things to fix low than I do to fix high...


----------



## FourLoko (Mar 12, 2012)

Linuss said:


> I have many more things to fix low than I do to fix high...



I'll remember that for later.


----------



## DrParasite (Mar 12, 2012)

Anjel1030 said:


> Ive called for ALS twice, per med controls orders.
> 
> Once was for hypotension,chest pain, and a confirmed AAA.
> 
> And the other was syncopal episode with hypertension, and chest pain.


than you haven't been in this field very long.

knowing when ALS is needed or not needed is part of being a good provider.  

bring proud of never calling for ALS, or always cancelling ALS, on sick person calls or those borderline cases is a sign that you are a poor provider.

I've called ALS for borderline stuff.  I've called for sick patients.  and sometimes we both arrive at the same time, and I will say "since you are here, why don't you check them out and throw them on the monitor?" which I only do to medics who treat BLS providers poorly.  

and on one borderline call, I had a 40 year old with chest pain, and when the paramedic arrived, her first words were "why are we here???" I told her "because I have a 40 year old man with chest pain, I don't know why.  I've ruled out anything I can think of, maybe you want to take a look? "  and while he isn't acutely dying, I don't know what the underlying cause is.  they assessed and M+T to the hospital with us.  and if they released to us oh well, I wanted to make sure there was nothing else going on that I couldn't detect.

for those paramedics that :censored::censored::censored::censored::censored: about getting called for BS, who cares??? you are paid by the hour right?  show up, do an assessment, find the patient stable, write a chart and release the patient to BLS to take to the hospital, and go back to your couch or TV.


----------



## Anjel (Mar 12, 2012)

DrParasite said:


> than you haven't been in this field very long.
> 
> knowing when ALS is needed or not needed is part of being a good provider.
> 
> ...



Ive been doing this a year. 

I'm not proud I haven't had to call. But I know when to. I know a lot of basics that call ALS just to get rid of the patient, so they don't have as much work to do. 

I work in a system where unless it is an IFT, a basic unit and ALS get.sent together on every call. And AlS can determine if they will take it or we can. We also have a good dispatchers who send the appropriate units per the chief complaint. 

I'm not afraid or too proud to call. But I know they are a important resource that needs to be available for priority calls, not BS calls that BLS is trying to pawn off.


----------



## medichopeful (Mar 12, 2012)

SoCal911 said:


> But use your brain



Pretty sure they removed that from the EMT-B curriculum


----------



## SoCal911 (Mar 12, 2012)

Bahaha^^  god I'm glad I have a decent partner


----------



## themooingdawg (Mar 14, 2012)

this job is all about making mistakes and learning from it, its an evidence based medicine. Being new, everything is scary, you're not sure what you're suppose to do in certain scenarios and you're not sure what is the right or wrong thing to do at that time. Everybody makes it, and if you don't, i sure as hell don't want to be your partner or your patient when you do make that mistake.


----------



## Hockey (Mar 14, 2012)

themooingdawg said:


> this job is all about making mistakes and learning from it, its an evidence based medicine. Being new, everything is scary, you're not sure what you're suppose to do in certain scenarios and you're not sure what is the right or wrong thing to do at that time. Everybody makes it, and if you don't, i sure as hell don't want to be your partner or your patient when you do make that mistake.



I don't make mistakes, I'm a Paramedic!


----------



## Tigger (Mar 14, 2012)

DrParasite said:


> than you haven't been in this field very long.
> 
> knowing when ALS is needed or not needed is part of being a good provider.
> 
> ...



Ok we get it, you have lots more experience than us. No one here has said that they're proud to have never called for ALS, and I doubt anyone will. I've been working for a year and have called for ALS once. I have no attachment to that number, I've only had one patient where it was clinically and operationally indicated to call. 

There is a distinction. 9/10 times the hospital is my ALS. I know, holding someone's hand is not cutting edge medicine, but a lot of time that and a pillow is all that someone's getting for treatment on the way to the hospital. For some of us, it makes a lot more sense to just go to the hospital than try and set up an intercept. 

Before you knock us for not having experience and, realize that we don't all work in your system either.


----------



## EFDUnit823 (Mar 14, 2012)

Anjel1030 said:


> I hate basics. They give other basics a bad name. No wonder most medics dont trust us.



Cool story, where are the dragons? :glare:


----------



## Anjel (Mar 14, 2012)

EFDUnit823 said:


> Cool story, where are the dragons? :glare:



Ooook? Most basics are not the brightest. And there are exceptions. 

How is that an incorrect statement?


----------



## mycrofft (Mar 14, 2012)

Not to worry.

"Freaking out"  repeatedly is a sign the practitioner needs to consider another line of work for  their sake and those of their co-workers, the driving public, and their patients. (Never hurts to consider).

