# Just another regular dialysis patient....so it was supposed to be.



## shadowstewie (Aug 21, 2009)

So me and my partner go on this call today with this dialysis patient whom is a regular and we've transported him a couple times before. I'm usually the attendant and I talk to him most of the time. He's a 48 y/o Male, about 380 lbs, amputated leg, has MSRA, ESRD, Obesity, etc. Seems like a normal guy who has a lot of problems. I talk to him and he's always perfectly fine to talk to, can hear me clearly and everything just like a normal person. We go to the dialysis center to pick him up and he's hooked up to the vital signs monitor and right when we get there, it starts beeping really loud because his blood pressure was at like 134/78 and pulse was at 125. We re-check the blood pressure on the other arm and it beeps again when it's done and it is at 142/82 and pulse is now 132. We start wondering why it's so high. We ask him multiple times if he feels fine, if he's complaining of anything specifically chest pain and he says "no no im fine, i don't feel anything wrong with me at all, i don't know why its doing that". The nurse starts him on Saline and waits till its done and now his BP is at 154/78, pulse is at 133. He starts getting worried and he seems to be getting upset that it keeps beeping because it's basically saying that something is wrong with him. He starts to tear up because he thinks something could be really bad going on with him when he feel's perfectly fine. His BP and Pulse again is checked 5 min later and now its 164/84 and 136bpm. I'm looking at my partner at this time and am thinking about just loading him up and taking him to the ER, while we are just a BLS unit, that we would just go Code 3 and take him ourselves to a hospital a couple minutes away. The nurse starts to talk to his doctor to see if he's fine to go home since he feels fine and the doctor said he would call her back. I almost had to argue with her that if it went up one more time, I'm taking him Code 3 to the ER, and btw his normal BP is 115/72 and pulse 84. I don't care if the nurse or doctor is higher for me...i'm not going to let this patient wait in the dialysis center if his BP and Pulse is raising higher and higher by the minute. I'm going to do what's in best interest for the patient. But after about 3 more sets of vital signs, they seems to just flow around 140/76 and 134bpm. The whole point of this story of a call is a couple things, for one, I don't care what anyone says to me, whether a Paramedic, RN, Doctor, whoever...if I feel something is better for the patient that's going to help them, I'm going to do it, plus that's what our company is strongly advising us to do, is to argue and do what's best interest for the patient. And also....I know this patient since he's a regular and I've taken him a couple times...just to see him start to tear up and almost start crying every time the machine beeped stating he wasn't in good condition, it kinda killed me after I got off work and I started to feel really bad for him because he's a good guy, really nice, really cooperative, really grateful. Just to see him tear up got me to feel kinda bad while I was on the job, but it didn't really phase me until an hour after I got off. I've been an EMT for this company for almost 1 month and this is my first EMT job. I know this is normal to feel like this, but I was told that I will get used to it and that it's just my job and to do the best I can. Can anyone else help me out with this? I know I will get better to not let it bother me or anything but can anyone help me or tell me things they've done to help cope with emotional calls that you feel really bad for the patient or even family members? Thank you very very much.


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## Dominion (Aug 21, 2009)

shadowstewie said:


> So me and my partner go on .....



Good lord sentence structure and paragraphs are your friend.


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## Aidey (Aug 21, 2009)

Did you consider that his blood pressure may have been rising because he was getting upset an anxious that the machine was beeping and because everyone around him was acting like something was wrong? 

If he's been attending dialysis there for a while the nurses and techs probably know him, and his baseline vitals pretty well. If you are planning on working for this company for a while, you need to be on good terms with these people, not questioning their judgment. 

Dialysis patients are consistently some of the sickest we will see, however, at the same time, for many that is their normal operating level and there is nothing that can be done to fix it. Their bodies have so many problems they just don't work very efficiently anymore.


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## Akulahawk (Aug 21, 2009)

Shadowstewie: Yeah, I know it's a forum and informal and all, but please, use good sentence and paragraph structure. It's just easier to read and follow what you're saying. As you go further in your education, it'll also help you with writing various papers. 

Anyway, dialysis patients can be some of the sickest, problem ridden patients around. Sometimes when people start getting anxious, their bodies will start releasing epinephrine, which will cause the body to get into it's fight/flight response. You see elevated BP and heart rates, and it's totally normal. Also, remember, while you can be an advocate for your patient, once you turn the patient over to a higher level of care provider, that patient becomes their responsibility. Be extremely careful about overriding their decisions. It could be _you_ who is making an improper patient care decision, which results in you losing your certificate if you do that. Also, once someone is placed on a dialysis machine, taking someone off of it improperly could result in them being VERY fluid overloaded or fluid deficient and both can be very bad for someone who has poor/non-functioning kidneys. 

You've been an EMT for 1 month. There's a LOT to learn. If you STOP learning, you'd better get out of the profession... So keep on learning. Please! 

As for "getting used to it"... it'll just happen naturally. I learned a long time ago that it's not _your_ emergency or problem... it's the _patient's_ emergency or problem. You are there to help them get to where they need to go. It may seem a little cold at first... but that attitude will help you cope with some of the more difficult calls. There's only so much you can do. The rest is out of your hands.


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## shadowstewie (Aug 21, 2009)

Okay, I understand about that. The patient was already done with dialysis and unhooked from the machines. He only had a blood pressure cuff on which was monitoring his vitals. There was a call one time where 2 of our crew members were dealing with a patient and they had to call ALS because of some reason. Fire shows up along with a company who is regularly contracted with the Fire Department. The paramedics asked us to take the patient out of our ambulance and put him in the other ambulance because they are contracted with them. Then our EMT says, "No, he's our patient, he's already in our ambulance, come with us to the ER", the Paramedic says, "You need to listen to me or I will have your license pulled" and the EMT says, "Too bad", and shuts the back doors to the ambulance and tells the driver to go to the ER. The medics just stood there with their jaws dropped and couldn't believe it. Later on, Fire tried to say something about it and the EMS Agency dropped it in favor of the EMT because it was for the patient's best interest. And no, our dialysis patient was calm before and after he was tearing up and he was still Tachy.


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## Aidey (Aug 21, 2009)

Not to mention if their treatment is ended early their blood won't be "cleaned" like it's supposed to, causing all sorts of electrolyte imbalances and causing their lab work to be off.


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## Aidey (Aug 21, 2009)

The tachycardia may be normal for him. Immediately after a dialysis treatment the pt has a reduced blood volume because of the liters of fluid that have been removed. It can some times take the body a little while to reach homeostasis, especially in pts with artery/vein diseases (like someone with a hx of diabetes has a high likelihood of having).

There are also patients that have a reactive tachycardia to the reduced pre-load post treatment. Suddenly there is less fluid and their heart is like "wow, I can beat better!" and it speeds up. 

If he's tearing up, he's probably not calm. The saline the RN gave him could have fixed tachycardia due to fluid loss, but by that time he was anxious which kept his pulse high.

I'm also *very* surprised that your EMT didn't get in trouble. If both ambulance companies are already on scene there is no delay in care for the ALS ambulance to take the pt. If a pt is an ALS pt, and the EMT refuses to turn pt care over they could end up with a major lawsuit on their hands if anything happened to the pt.


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## Smash (Aug 21, 2009)

Great, now this has happened







Try again with some sentences and paragraphs thrown in for laughs and I may be able to manage some meaningful response.


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## Dominion (Aug 21, 2009)

Also remember you treat the patient not the machine.


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## Akulahawk (Aug 21, 2009)

shadowstewie said:


> Okay, I understand about that. The patient was already done with dialysis and unhooked from the machines. He only had a blood pressure cuff on which was monitoring his vitals. There was a call one time where 2 of our crew members were dealing with a patient and they had to call ALS because of some reason. Fire shows up along with a company who is regularly contracted with the Fire Department. The paramedics asked us to take the patient out of our ambulance and put him in the other ambulance because they are contracted with them. Then our EMT says, "No, he's our patient, he's already in our ambulance, come with us to the ER", the Paramedic says, "You need to listen to me or I will have your license pulled" and the EMT says, "Too bad", and shuts the back doors to the ambulance and tells the driver to go to the ER. The medics just stood there with their jaws dropped and couldn't believe it. Later on, Fire tried to say something about it and the EMS Agency dropped it in favor of the EMT because it was for the patient's best interest. And no, our dialysis patient was calm before and after he was tearing up and he was still Tachy.


Train of thought writing works for people who know how to do it well. 

As for the other story, without knowing the specifics, I'd have to guess that the crew did put their certificates in jeopardy for what they did. If that patient had an adverse outcome, that would have required ALS intervention en-route, I would imagine that the end result might easily have been different for both the Paramedic and the EMT crew. There's a lot more that I could probably go into, but without knowing more, including OC EMS protocols, I'm going to hold off. Personally, I think they were probably very lucky that they retained their certs.


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## Akulahawk (Aug 21, 2009)

Dominion said:


> Also remember you treat the patient not the machine.


They start drumming that into you in EMT school. It doesn't stop... evah...


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## Smash (Aug 21, 2009)

Ok, I've waded through these posts, mopping the blood from my bleeding eyeballs, and so far all I can ascertain is this:  

1)  You didn't know what was wrong with the patient but you were going to take him away from the RN (who was at least attempting to consult with an MD) Code 3 (why?).  2)  The patient got upset.  3)  This upset you.  4)  Some EMTs in your service need to be disciplined.

Have I missed anything?


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## VentMedic (Aug 21, 2009)

Smash said:


> Ok, I've waded through these posts, mopping the blood from my bleeding eyeballs, and so far all I can ascertain is this:
> 
> 1) You didn't know what was wrong with the patient but you were going to take him away from the RN (who was at least attempting to consult with an MD) Code 3 (why?). 2) The patient got upset. 3) This upset you. 4) Some EMTs in your service need to be disciplined.
> 
> Have I missed anything?


 
Thank you for reading through that "paragraph" and I'm going to respond off your effort. 

It is not that uncommon for the dialysis RNs to have to correct a few things before the patient is released.  They know what they did during dialysis, including the recipe they were using that day.  They know the doctor and the doctor knows the patient.   By racing to an ED, you have placed the patient into unfamilar hands who will have to call the RN at the dialysis center and then get the information from the doctor before they can do very much.    

The EDs are not always the "definitive" treatment for everything.


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## Hoofguy (Aug 21, 2009)

That BP is not uncommon for someone coming off dialysis and he is a little tacky, so what? You need to drop the Charlie Sheen gun ho :censored::censored::censored::censored: before you lose that freshly printed license. You need to learn to step back and not try to be more than you are, you are a basic NOT a savior to the world.. 

So you were going to rip this patient out of the care of an RN and DR to run code 3 to the ER? Dude seriously if you did that here they would bust your *** when you showed up at the ER, you'd get that look like "code 3? serious?" and then the Dr would belittle you until you pissed yourself and cried.. 

I know you can't wait to turn on the pretty lights and sirens but this was not the run to even consider it. YOU made the patient cry, not the problem. I would be willing to bet the looks you were giving and what you were saying in front of the patient is what got him all freaked out.. 

Knock it down a few clicks


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## Sasha (Aug 21, 2009)

I don't get why you paniced to begin with.. 134?? Did the patient finish the complete dialysis? They are often hypertensive prior to dialysis and will drop post dialysis, but not as signficantly if they did not finish their entire treatment.

 Did you consider your cuff may be wrong? Of course he's going to start getting hypertensive you're scaring him to death! 

He felt fine. A little critical thinking goes a long way.



> The whole point of this story of a call is a couple things, for one, I don't care what anyone says to me, whether a Paramedic, RN, Doctor, whoever...if I feel something is better for the patient that's going to help them, I'm going to do it,



You don't think they have the patient's best interest at heart either? They have a lot more education than you, just because you think that something may be best, does not necessarily mean it's going to be best for them because you can't see the bigger picture. Especially in situations like these where you have little to no education at all in the situation at hand.


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## Hoofguy (Aug 21, 2009)

That's another thing, did you manually take a pulse or BP? Or just look at the machine and want to go A-Team to the hospital? Treat the patient NOT the machine..


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## Sasha (Aug 21, 2009)

Hoofguy said:


> That's another thing, did you manually take a pulse or BP? Or just look at the machine and want to go A-Team to the hospital? Treat the patient NOT the machine..



Even if the BP was correct, it's not hypertensive and does not warrant a code 3 response, especially if the patient feels fine.


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## Aidey (Aug 21, 2009)

A special note on NIBP and dialysis pts. Most clinic dialysis machines (if not all now) have built in NIBP that goes off as often as its set. If the cuff is tight at the beginning of the treatment, and  then you remove 4L of fluid from them, there is a chance the cuff will now be loose because of reduced edema. So when using NIBP ALWAYS readjust the cuff if you get an odd BP before calling in the cavalry.


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## Hoofguy (Aug 21, 2009)

Sasha said:


> Even if the BP was correct, it's not hypertensive and does not warrant a code 3 response, especially if the patient feels fine.



Like I had said above that BP wasn't anything to be concerned with in the first place, however I was just curious if he bothered taking manual vitals instead of reading the machine.


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## Ridryder911 (Aug 21, 2009)

Okay, I will say it. Noobie, you and your partner have* NO* business in prehospital care, transporting live patients... heck; even dead one's. I would not even suggest being a driver of carcass removal transport system. 

I will say thank-you though. Yeah, thanks for setting EMS back 40 years to the old "ambulance driver" stigma. 

You both attempted to disguise yourself as a knowledgeable EMT's but in reality displayed  the biggest case of dumbass! Seriously, you have just completed a first aid course and now you and your idiot partner attempts to interpret numbers that you have no clue what they represent! 

As previously stated and discussed, there are multiple reasons for those numbers as well as numerous other potential risks and dangers. Again, material not taught in your first aid course. 

If you do value your certification, then I would request to never work with that person again. I do hope the medics pursue and request formal action against your EMS and the other EMT. As well, as the patient and family take legal action and litigation against both of you. 

I doubt that you will return and discuss this further, and I dare your partner to attempt to defend their action(s). I would welcome the opportunity! 

I highly suggest to start hitting the books and gaining some real education and maturity. You will look back at this and hopefully chalk this up as experience on what not to do from now on. 
R/r 911


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## Hoofguy (Aug 21, 2009)

Ridryder911 said:


> Okay, I will say it. Noobie, you and your partner have* NO* business in prehospital care, transporting live patients... heck; even dead one's. I would not even suggest being a driver of carcass removal transport system.
> 
> I will say thank-you though. Yeah, thanks for setting EMS back 40 years to the old "ambulance driver" stigma.
> 
> ...



 Oh snap, he went there!

Excuse me while I clean up the mess I made with my drink while reading that.. Truth can be painful sometimes


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## jgmedic (Aug 21, 2009)

There's a reason those fire medics tried to take your patient out of your ambulance and put them in another. In OC, there are few ambulance companies full of EMT's who think that they know what's best, most medics will not transport with these people and will request that the patient be transported by their usual transport agency. The OC system is f-d up as it is, but shutting the doors on a higher level of care because you "know what's better", come on now.


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## shadowstewie (Aug 21, 2009)

Aidey said:


> The tachycardia may be normal for him. Immediately after a dialysis treatment the pt has a reduced blood volume because of the liters of fluid that have been removed. It can some times take the body a little while to reach homeostasis, especially in pts with artery/vein diseases (like someone with a hx of diabetes has a high likelihood of having).
> 
> There are also patients that have a reactive tachycardia to the reduced pre-load post treatment. Suddenly there is less fluid and their heart is like "wow, I can beat better!" and it speeds up.
> 
> ...



From what my Manager told me, the Paramedics were supposed to go in the ambulance with our crew since it is OUR patient, not the other company's. But the paramedics didn't, all they wanted to do was move the patient to the other ambulance since they were contracted with them. I'm not saying I know everything, but that I believe is not a smart move by the Paramedics.


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## triemal04 (Aug 21, 2009)

Ok, that is about enough of this crap.  You need to seriously wake up, start thinking about what it is you do, what it is you know, what you DON'T know (a lot apparently) how EMS works, and how your system works.

You have a pt with a condition you know nothing about possibly having a problem you know nothing about and you want to drag him with lights and sirens screaming to the ER because you think you know best?

You want to sit and argue with someone about transport because the pt's BP is rising...after you spent how long grilling him and rechecking his pressure?  Think it might have been because of you that his BP rose?  That it might have been because of his dialysis? 

You think that you actually know better than a doc and RN...you know, people who have way more knowledge than you, and in this case have specific education for this type of pt?

You actually think that it's acceptable to blow off people who know what they're talking about and do what you want because you think it's better for the pt?

You think it's acceptable to refuse to turn a pt over to a higher level of care (after ASKING for help no less) because you wouldn't get to drive and pay with the woo-woos and flashies?

You think it's acceptable to do that so that your company can bill the pt instead of someone else?

I'd go on but I'm allready foaming at the mouth.

Quit.  Quit your job, turn in your cert leave everything to do with EMS for at least 5 years.  Then maybe, just maybe start over from scratch.  Which means learning about medicine, what we do, why we do it, how the system works, and what should have been done in all the situations above.


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## NEMed2 (Aug 21, 2009)

Hoofguy said:


> Oh snap, he went there!
> 
> Excuse me while I clean up the mess I made with my drink while reading that.. Truth can be painful sometimes



I almost dropped my beer... The brutal truth in some cases is the only way to set someone on the correct path.


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## medichopeful (Aug 21, 2009)

shadowstewie said:


> The whole point of this story of a call is a couple things, for one, I don't care what anyone says to me, whether a Paramedic, RN, Doctor, whoever...if I feel something is better for the patient that's going to help them, I'm going to do it, plus that's what our company is strongly advising us to do, is to argue and do what's best interest for the patient.