When in doubt, call. Know the protocols, and ask about why they have certain parameters (a shortcut  to knowing more about physiology sometimes). Get a mentor. And we all went through the excitable stage and will instantly resort to it when it is us, our family, or another loved one that's in trouble...I hope.


----------



## Sasha (Mar 14, 2012)

Anjel1030 said:


> Ooook? Most basics are not the brightest. And there are exceptions.
> 
> How is that an incorrect statement?



Don't worry love some people are just insecure in their own competence.


----------



## mycrofft (Mar 14, 2012)

..or over-secure in our self-alleged competence!:blush:


----------



## Bullets (Mar 14, 2012)

Anyone take the other route? Adhere strictly to the protocols, request ALS for anything that doesnt comply with the strict protocols  set by your archaic medical director? Hopefully annoy the MDs until they actually engage field providers and change


----------



## Jon (Mar 16, 2012)

Linuss said:


> ...As I walk in, the Intermediate is doing paperwork while the EMT is hanging out with the patient.  The Intermediate looks perturbed that I was there, saying "I can handle it, I don't know why they sent you".   I check out the patient anyhow....



I've never been able to get the hang of the IFT "stand at nurses station and do paperwork for 20 minutes before I see the patient" routine. It drives me bonkers when my partners do it... so I go assess their patient for them. Some of my partners have picked up on that... some are too entrenched to care.



DrParasite said:


> knowing when ALS is needed or not needed is part of being a good provider.
> 
> bring proud of never calling for ALS, or always cancelling ALS, on sick person calls or those borderline cases is a sign that you are a poor provider...


While I don't think he was directly adressing anyone in this thread... it bears repeating. 



medichopeful said:


> Pretty sure they removed that from the EMT-B curriculum


Too true.



themooingdawg said:


> this job is all about making mistakes and learning from it, its an evidence based medicine. Being new, everything is scary, you're not sure what you're suppose to do in certain scenarios and you're not sure what is the right or wrong thing to do at that time. Everybody makes it, and if you don't, i sure as hell don't want to be your partner or your patient when you do make that mistake.



My favorite quote on this, when precepting N00B's:
Good judgment comes from experience, and experience comes from bad judgment. (I can't find a definitive cite for the quote).



Bullets said:


> Anyone take the other route? Adhere strictly to the protocols, request ALS for anything that doesnt comply with the strict protocols  set by your archaic medical director? Hopefully annoy the MDs until they actually engage field providers and change



I've worked with EMT's that do that. It's annoying, for a bunch of reasons.


----------



## Aidey (Mar 16, 2012)

Jon, I never make contact with the patient until staff know we are there. I don't spend 20 minutes doing paperwork, but if the RN isn't available I'll work on the paperwork until she is. 

It might seem strange, but there have been more than several times where it has saved my butt because of pissed off family, cranky patients etc. An oddly large number of nursing home staff don't tell patients they are being sent out until the last second. It is always fun having a 90 yo tell you you're crazy and not taking them anywhere because staff never gave them the heads up that they were being sent in for their fever of 90 degrees.


----------



## firecoins (Mar 16, 2012)

Jon said:


> I've never been able to get the hang of the IFT "stand at nurses station and do paperwork for 20 minutes before I see the patient" routine. It drives me bonkers when my partners do it... so I go assess their patient for them. Some of my partners have picked up on that... some are too entrenched to care.


I expect my EMT-B to be assessing the patient while I stand at the RN's desk doing paperwork, asking the RNs for report. Can't stand when I turn around see my EMT prepping the cot and he doesn't have vitals.


----------



## Aidey (Mar 16, 2012)

Aidey said:


> Jon, I never make contact with the patient until staff know we are there. I don't spend 20 minutes doing paperwork, but if the RN isn't available I'll work on the paperwork until she is.
> 
> It might seem strange, but there have been more than several times where it has saved my butt because of pissed off family, cranky patients etc. An oddly large number of nursing home staff don't tell patients they are being sent out until the last second. It is always fun having a 90 yo tell you you're crazy and not taking them anywhere because staff never gave them the heads up that they were being sent in for their fever of 90 degrees.



That is supposed to be fever of 99 degrees.


----------



## Sasha (Mar 16, 2012)

Jon said:


> I've never been able to get the hang of the IFT "stand at nurses station and do paperwork for 20 minutes before I see the patient" routine. It drives me bonkers when my partners do it... so I go assess their patient for them. Some of my partners have picked up on that... some are too entrenched to care.
> 
> 
> While I don't think he was directly adressing anyone in this thread... it bears repeating.
> ...