You can't be serious.  You are seriously going to go against the orders or opinion of somebody who has WAY more education than you to do what _you_ think is the right thing?  Get your ego in check.  NOW.

I understand that your company is _saying_ that they want you to do what is best for the patient.  Stop being a cocky :censored::censored::censored::censored::censored::censored::censored: and do what is best for the patient: leave them with somebody who actually knows what their doing.

When questioning a doctor's or RN's orders, do it to learn.  Don't do it to show how brilliant you think you are.

I, like others on this forum, question whether you have any right being in EMS.


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## jgmedic (Aug 21, 2009)

shadowstewie said:


> From what my Manager told me, the Paramedics were supposed to go in the ambulance with our crew since it is OUR patient, not the other company's. But the paramedics didn't, all they wanted to do was move the patient to the other ambulance since they were contracted with them. I'm not saying I know everything, but that I believe is not a smart move by the Paramedics.



Hmm...maybe the paramedics knew they type of shenanigans your company has pulled(like BLS'ing obviously ALS patients, or arguing about transports on scene, in front of patients) and don't want to be involved in that type of business. Maybe not, but having worked in that system for several years before becoming a medic, it would not surprise me, things I have personally witnessed, like managers arguing with fire, because it is THEIR patient(not for pt care reasons, but for billing) and con homes telling me if I call for ALS(911) then they won't call our company anymore, because it'll ruin their stats.


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## Akulahawk (Aug 21, 2009)

shadowstewie said:


> From what my Manager told me, the Paramedics were supposed to go in the ambulance with our crew since it is OUR patient, not the other company's. But the paramedics didn't, all they wanted to do was move the patient to the other ambulance since they were contracted with them. I'm not saying I know everything, but that I believe is not a smart move by the Paramedics.


If that crew called for ALS, waited on scene for ALS to arrive, then transport the patient to the hospital, that's generally considered delaying treatment for that patient. If that patient had an adverse event during transport, guess who butt is on the line? Not the Paramedic... Did that BLS transport unit have ALL the ALS equipment necessary for care on board? Doubt it. Probably not exactly legal. I doubt that the ALS crew had all their necessary equipment available in a bag to be able to deliver ALS care to the patient to the same level of care that they could in their ambulance.

I don't know what the transportation guidelines are for BLS -> ALS turn overs in your County, but I do know that Santa Clara County has a VERY specific policy in this case. It's simple for BLS: from the time you get on scene, you have 10 minutes to deliver the patient to an ER (only for patients requiring ALS care). Otherwise, you sit and wait for ALS. Period. Until about 2000-1 timeframe, the standard was get to the ER before you could get ALS to you = BLS transports. After that, an ALS unit was almost always within 10 minutes...

Now, back when I was an EMT, I did take an ALS Supervisor (non-transport unit) to the ER with a patient. That was a mutual decision by my crew and him. We were not with the same company. We turned our BLS unit into an ALS transport unit emergently. We loaded his equipment onto our ambulance. Nobody got grilled over it. Patient's best interest. The only issue was transport. The Supervisor had to fill out an "Unusual Occurrence" report... but that was the end of that story.

Learn the protocols and know exactly under what circumstances you can transport patients needing ALS care and when you should turn the patient over to ALS. Your boss might chew you out, but you'll still have your EMT Certificate... even if you become unemployed because of it.

Here's Santa Clara County's BLS Ambulance Utilization policy: BLS Ambulance Utilization Read it. It's very informative for these situations. Look for Orange County's version of this, if it exists, and follow it.


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## Akulahawk (Aug 21, 2009)

jgmedic said:


> Hmm...maybe the paramedics knew they type of shenanigans your company has pulled(like BLS'ing obviously ALS patients, or arguing about transports on scene, in front of patients) and don't want to be involved in that type of business. Maybe not, but having worked in that system for several years before becoming a medic, it would not surprise me, things I have personally witnessed, like managers arguing with fire, because it is THEIR patient(*not for pt care reasons, but for billing*) and con homes telling me if I call for ALS(911) then they won't call our company anymore, *because it'll ruin their stats.*


That brings back memories too... Mostly from other employees of other companies. We followed the BLS transport policies to the letter... back when I worked BLS. Doing that kept out collective butts out of the wrath of the County EMS Agency. I suspect that one company didn't do that... and no longer is an approved provider for anything over there...


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## jgmedic (Aug 21, 2009)

Unfortunately, in OC the only ALS 911 ambos are FD. All others are BLS, most cities use a private BLS ambo with Engine based medics who ride in on ALS calls. The problem is that some con homes and other facilities know what companies will call for ALS and which ones will just haul the pt off with few to no questions asked. They are the same places that train their EMT's to act like this guy and flaunt their "knowledge" in everyone's face.


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## Akulahawk (Aug 21, 2009)

jgmedic said:


> Unfortunately, in OC the only ALS 911 ambos are FD. All others are BLS, most cities use a private BLS ambo with Engine based medics who ride in on ALS calls. The problem is that some con homes and other facilities know what companies will call for ALS and which ones will just haul the pt off with few to no questions asked. *They are the same places that train their EMT's to act like this guy and flaunt their "knowledge" in everyone's face.*


And doing that does him (and everyone else) a huge dis-service.


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## Ridryder911 (Aug 21, 2009)

Anyone want to bet that the blood pressure might have been taken in the arm with the shunt? ......

R/r 911


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## Akulahawk (Aug 21, 2009)

Ridryder911 said:


> Anyone want to bet that the blood pressure might have been taken in the arm with the shunt? ......
> 
> R/r 911


And this would not surprise me... a 1 month EMT with little education in dealing with Dialysis patients...


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## lsingleterry (Aug 21, 2009)

*dialysis patient run*

I am really disgusted by the actions of this BLS unit.  These guys should not be ems providers.  They will not be beneficial to the community that they serve.  They will become an eyesore to other EMS providers, and if they are not careful they will lose certs. and cost the company some money if not the right to practice in the community they should love.


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## Tiberius (Aug 22, 2009)

Holy crap....I must have received the wrong training.

I mean, after only a month on the truck and this cat knows everything. I've been out here for about 10 years and feel as though I know nothing...wow.




shadowstewie said:


> From what my Manager told me, the Paramedics were supposed to go in the ambulance with our crew since it is OUR patient, not the other company's. But the paramedics didn't, all they wanted to do was move the patient to the other ambulance since they were contracted with them. I'm not saying I know everything, but that I believe is not a smart move by the Paramedics.



The last sentence in your post contradicts itself and proves everyone's point. HOW do you know it wasn't a smart move by the medics??? The ink on your card is still wet. Trust me, you are no authority on what is and isn't a smart move by the medics. I sure wasn't after a month out of school. 

Furthermore, we are out here to to what's right for the PATIENT, NOT FOR THE AMBULANCE COMPANY'S BOTTOM LINE!!! Once ALS is called and arrives on scene, the PARAMEDIC calls the shots. NOT YOU! Your patient now becomes the medic's responsibility. The medic should have went after your and your partner's license. 

Oh, and BTW, your manager is a :censored: incompetent moron.


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## Sasha (Aug 22, 2009)

> From what my Manager told me, the Paramedics were supposed to go in the ambulance with our crew since it is OUR patient, not the other company's. But the paramedics didn't, all they wanted to do was move the patient to the other ambulance since they were contracted with them. I'm not saying I know everything, but that I believe is not a smart move by the Paramedics.



I'm wondering how you think that a paramedic can treat a patient in a BLS truck. Surely they cannot move all the equipment over to the BLS truck. IV and a bag of saline, maybe the drug box, maybe, but they can require more than that and you wouldnt even know it.


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## daedalus (Aug 22, 2009)

Duuude. You have NOO idea what you don't know. and if you plan on over riding doctors and nurses you are in for a short career. My CCT RN had a few EMTs fired the other month because they choose to fight with a cardiologist about the transfer of a patient who the EMTs said was "unstable". The guy needed a very quick and stress free ride to the cath lab. EMTs cannot possibly think that they can interpret vital signs or other diagnostic information.

EMTs are not taught anything about how to manage this patient. The amount of pathology going on in that patient (the renal failure, the obesity, the probable DM and other co-morbidites) requires an internal medicine doctor to sort out. The kind of person who spends four years *after* medical school learning how disease states of the adult body alter function. All of these diseases also will affect vital signs. An EMT with a few hours of training on how to take vital signs is no better than a man who stayed in a Holiday Inn Express last night when it comes to helping a patient like this.

EDIT: Holly Hells Bells, I just read some of the original poster's follow up comments. If I knew who you were, OP, I would work hard to make sure you never treated a patient again. To think you knew what was best over the nephrologist and dialysis RN, and than the responding paramedic, is ludicrous. You disobeyed a paramedic on scene, who according to the state and county, is the in charge medical authority at the scene of a prehospital incident. That alone can land your company in hot water and yourself flipping burgers. I hope that you take Rid/Ryder's and others comments on here very seriously and leave our profession expeditiously.


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## shadowstewie (Aug 22, 2009)

Hoofguy said:


> That's another thing, did you manually take a pulse or BP? Or just look at the machine and want to go A-Team to the hospital? Treat the patient NOT the machine..



Okay, a couple of things. For one, the patient's pulse kept elevating higher and higher. Two, the RN was the one who was getting worried and didn't know why the patient's pulse was that high. According to her, his pulse is always in the mid 80's right after he is done with dialysis. I wasn't near the patient when I was talking to my partner on what we should do. Plus I wasn't freaking out over anything. I was calm and so was my partner. The one who didn't seem to know what was going on was the RN, and it took her about 25 minutes to finally get an answer from the doctor on what she should do.

And last. We took his blood pressure with our cuff multiple times switching arms. Even my partner used a thigh cuff once on him, and his BP and pulse was still matching the machine.


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## shadowstewie (Aug 22, 2009)

Sasha said:


> I'm wondering how you think that a paramedic can treat a patient in a BLS truck. Surely they cannot move all the equipment over to the BLS truck. IV and a bag of saline, maybe the drug box, maybe, but they can require more than that and you wouldnt even know it.



No, I understand that. Just that every BLS call we've had to turn into it being an ALS call...the paramedics would always just hop in the back of our BLS ambulance with their bag.


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## shadowstewie (Aug 22, 2009)

daedalus said:


> Duuude. You have NOO idea what you don't know. and if you plan on over riding doctors and nurses you are in for a short career. My CCT RN had a few EMTs fired the other month because they choose to fight with a cardiologist about the transfer of a patient who the EMTs said was "unstable". The guy needed a very quick and stress free ride to the cath lab. EMTs cannot possibly think that they can interpret vital signs or other diagnostic information.
> 
> EMTs are not taught anything about how to manage this patient. The amount of pathology going on in that patient (the renal failure, the obesity, the probable DM and other co-morbidites) requires an internal medicine doctor to sort out. The kind of person who spends four years *after* medical school learning how disease states of the adult body alter function. All of these diseases also will affect vital signs. An EMT with a few hours of training on how to take vital signs is no better than a man who stayed in a Holiday Inn Express last night when it comes to helping a patient like this.
> 
> EDIT: Holly Hells Bells, I just read some of the original poster's follow up comments. If I knew who you were, OP, I would work hard to make sure you never treated a patient again. To think you knew what was best over the nephrologist and dialysis RN, and than the responding paramedic, is ludicrous. You disobeyed a paramedic on scene, who according to the state and county, is the in charge medical authority at the scene of a prehospital incident. That alone can land your company in hot water and yourself flipping burgers. I hope that you take Rid/Ryder's and others comments on here very seriously and leave our profession expeditiously.



Wooow dude relax. All I'm saying is that I don't feel like leaving a patient with an RN who seems to be having trouble not knowing why the patient's pulse is extremely higher than normal and how she's running around the dialysis center looking for things to help him when nothing is working. The oxygen didn't work. The Saline didn't work. Nothing was working and his pulse kept elevating higher and higher. I mean if everyone here is going to tell me to not care what's going on and to let the higher authority deal with the patient...when there could be an option that is in better interest for the patient, then so be it I guess. I'm just trying to see if anyone knows where I'm coming from with the RN running around not knowing a clue what she's doing.


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## shadowstewie (Aug 22, 2009)

Tiberius said:


> Holy crap....I must have received the wrong training.
> 
> I mean, after only a month on the truck and this cat knows everything. I've been out here for about 10 years and feel as though I know nothing...wow.
> 
> ...



Okay lol, I wasn't on that call nor was even hired when our company's EMT disobeyed the Paramedic. Our manager just told us that story. And yes, the Paramedic did try to have the EMT's license pulled but the OCEMS Agency denied it because the EMT did what was right and it was in the patient's best interest. The OCEMS Agency was the one who told our company to not let Medics say that they can pull anyone's license because they can't. Only the OCEMS Agency is allowed to do that.


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## shadowstewie (Aug 22, 2009)

Ridryder911 said:


> Okay, I will say it. Noobie, you and your partner have* NO* business in prehospital care, transporting live patients... heck; even dead one's. I would not even suggest being a driver of carcass removal transport system.
> 
> I will say thank-you though. Yeah, thanks for setting EMS back 40 years to the old "ambulance driver" stigma.
> 
> ...



Like I said before and i'll say it again. That Paramedic DID try to pull the EMT's license but the OCEMS Agency DENIED HIS CLAIM because the EMT was doing what was for the patient's best interest. The OCEMS also told our COMPANY to not listen to Paramedics if they say anything about pulling our licenses because they cannot officially do that. Only the OCEMS is allowed to do that.


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## medichopeful (Aug 22, 2009)

shadowstewie said:


> Like I said before and i'll say it again. That Paramedic DID try to pull the EMT's license but the OCEMS Agency DENIED HIS CLAIM because the EMT was doing what was for the patient's best interest. The OCEMS also told our COMPANY to not listen to Paramedics if they say anything about pulling our licenses because they cannot officially do that. Only the OCEMS is allowed to do that.



I'm sorry, but I don't see how refusing to hand off a patient to a higher medical authority is in the patient's best interests. 

And check your ego, or you'll be the one pulling this move next.


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## Sasha (Aug 22, 2009)

I really don't see how not listening to the paramedic and taking the patient with a lower level of care is in the best interest of the patient. I'm starting to think this whole thread is BS. 

A nurse not knowing what to do? No love. A nurse works on orders, she can't just send the patient to the hospital unless it is a true, dire emergency without orders. That's how it works around here. If it's not cardiac arrest she must contact the doctor and get the go ahead. 

Just because you weren't standing next to him doesn't mean you weren't scaring the bejeesus out of him.


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## VentMedic (Aug 22, 2009)

Sasha said:


> A nurse not knowing what to do? No love. A nurse works on orders, she can't just send the patient to the hospital unless it is a true, dire emergency without orders. That's how it works around here. If it's not cardiac arrest she must contact the doctor and get the go ahead.


 
No, nurses have standing orders or protocols for many things also. If they believe there might be something else that can be done or to see if the patient needs to be admitted, then they will make the call to a doctor. The patient is going to be leaving their clinic and they do want to run any possibilites past a physician first and allow him/her to assume the responsibility in situations that are borderline.


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## VentMedic (Aug 22, 2009)

shadowstewie said:


> Okay lol, I wasn't on that call nor was even hired when our company's EMT disobeyed the Paramedic. Our manager just told us that story. And yes, the Paramedic did try to have the EMT's license pulled but the OCEMS Agency denied it because the EMT did what was right and it was in the patient's best interest. The OCEMS Agency was the one who told our company to not let Medics say that they can pull anyone's license because they can't. Only the OCEMS Agency is allowed to do that.


 
Do you not see the problem with this?  Under a different medical director for the county, do you think things might have a very different outcome?  If this happened in a neighboring county, do you think things might be different?  If the state EMSA decides to investigate as they now have for several complaints about the direction of different counties and disturbing issues, do you not think things might turn out very differently for someone else?   Right now in California, if you know the Medical Director, you can get an EMT cert even if you are a convicted child killer.  The situation you have described is also why the state needs to take some of the disciplining authority away from each county and start holding those with certifications more accountable for their actions.

Regardless of the issues with California, it is important *YOU* understand why blatantly defying a higher medical level is not in the best interest of the patient.   If you can not see a problem with this, then yes I will agree with the others. You will not do well in this profession nor will the patients you come into contact with.


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## shadowstewie (Aug 22, 2009)

VentMedic said:


> Do you not see the problem with this?  Under a different medical director for the county, do you think things might have a very different outcome?  If this happened in a neighboring county, do you think things might be different?  If the state EMSA decides to investigate as they now have for several complaints about the direction of different counties and disturbing issues, do you not think things might turn out very differently for someone else?   Right now in California, if you know the Medical Director, you can get an EMT cert even if you are a convicted child killer.  The situation you have described is also why the state needs to take some of the disciplining authority away from each county and start holding those with certifications more accountable for their actions.
> 
> Regardless of the issues with California, it is important *YOU* understand why blatantly defying a higher medical level is not in the best interest of the patient.   If you can not see a problem with this, then yes I will agree with the others. You will not do well in this profession nor will the patients you come into contact with.



Noooo, I completely see where you are coming from. I guess the EMT that was working for our company had been on for years and years and was also a registered Medic even though he was only hired on BLS. Supposedly he knew that it wasn't in the best interest for the patient because the patient was posing life threatening problems and the Medic's wanted him to take the patient out of his BLS ambulance and put them into another BLS ambulance which would have wasted precious time dealing with the patient, because the Paramedic told him once the patient was secure in the other BLS ambulance, they would work on him. I don't know. I just think that is kind of dumb to switch ambulances if they are both BLS. Going from a BLS to an ALS rig, that's a different story. But does anyone kinda see where I'm coming from a little?