It doesn't bear repeating. A sign of a great provider is recognizing the need for definitive care over field treatment and getting said patient to that care in the quickest and safest way possible vs waiting around for an ALS truck. 

It grates my nerves when EMTs call for ALS and they're within five minutes of the hospital. 

And as for paperwork, there has to be certain paperwork in the chart that I need for good continuity of care. Our calls are often more complex than an otherwise healthy person going to the ER for a tummy ache. If it isn't there I need to get the nurses on it sooner rather than later. My partner better have a fresh set of vitals for me when I walk in the room. Eff the stretcher.


----------



## Sasha (Mar 16, 2012)

Aidey said:


> Jon, I never make contact with the patient until staff know we are there. I don't spend 20 minutes doing paperwork, but if the RN isn't available I'll work on the paperwork until she is.
> 
> It might seem strange, but there have been more than several times where it has saved my butt because of pissed off family, cranky patients etc. An oddly large number of nursing home staff don't tell patients they are being sent out until the last second. It is always fun having a 90 yo tell you you're crazy and not taking them anywhere because staff never gave them the heads up that they were being sent in for their fever of 90 degrees.



Or combative patients. 

Nothing like going in
Me: "hi I'm sasha blahblahblah"
Patient: *whack*


----------



## EMTHokie (Mar 19, 2012)

johnrsemt said:


> Basics that get worried/freak out due to HR of 140-160 while running a fever of 104F.   Oh wait that was me, until someone sat down and educated me about things like that.



If someone doesn't mind, can you explain to a new EMT why this isn't an ALS issue? Just so I don't do the same


----------



## exodus (Mar 19, 2012)

EMTHokie said:


> If someone doesn't mind, can you explain to a new EMT why this isn't an ALS issue? Just so I don't do the same



Because sepsis is a BLS call, right?


----------



## EMTHokie (Mar 19, 2012)

exodus said:


> Because sepsis is a BLS call, right?



Yeah, I guess so as long as there aren't any extenuating circumstances.

So in this case, monitor vitals, put on O2 and transport?


----------



## exodus (Mar 19, 2012)

EMTHokie said:


> Yeah, I guess so as long as there aren't any extenuating circumstances.
> 
> So in this case, monitor vitals, put on O2 and transport?



I was using sarcasm h34r:


----------



## EMTHokie (Mar 19, 2012)

exodus said:


> I was using sarcasm h34r:



Yeah, missed that one :sad:


----------



## iPhonemedic (Mar 21, 2012)

If you're on a BLS unit an you decide that your pt should be ALS but it's gonna take 20 minutes for an ALS unit to arrive yet your BLS truck is only 15 min code 3, why would you not bring the pt in hot BLS? I have to have this discussion probably once a week with a BLS truck that upgrades a call. Our job is to get the pt to definitive care which is a hospital, not the back of an ALS unit, it don't matter if they arrive ALS or BLS. Things like this need to be considered when calling for an ALS unit. There are very few calls where it is worth the time to wait on ALS if a BLS unit can get the pt to a hospital quicker than the ALS unit you just called will.


----------



## Martyn (Mar 21, 2012)

Sasha said:


> It doesn't bear repeating. A sign of a great provider is recognizing the need for definitive care over field treatment and getting said patient to that care in the quickest and safest way possible vs waiting around for an ALS truck.
> 
> It grates my nerves when EMTs call for ALS and they're within five minutes of the hospital.
> 
> And as for paperwork, there has to be certain paperwork in the chart that I need for good continuity of care. Our calls are often more complex than an otherwise healthy person going to the ER for a tummy ache. If it isn't there I need to get the nurses on it sooner rather than later. My partner better have a fresh set of vitals for me when I walk in the room. Eff the stretcher.


 
Had a patient, BP 78/46 P124 RR18 less than 5 minutes to ER, stuff ALS etc...we scooped and went. Another patient BP 54/P P90 RR16 about 8 minutes from ER...scooped and went. Even in the middle of Tampa we are probably talking about 8-10 minutes for ALS (county) to get on scene. I would much rather think of my patient and go straight to ER than mess about waiting for ALS. And yes I am an EMT-B on a BLS truck.


----------



## Martyn (Mar 21, 2012)

BTW, last thursday had a BLS 911 non emergency call for hypertension, on scene BP 168/68 P90 RR16 er, sort of er, took him to the wrong hospital. Got written up, suspended a day without pay and put on 90 days probation!!!   (Last I heard the patient was still alive though...lol)


----------



## DrParasite (Mar 21, 2012)

Martyn said:


> BTW, last thursday had a BLS 911 non emergency call for hypertension, on scene BP 168/68 P90 RR16 er, sort of er, took him to the wrong hospital. Got written up, suspended a day without pay and put on 90 days probation!!!   (Last I heard the patient was still alive though...lol)


ummm, not to get off topic, but based on what you just described (assuming no other alarming factors) the patient sounds relatively stable, could have went to the hospital they requested and doesn't sounds like they are imminently unstable or dying (and yes, a RR of 16 isn't too alarming)

maybe your write up and suspension was justified for not following company policy and the patient's wishes?