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## medichopeful (Aug 22, 2009)

shadowstewie said:


> Noooo, I completely see where you are coming from. I guess the EMT that was working for our company had been on for years and years and was also a registered Medic even though he was only hired on BLS. Supposedly he knew that it wasn't in the best interest for the patient because the patient was posing life threatening problems and the Medic's wanted him to take the patient out of his BLS ambulance and put them into another BLS ambulance which would have wasted precious time dealing with the patient, because the Paramedic told him once the patient was secure in the other BLS ambulance, they would work on him. I don't know. I just think that is kind of dumb to switch ambulances if they are both BLS. Going from a BLS to an ALS rig, that's a different story. But does anyone kinda see where I'm coming from a little?



So you're saying that your partner, a trained paramedic who had been working for years, wasted time by arguing with a paramedic who was on duty as a paramedic, all while the patient's life was in danger?  And you're saying that your co-worker called for ALS, decided that he didn't like what showed up, and then decided that he would, instead, keep the patient in his truck, even though an ALS unit was there? 


I just want to point this out:


> I just think that is kind of dumb to switch ambulances if they are both BLS. Going from a BLS to an ALS rig, that's a different story



Wouldn't going from a truck staffed by basics to  a truck staffed by at least one medic count?  Why would an on duty paramedic work in a BLS ambulance?

Your story isn't really making much sense.


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## shadowstewie (Aug 22, 2009)

medichopeful said:


> So you're saying that your partner, a trained paramedic who had been working for years, wasted time by arguing with a paramedic who was on duty as a paramedic, all while the patient's life was in danger?  And you're saying that your co-worker called for ALS, decided that he didn't like what showed up, and then decided that he would, instead, keep the patient in his truck, even though an ALS unit was there?
> 
> 
> I just want to point this out:
> ...



Okay, for the last time! I was not working with this crew when it happened! I wasn't even hired with this company yet when all this happened! I was just telling a story about it. No, an ALS unit wasn't there at all. The Fire Department engine showed up along with their private contracted BLS company. There was no Rescue ALS unit on scene. Both units were BLS units that had BLS supplies in them. Why would the Medic not go in our company's BLS ambulance and treat the patient while the patient is already secure in it ready to go, instead of what he wanted to do in the first place; switch out the patient while the patient was posing life threatening problems to put him in the same kind of ambulance as ours, just a regular BLS. That's wasting time isn't it? The Medic stated that once the patient was secure in the other BLS ambulance, they would work on him. Why wouldn't the Medic work on the patient in OUR ambulance since the patient is ready to go and all? The Medic wanted our company's EMT to move the patient onto ANOTHER BLS stretcher. Don't you guys thing that isn't right? Or am I completely missing something?


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## Sasha (Aug 22, 2009)

Am I the only one really confused?


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## rescue99 (Aug 22, 2009)

The Medic wanted our company's EMT to move the patient onto ANOTHER BLS stretcher. Don't you guys thing that isn't right? Or am I completely missing something?[/QUOTE]


With everything else aside...not! No way would I have played musical cots with another equally licensed crew. On this, you are correct. ALS should have done a quick ALS equipment grab just as in any other intercept. There was no justification to do anything differently. Now I see why the BLS boss defended his crew.


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## Tiberius (Aug 22, 2009)

:huh:

Okay.....I think I know which direction this thread is going....

                                        or

This thread makes as much sense as this does...








My head hurts now.


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## shadowstewie (Aug 22, 2009)

shadowstewie said:
			
		

> The Medic wanted our company's EMT to move the patient onto ANOTHER BLS stretcher. Don't you guys thing that isn't right? Or am I completely missing something?





rescue99 said:


> With everything else aside...not! No way would I have played musical cots with another equally licensed crew. On this, you are correct. ALS should have done a quick ALS equipment grab just as in any other intercept. There was no justification to do anything differently. Now I see why the BLS boss defended his crew.



Thank you! I'm glad you know where I'm finally coming from.


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## NEMed2 (Aug 22, 2009)

shadowstewie said:


> Thank you! I'm glad you know where I'm finally coming from.



Where was this medic when they were instructing you to move the pt to the other BLS ambulance?  In your original post it sounded like the medic was on scene, which completely changes the situation.




Sasha said:


> I'm wondering how you think that a paramedic can treat a patient in a BLS truck. Surely they cannot move all the equipment over to the BLS truck. IV and a bag of saline, maybe the drug box, maybe, but they can require more than that and you wouldnt even know it.



I run on a BLS ambulance and if a call is ALS we either intercept en route or meet ALS on scene if time allows.  They typically will grab their gear & get into our ambulace.  The ALS departments we work with have their gear set up this way. I have never had an instance where a paramedic needed something and did not have it.


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## VentMedic (Aug 22, 2009)

shadowstewie said:


> Noooo, I completely see where you are coming from. *I guess the EMT that was working for our company had been on for years and years and was also a registered Medic even though he was only hired on BLS.* Supposedly he knew that it wasn't in the best interest for the patient because the patient was posing life threatening problems and the Medic's wanted him to take the patient out of his BLS ambulance and put them into another BLS ambulance which would have wasted precious time dealing with the patient, because the Paramedic told him once the patient was secure in the other BLS ambulance, they would work on him. I don't know. I just think that is kind of dumb to switch ambulances if they are both BLS. Going from a BLS to an ALS rig, that's a different story. But does anyone kinda see where I'm coming from a little?


 
I don't think you know any of the facts of this situation.

As far as this Paramedic(?), I think if any of this is true, there is little doubt as to why he is only working BLS.


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## Akulahawk (Aug 22, 2009)

My comments inline... for easy reading 


NEMed2 said:


> Where was this medic when they were instructing you to move the pt to the other BLS ambulance?  In your original post it sounded like the medic was on scene, which completely changes the situation.
> 
> From what I read from the original post (which is likely company legend), it definitely sounds like the Paramedic was on-scene. If the medic made patient contact, he's officially in charge... and that BLS crew could been charged with (or hassled for) PC 148...
> 
> ...


In the past, the few times we've _had _to do ALS intercepts, the medic was aware that there was no ALS transport unit coming, or the ETA for that transport was so long that they would ensure that whatever they needed for that transport was all in one bag. They'd toss it in the BLS unit and away they go. Of course, this was in a system with ALS Ambulances and uses BLS Ambulances as backup as needed. Doing an intercept was unusual, but nowhere close to unheard-of.


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## harkj (Aug 22, 2009)

ugh some people give emt-b such bad names for one if you felt the need to ask for an ALS unit you were all ready way over your head and you couldnt do what was needed for the pt and thats why we are here (hopefully)


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## Ridryder911 (Aug 22, 2009)

Sniff...sniff... anyone else smell that? Smells like B.S. or let's change the scenario as we have found out by unanimous opinion of what a case of dumbass is? 

Now, the story changes with each post.. ALS working BLS.. BLS w./Paramedic's .. dumb and scared RN from arrogant and an idiot EMT. 

Sorry, either you did not post correctly the first time or building (attempting) to dig yourself out of stupidity with a spoon. 

It's much better to face the music and say... "You know what? I screwed the pooch" and go on and live to learn not to ever do the same mistake again. Never tolerate such erroneous decision making. 

RN upset or not, the EMT did not allow the higher trained (they were able to provide care) to do their duty, as well whom ran in with lights & sirens representing that it was a life threatening emergency? ..... 

Part of maturing in this business is being able to justify each and every action you perform. Right or wrong! Own up to your decisions and build up to be better each every time. This is how those that become good do so.. they learn off their and everyone elses mistakes on what NOT to do. 

R/r 911


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## kittaypie (Aug 23, 2009)

Ridryder911 said:


> It's much better to face the music and say... "You know what? I screwed the pooch" and go on and live to learn not to ever do the same mistake again.




i know this is a little off topic but i was watching the scrubs episode today where Dr. Cox mentions "screwing the pooch" and it made me giggle a bit...

anyway... carry on!


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## usafmedic45 (Aug 23, 2009)

Ridryder911 said:


> Okay, I will say it. Noobie, you and your partner have* NO* business in prehospital care, transporting live patients... heck; even dead one's. I would not even suggest being a driver of carcass removal transport system.
> 
> I will say thank-you though. Yeah, thanks for setting EMS back 40 years to the old "ambulance driver" stigma.
> 
> ...


Wow....even as a guy who gets regularly told he's too harsh to the newbies.....wow.  However, I do not disagree in the slightest.



> Anyone want to bet that the blood pressure might have been taken in the arm with the shunt? ......



You beat me to it.


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## shadowstewie (Aug 23, 2009)

VentMedic said:


> I don't think you know any of the facts of this situation.
> 
> As far as this Paramedic(?), I think if any of this is true, there is little doubt as to why he is only working BLS.



Because out here, you can only work as a Paramedic if you're hired with Fire. All other companies that hire Medic's aren't hiring at all and are actually laying people off. My cousin is a registered Medic but he works for a BLS Ambulance out here because no one else is hiring but Fire.