----------



## medicdan (Mar 21, 2012)

iPhonemedic said:


> If you're on a BLS unit an you decide that your pt should be ALS but it's gonna take 20 minutes for an ALS unit to arrive yet your BLS truck is only 15 min code 3, why would you not bring the pt in hot BLS? I have to have this discussion probably once a week with a BLS truck that upgrades a call. Our job is to get the pt to definitive care which is a hospital, not the back of an ALS unit, it don't matter if they arrive ALS or BLS. Things like this need to be considered when calling for an ALS unit. There are very few calls where it is worth the time to wait on ALS if a BLS unit can get the pt to a hospital quicker than the ALS unit you just called will.



I absolutely agree, with one caveat. In every system I've worked in, care quality is measured (either formally or informally) by specific factors-- one of which being whether we request ALS for patients requiring that care. That means that even though the hospital is less than five minutes away, and I know that the patient will probably not benefit from the intercept, but I feel compelled to request it, if nothing else, so I can document that I made the effort. 
I just hope that if we end up with an ALS truck the medic has the sense to say "just drive".


----------



## Brandon O (Mar 21, 2012)

Sasha said:


> It doesn't bear repeating. A sign of a great provider is recognizing the need for definitive care over field treatment and getting said patient to that care in the quickest and safest way possible vs waiting around for an ALS truck.
> 
> It grates my nerves when EMTs call for ALS and they're within five minutes of the hospital.



I think this is actually both appropriate and important (not that the medics always agree) in certain situations -- mostly, when there's a question about the appropriate transport destination, and the medics can help answer it. A couple canonical examples, both of which have happened recently:

1. Sick stroke patient who probably needs a major tertiary facility with neurosurgery, but by protocol would need to go to nearest "stroke center," which is a community hospital that will just end up transferring them out. Medics are intercepted and due to greater leeway in such decisions order transport to the appropriate destination.

2. Chest pain patient, possible MI, a few minutes from a community hospital with no PCI capability. If we scoot over there, by crossing their doors we'll probably add 30-45 minutes to this patient's time until reperfusion in the event they do have a STEMI -- it's not like there will be an immediate 12-lead in the ED followed by us turning around and leaving, they'll go through a lengthy process followed by eventual transfer to the place we should've gone originally. Even if we meet the medics in their parking lot, if they can do the 12-lead, divert us to the right hospital and possibly activate the cath lab from the field, this will be far better for the patient.

Think of the course of care and what the patient needs, that's my motto.


----------



## Medic29 (Mar 27, 2012)

johnrsemt said:


> ...
> 
> 
> All of these 'new' and 'inexperienced' and 'lousy' basics that we complain about now, have the potential to be us in 5, 10 and 20 years.  If someone like us doesn't scare them away.



I appreciate this statement


----------



## systemet (Mar 28, 2012)

I think it's far better to call ALS in a situation where you're uncertain than to not call them, and have the patient suffer as a result.  

Any half-decent paramedic should be willing to come and assess a patient for a BLS crew if they're uncertain about it.  

No one likes the sense of entitlement and belittlement when it comes from the MDs (fortunately, only from a very small, but very vocal, portion of them).  Imitating this doesn't make us better paramedics.


----------



## NYMedic828 (Mar 28, 2012)

Your job as a paramedic isn't just to provide ALS care.

You should always be considering things you can teach to coworkers. If you are with a BLS crew, try and explain what you are doing and get them involved even if it's just holding the patients arm for you. Teach them to spike a bag, review the job with them after. If someone gives you an attitude and isn't willing to learn then you have the right to get frustrated. 

Don't get mad or annoyed because people called you and you feel they are incompetent. Instead be part of the solution so they know better next time.

Many EMTs don't actually know the scope of a paramedic and what is actually treatable via ALS

So they called you because they thought they had a diabetic but it was a CVA or they called you for hypertension. Big deal, it's 30 minutes out of your day and that's what you are there for. Everyone makes mistakes from time to time. Cut them some slack and don't forget where you come from.

I remember a job once when I was an EMT up in Harlem. Spanish speaking family, I don't speak Spanish and called ALS because he had an irregular rate. The guys that showed up happened to speak Spanish turned out the guy had a demand pacemaker and the medic was an obnoxious **** about it. It's discouraging and unneccesary.


----------