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## shadowstewie (Aug 23, 2009)

Ridryder911 said:


> Sniff...sniff... anyone else smell that? Smells like B.S. or let's change the scenario as we have found out by unanimous opinion of what a case of dumbass is?
> 
> Now, the story changes with each post.. ALS working BLS.. BLS w./Paramedic's .. dumb and scared RN from arrogant and an idiot EMT.
> 
> ...



Why would I admit that I screwed up on something when I didn't even do anything wrong in the first place?


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## shadowstewie (Aug 23, 2009)

usafmedic45 said:


> Wow....even as a guy who gets regularly told he's too harsh to the newbies.....wow.  However, I do not disagree in the slightest.
> 
> 
> 
> You beat me to it.



The blood pressure was taken on both arms multiple times, and also on his thigh. All 3 limbs had same results.


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## usafmedic45 (Aug 23, 2009)

> Why would I admit that I screwed up on something when I didn't even do anything wrong in the first place?



Uh.....because you did do something wrong?  Actually you did something wrong (overreacted) and did it in a manner that pretty much guarantees that nurse, that doc and anyone they talk to about you is never going to take your word at even face value ever again. 



> The blood pressure was taken on both arms multiple times, and also on his thigh. All 3 limbs had same results.



No, by your own posts, they did not:
134/78  in one arm, and 142/82 in the other and increasing with each remeasurement.....



> He starts to tear up because he thinks something could be really bad going on with him when he feel's perfectly fine.



This would be because of you and/or your partner repeatedly asking him if he's OK when he thinks he is.  Trust me, if I reversed the scenario, you'd become a little tachycardic and your BP would rise if you were being interrogated more or less.  After the second or third time of someone going "Are you SURE you're not having chest pain?", most people are going to start worrying that the "medical professional" is picking up on something they are not. Welcome to the wonderful world of playing mind games with people, even though it was done inadvertently.



> I almost had to argue with her that if it went up one more time, I'm taking him Code 3 to the ER



You're extremely lucky you walked away with your job.  I've fired people for copping an attitude and/or picking a fight over something stupid.  You'd be amazed how much hell a nurse can unleash upon EMTs if she decides to take it to her director of nursing who in turn calls your boss and reports you for basically acting wholely unprofessionally.  When the saying "Hell hath no fury like a woman scorned", I'm pretty sure the woman they were talking about was a nurse.  You'd be amazed how little your boss values your continued presence as an employee of his company when the phrase "He goes or we barr your service from ever bringing someone to our dialysis center again" gets uttered by a facility administrator.  Trust me, I've heard it come out of the mouth of a director of nursing myself.     



> btw his normal BP is 115/72 and pulse 84.



The thing you have to remember about hypertension is that it is only significant- in the short term at least- if it is causing end-organ symptoms (chest pain, neurologic issues, headache, shortness of breath, etc).  Also define "normal": are we talking his "normal" before his treatment, during or afterwards? Laying down, seated, standing?   I also suggest you google "white coat hypertension" and see why the very presence of a freaked out health care worker may have been a good reason for the "elevated BP".  

One of the tricks to develop in health care is the ability to read or see something and go "Oh ****" inside your head but not show it on your face, in your tone of voice or your mannerisms.  This also comes in handy should you ever decide to join the World Poker Tour.  



> I don't care what anyone says to me, whether a Paramedic, RN, Doctor, whoever...if I feel something is better for the patient that's going to help them, I'm going to do it, plus that's what our company is strongly advising us to do, is to argue and do what's best interest for the patient.



Then may I recommend you learn the phrase, "Hi, welcome to Burger King, would you like to try the new Angry Whopper?" because with that attitude- and an apparent inability to know when/how/why to pick your battles, you're not going to last long in this field or any branch of medicine.  

It's one thing if you can prove to the person- especially docs and nurses- that you have a damn good reason for standing up and telling them "I may only have 150 hours of training under my belt, but you're wrong!" (because that is exactly how they are going to view that attitude, not as some righteous savior out for the good of the patient) and an entirely different beast to freak out over something paltry and make yourself look like Chicken Little every time you see something that isn't spot on perfect and you can't reason through figuring it out.  

I am not saying this to be mean- trust me, I've got better things to do with my time than to be sitting at 0730 trying to think of a good way to make you cry by crushing your soul and breaking your spirit- but rather to try to keep you from further screwing up your job by continuing with this attitude.  If I didn't think there was some value inherent in you, I would just let Ridryder continue to feast upon your entrails until you decide that this forum isn't for you and migrate over to EMTCity.  



> I know this patient since he's a regular and I've taken him a couple times



You "know" him about as well as I know one of my wife's friends: we talk, I know she's an bleeding heart who thinks she's going to save the world by doing missionary work as an RN, and is an insulin-dependent diabetic with a weight issue, but beyond that....

Chances are the nurse you paint as a bumbling, uncaring piece of work and the doc who didn't respond to your concerns with "_Ja wohl mein Herr_!" probably know this patient a HECK of a lot better than you do.



> just to see him start to tear up and almost start crying every time the machine beeped stating he wasn't in good condition, it kinda killed me after I got off work and I started to feel really bad for him because he's a good guy, really nice, really cooperative, really grateful.



Not to add salt to the wound man, but you and/or your partner pretty much caused most of that because of the way you handled the case.  This is why HOW something is said is usually more important than WHAT is said.   That said, I know I'm going to hear from the mods on this one about how I need to follow my own advice since I'm know around here as a total raging a**hole who occasionally shows his softer side (like I'm trying to do now).   



> I know I will get better to not let it bother me or anything but can anyone help me or tell me things they've done to help cope with emotional calls that you feel really bad for the patient or even family members?



It should bother you.  That's called having a conscience and there's absolutely nothing wrong with having one.  If what you did and the results of it didn't bother you, you would pretty much be a sociopath.  Actually if seeing another person in pain, discomfort or fear didn't make you feel for them, I would be very afraid of you.

The problem here is that you're misreading the cues of the scenario and assuming that the problem lay with the patient - for whom you feel badly-and his perceived medical issues but failing to see that your actions made the situation worse.  They may not have caused the initial slight elevation in BP and HR but it sure didn't seem to help much.  

It's not an uncommon problem in emotionally immature or socially/professionally inexperienced persons (not meant as an insult or degradation and I'm not speaking specifically about you either....these are general statements) to lack the ability to analytically pick apart their actions, to be introspective and to admit fault in a socially or professionally unpleasant situation but these are vital things you have to have to excel in medicine in any way shape or form.  The sooner someone lacking these traits works on developing them and not taking constructive criticism- such as is being offered (for the most part) here- without becoming defensive or changing the story to avoid the criticism, the better for everyone involved.   

As I said, there's nothing wrong with screwing up in a small way once in a while through plain old fashioned ignorance (we all do it, myself included).  What is a problem is when ignorance (simply not knowing any better because you've never been told any different) ends and stupidity (you've been corrected and still persist in your belief that you're right and everyone else is wrong) begins.  As the saying goes, stupidity kills, but it tends to kill the wrong people in far too great of numbers and the right people in far too small of numbers.

I sincerely wish you the best in your career.


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## VentMedic (Aug 23, 2009)

shadowstewie said:


> Because out here, you can only work as a Paramedic if you're hired with Fire. All other companies that hire Medic's aren't hiring at all and are actually laying people off. My cousin is a registered Medic but he works for a BLS Ambulance out here because no one else is hiring but Fire.


 
Other medics in similar situations in California have relocated to an area where they can work as a Paramedic. 

The fact that he was a Paramedic who understood this patient needed advanced care which he did not have the meds or equipment to even monitor the patient makes this even more irresponsible. 



shadowstewie said:


> The blood pressure was taken on both arms multiple times, and also on his thigh. All 3 limbs had same results.


 
Did they not teach you about BP and stressful situations? You look at the patient. The fact that you kept repeating the BP, including the arm with the shunt, was probably arguing with the RN, was rushing with "gotta go to ED real fast" motions and attitude and made this patient cry probably contributed to much of the BP problems or didn't help matters when the RN was in the process of stabilizing the patient. This RN also may have seen this patient for at least 4 hours per day and 3 days per week for several years. 

I would suggest you work in a more controlled situation like an ED for awhile, along with continuing your education, until you gain some experience in seeing many different patients and working with other healthcare professionals. You are not ready to be working with patients without supervision. The fact that you don't want to see where you could have handled this situation differently shows you are not willing to learn from your mistakes and will continue to make the same ones over and over. The EMT-B class you took does not teach very much about medical emergencies and it also failed to prepare you in how to handle yourself with patients and other professionals in healthcare.


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## Aidey (Aug 23, 2009)

shadowstewie said:


> The blood pressure was taken on both arms multiple times, and also on his thigh. All 3 limbs had same results.



Where is the pts dialysis access?


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## rescue99 (Aug 23, 2009)

I'll absolutely argee; this BLS crew was over zealous, under trained and pretty darned disrespectful of their patient's welfare as a whole. There is no doubt a person will worsen when he's constantly asked "ya sure ya don't feel sick", by what is perceived as a medical professional. Don't need 1000 words to say...wow, get a little more skill under yer belts there kiddo.


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## KillTank (Aug 23, 2009)

Dominion said:


> Good lord sentence structure and paragraphs are your friend.



Had to be a Paramedic...


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## shadowstewie (Aug 23, 2009)

VentMedic said:


> Other medics in similar situations in California have relocated to an area where they can work as a Paramedic.
> 
> The fact that he was a Paramedic who understood this patient needed advanced care which he did not have the meds or equipment to even monitor the patient makes this even more irresponsible.
> 
> ...



Actually there is a lot of registered medic's here in Orange County/LA County that work for a BLS company because they cannot find a job working ALS, and maybe they cannot reside somewhere else at this time due to other issues.

The RN was mostly asking him if he felt fine or not like 5x. My partner and I asked him maybe twice and that was it, and that was in the beginning. No one was arguing with the RN at all, she was running around trying to figure out what was wrong with him. And as for the ER...we weren't near the patient when we were talking about that. Plus the RN was telling us that we might possibly have to take him to the ER but she wanted to wait for the Doctor which took like 20-25 minutes to call her back.


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## Sasha (Aug 23, 2009)

KillTank said:


> Had to be a Paramedic...



....Did you read the post at all?


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## shadowstewie (Aug 23, 2009)

Aidey said:


> Where is the pts dialysis access?



If I remember, it's in his chest. That's where she started Saline on him was through that.


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## VentMedic (Aug 23, 2009)

shadowstewie said:


> If I remember, it's in his chest. That's where she started Saline on him was through that.


 
Do you check the arms for working or old shunts before you place a BP cuff?  What about for PICC lines or mastectomy patients?


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## rescue99 (Aug 23, 2009)

shadowstewie said:


> If I remember, it's in his chest. That's where she started Saline on him was through that.



Hey Shadow..take this particular call as a great opportunity to learn. There are a few things you can think back on and do differently the next time. Not a person in here hasn't been a greenie. We've allll....YES ALL, have been where you are. Good luck and never stop asking, listening and learning.


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## shadowstewie (Aug 23, 2009)

VentMedic said:


> Do you check the arms for working or old shunts before you place a BP cuff?  What about for PICC lines or mastectomy patients?



I'm not sure. We were just following what the Nurse was telling us to do. She told us to check both arms to see if any of them are normal. And my partner  upon himself used a thigh cuff also just because the patient was 380lbs and wanted to see if there was a difference. I know i've stated that the blood pressure kept rising, and another post that the blood pressure stayed the same. What I meant by that is that the BP stayed the same way as it was...that it was elevating, and that the BP wasn't going back to normal.


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## Ridryder911 (Aug 23, 2009)

rescue99 said:


> Hey Shadow..take this particular call as a great opportunity to learn. There are a few things you can think back on and do differently the next time. Not a person in here hasn't been a greenie. We've allll....YES ALL, have been where you are. Good luck and never stop asking, listening and learning.



Not quite, yes we all have made many mistakes. I and many others have had FTO's and partners that closely monitored and not allowed such an occurrence and definitely no attitude to go along with it. The reason many of us are upset is that not only you have a newbie but one that is paired up with a screw up. 

As you are aware how so many bad habits are formed and many are not aware because no one is out there informing them differently. As well so many educators are beginning to see a clean slate (no experience) is better than those that have already bad habits ingrained in them.

p.s. Why is this call appearing to be totally different than the original post? 

R/r 911


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## Sasha (Aug 23, 2009)

> p.s. Why is this call appearing to be totally different than the original post?



Because he's back peddling.


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## KillTank (Aug 23, 2009)

Sasha said:


> ....Did you read the post at all?



yes I did. What is your point?


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## shadowstewie (Aug 24, 2009)

Sasha said:


> Because he's back peddling.



How am I back peddling? People are asking me questions about things and I'm clearing them up. I wasn't completely specific in my first post if that's what you're talking about.


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## Flight-LP (Aug 24, 2009)

shadowstewie said:


> I'm not sure. We were just following what the Nurse was telling us to do. She told us to check both arms to see if any of them are normal.



This is back peddling. You now say you are following the orders of the very person you were questioning. QUIT WHILE YOU ARE AHEAD!

Chalk this up as a learning experience and get a little more of that experience before you start strutting around telling folks that you aren't going to listen to them. Otherwise, you will find yourself out of a job, and depending on how badly you piss someone off, maybe a career.


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## KillTank (Aug 25, 2009)

shadowstewie said:


> I'm not sure. We were just following what the Nurse was telling us to do. She told us to check both arms to see if any of them are normal. And my partner  upon himself used a thigh cuff also just because the patient was 380lbs and wanted to see if there was a difference. I know i've stated that the blood pressure kept rising, and another post that the blood pressure stayed the same. What I meant by that is that the BP stayed the same way as it was...that it was elevating, and that the BP wasn't going back to normal.



Fun Fact... RN, LVN or CNA are NOT trained in Emergency Pre Hospital. Only A doctor can give orders on a scene and that is if medical directive will allow it.


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## Aidey (Aug 25, 2009)

An RN is still legally a higher level of care than an EMT or Paramedic. They may not be able to give orders to the EMT or Paramedic, but they can refuse to turn over care, and continue to care for the pt within the scope of their own protocols and orders. 

Telling someone to do something like checking a BP on both arms is part of a through medical assessment. Doing that is a lot different than saying "Give him 10mg of morphine". 

I'm not sure about LVNs, but in the case of CNAs for sure, they are not considered medical practitioners, and a Paramedic is (but not an EMT), and thus they are a higher level of care.


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## wyoskibum (Aug 25, 2009)

Aidey said:


> An RN is still legally a higher level of care than an EMT or Paramedic. They may not be able to give orders to the EMT or Paramedic, but they can refuse to turn over care, and continue to care for the pt within the scope of their own protocols and orders.



While I agree that a RN is a higher level of care, I don't think it applies in the field.  Unless the RN in a Nurse Practitioner or is part of a Prehospital response with some sort of medical direction, they are not anything more than a good Samaritan.  Outside of the clinical environments, they usually do not have any protocols or orders. RN's in the field cannot do anything more than assess the patient and provide first aid.  Same goes for a Paramedic who happens upon a scene and not in their jurisdiction. 

The Paramedic who has a duty to act and has online medical direction has more legal authoriti. ;-D


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## Akulahawk (Aug 25, 2009)

Aidey said:


> An RN is still legally a higher level of care than an EMT or Paramedic. They may not be able to give orders to the EMT or Paramedic, but they can refuse to turn over care, and continue to care for the pt within the scope of their own protocols and orders.
> 
> Telling someone to do something like checking a BP on both arms is part of a through medical assessment. Doing that is a lot different than saying "Give him 10mg of morphine".
> 
> I'm not sure about LVNs, but in the case of CNAs for sure, they are not considered medical practitioners, and a Paramedic is (but not an EMT), and thus they are a higher level of care.


An RN might legally be a higher level of care, depending upon the scene. If the scene is treated as an interfacility transport, the RN is a higher level of care. If the scene becomes a prehospital scene, a Paramedic assumes command/control. Regardless, the EMT's in this case, could not do that. They should have remained under the direction of the RN.

The transition from interfacility transport to a prehospital call can be very sticky and have ramifications beyond that particular patient, if not done properly.


wyoskibum said:


> While I agree that a RN is a higher level of care, I don't think it applies in the field.  Unless the RN in a Nurse Practitioner or is part of a Prehospital response with some sort of medical direction, they are not anything more than a good Samaritan.  Outside of the clinical environments, they usually do not have any protocols or orders. RN's in the field cannot do anything more than assess the patient and provide first aid.  Same goes for a Paramedic who happens upon a scene and not in their jurisdiction.
> 
> The Paramedic who has a duty to act and has online medical direction has more legal authoriti. ;-D


In any of the County EMS systems I've worked in, _most _RN's in the field are considered a lower level of care than a Paramedic... they're required to be BLS unless they're MICN's... and even then they may assist the Paramedic at most. This is in the prehospital setting. Where things get wierd is in medical facilities that call for a 911 ALS response. I've seen two different ways of handling these. One way is that an ALS crew can wait for 10 minutes... if the patient is not ready, the crew goes back in service and is available for other calls. The other way is that the scene becomes a prehospital one and the crew then reverts to their protocols and Physician/RN on scene protocol. Around here, I've rarely heard of problems with this as most of the time, the facilities call for IFT units instead of 911 units... they can go to entirely off-line medical direction... and they can wait for patients to be made ready for transport. They still can call for orders in the rare event that a patient's condition falls outside the existing protocols but still within a Paramedic's Scope of Practice.


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## Aidey (Aug 25, 2009)

wyoskibum said:


> While I agree that a RN is a higher level of care, I don't think it applies in the field.  Unless the RN in a Nurse Practitioner or is part of a Prehospital response with some sort of medical direction, they are not anything more than a good Samaritan.  Outside of the clinical environments, they usually do not have any protocols or orders. RN's in the field cannot do anything more than assess the patient and provide first aid.  Same goes for a Paramedic who happens upon a scene and not in their jurisdiction.
> 
> The Paramedic who has a duty to act and has online medical direction has more legal authoriti. ;-D



In this situation the pt WAS in the clinical environment though, which is why I made the point I did. This is not some guy with chest pain in Starbucks and an RN happens to be there on a coffee run. Dialysis nurses have standing orders and follow protocols just like we do. In this situation, or in the case of a RN at a SNF/Rehab facility they may be able to do more to treat and stabilize the pt than you can.


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## wyoskibum (Aug 25, 2009)

Aidey said:


> In this situation the pt WAS in the clinical environment though, which is why I made the point I did. This is not some guy with chest pain in Starbucks and an RN happens to be there on a coffee run. Dialysis nurses have standing orders and follow protocols just like we do. In this situation, or in the case of a RN at a SNF/Rehab facility they may be able to do more to treat and stabilize the pt than you can.



Sorry, my mistake.  You are correct.  This thread has been going on so long, I forgot what the original details were! ;-D


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## Akulahawk (Aug 25, 2009)

Aidey said:


> In this situation the pt WAS in the clinical environment though, which is why I made the point I did. This is not some guy with chest pain in Starbucks and an RN happens to be there on a coffee run. Dialysis nurses have standing orders and follow protocols just like we do. In this situation, or in the case of a RN at a SNF/Rehab facility they may be able to do more to treat and stabilize the pt than you can.


Yep. Dialysis RN's typically have, on hand, the orders and equipment to render actual care at a higher level than EMT-B personnel. Even as an ALS call, I'd be inclined to treat this patient as an interfacility transport that is emergent than a regular scene call. 

I've been in SNF/Rehab facilities where the RN's orders were more restrictive than the prehospital EMT-B's. No IV's unless specifically ordered, no Advanced Airways, (actually, they'd need orders to put in an airway adjunct) No ACLS... Just basic CPR, whatever orders are in the patient's chart, and O2... max @ 3 LPM. Yes, I said 3 LPM by Nasal Cannula... for patients who are acutely SOB.


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## medic_texas (Aug 25, 2009)

Sasha said:


> Am I the only one really confused?



Nope  

It's one story, and another story, then the other story but this time the other basic is a medic who works as a basic who tells paramedics working as such that they know what's best for the patient and off they went.  

I think that clears it up.


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## medic_texas (Aug 25, 2009)

Did the patient ever consent to being treated/transported?  He "feels fine", why would he want to go to the hospital?  ..Other than 2 rookie-asses jumping around like a couple of monkeys :censored::censored::censored::censored:ing a football.


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## VentMedic (Aug 25, 2009)

Akulahawk;172761 
I've been in SNF/Rehab facilities where [B said:
			
		

> the RN's orders were more restrictive than the prehospital EMT-B's.[/b] No IV's unless specifically ordered, no Advanced Airways, (actually, they'd need orders to put in an airway adjunct) No ACLS... Just basic CPR, whatever orders are in the patient's chart, and O2... max @ 3 LPM. Yes, I said 3 LPM by Nasal Cannula... for patients who are acutely SOB.


 
Can an EMT-B administer Nitro (any form except drip), pain meds, inhalers, lasix, or BP meds? 

Many of the SNF patients have PRN meds with parameters and may already have been given before EMS or a transport ambulance is called. Yes, these can still considered emergent. 

Orders for an EMT-B are usually very generic and may do little harm if initiated. For a more definitive care, RNs will have PRN or standing orders specific to each patient. Also, RNs have many drugs at their access and may call a physician, not because they don't know nothing, but because each patient presents with different disease processes and a plan of care for definitive treatment can be initiated before the patient arrives at the hospital. That physician will then call the ED him/herself with more information and orders until he/she can assume care. Of course the ED physician can also do what he/she feels necessary. 

This is not about who can do more or what, but rather what is best for the patient. If a definitive plan of care can be initiated by the RN at the SNF, who care if he/she calls the physician. This is for the good of the paitent. It is much better than an EMT-B just scooping the patient and running with only O2 real fast to the ED because "their medical directors says they can do that without calling". 

Also, the reason a physician is called when a nurse initiates O2 or an airway adjunct is because the status of that patient has changed. That is a big deal and further assessment may need to be done to determine the level of care. Why does the person need a nasal trumpet when they were up playing cards just a couple hours prior? What changed to cause a patient to require O2?

The decision to transfer is patient to a hospital is a big deal and does require a physician's approval for many situations unless it is a true emergency. Yes, sepsis can be an emergency especially in a frail patient.


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## Aidey (Aug 25, 2009)

Akulahawk said:


> Yep. Dialysis RN's typically have, on hand, the orders and equipment to render actual care at a higher level than EMT-B personnel. Even as an ALS call, I'd be inclined to treat this patient as an interfacility transport that is emergent than a regular scene call.
> 
> I've been in SNF/Rehab facilities where the RN's orders were more restrictive than the prehospital EMT-B's. No IV's unless specifically ordered, no Advanced Airways, (actually, they'd need orders to put in an airway adjunct) No ACLS... Just basic CPR, whatever orders are in the patient's chart, and O2... max @ 3 LPM. Yes, I said 3 LPM by Nasal Cannula... for patients who are acutely SOB.



Just FYI I used to work in a Dialysis clinic.  On the flip side of the SNF issue, I was at a facility the other day that had standing orders for the RN to administer several painkillers, and she could get verbal orders for Morphine. It is facility dependent, which is why it is important to know the capabilities of the facilities you go to. And rather than challenging the RN or whomever, ask what they can and can't do, rather than assuming you can do more than they can. (That is a general statement, not directed at you AKulahawk)


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## medic_texas (Aug 25, 2009)

This again eh..

As a nurse working in the hospital (ER and SICU) we have protocols and standing orders that we do not have to have a "doctor tell us what to do".  Many of the protocols in the ER are similar to my EMS protocols and others are more invasive than my paramedic protocols on the street.  The standing orders are more patient specific and in this situation, is probably what the nurse was initiating.  

Until that patient is on your cot and you have consent to treat and transport, keep your mouth shut and let people do their job.


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## KillTank (Aug 26, 2009)

On the scene I will only follow a medic or a doctor. In the hospital I will follow a RN or Doctor. I checked my protocall today and it states that In pre hospital care only a Doctor or Medic can control the scene and Only a EMT, Doctor, or Paramedic may give care. The way I look at it... A RN or LVN have a emergency room at there disposal. In the field they don't and are not trained in pre hospital care. The patient was In a clinic the RN is in charge until the Paramedic has begun care on the patient.


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## Hal9000 (Aug 26, 2009)

*Learn*

Learn from mistakes.  Understand your failures.  Correct them.  When life knocks you down, dust yourself off, start over, and eliminate the next challenge.  Learn to keep your balance.

The odds are that this will be one of the things where you look back and say, "Man, what an a:censored::censored::censored::censored::censored::censored: I was.  Hope I never seem like that to anyone again."

Learn.  Learn from these things.  Don't be too cowardly to accept them.  Admitting flaws that the public has seen is hard; it's easier to wall them off.  The pain is worth it.  You'll be a better person all around for it.  You will gain perspective.  You will eliminate the old self and rebuild someone more dignified.  Realize that being calm is a virtue in this field.  

I know this is true.  I've been a foolish idiot more times than I can count, but I do count those times, and I count them often.  The best way I can teach people is with the examples of my own failures.  IF you can do this, you will have the ability to progress.  I have found that my biggest failures have had a silver lining: the worse the fall, it seems the bigger my recovery stride has been, taking me to new, undiscovered levels.  Each of these has made me more valuable to true professionals and has earned me more respect.

You have that same chance.


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## medic_texas (Aug 26, 2009)

So when the nurse takes a phone order from a doctor and tries to initiate the order while you run in and save the day, are you following the doctor or are you stepping out of your boundaries?

Apparently, the OP was to take this patient back home or wherever, they were never called there; it was a scheduled transfer.

Obviously, if there was a need for EMS they would have called EMS; not the basics who showed up. If I'm in the clinical setting and I'm a little uneasy about the basics showing up, I can refuse to have them transport the patient and call for another unit. A nurse's license will outweigh a basics certification any day. If two jackasses come to transport a patient and make the patient even more anxious, I can ask them to leave.  The patient is still in the care of the LICENSED healthcare provider and does not have to release care of the patient.  Who are you going to take the patient to anyways; another nurse?

Luckily for me, I don't work in a dialysis center or the clinical setting.


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## KillTank (Aug 26, 2009)

medic_texas said:


> So when the nurse takes a phone order from a doctor and tries to initiate the order while you run in and save the day, are you following the doctor or are you stepping out of your boundaries?
> 
> Apparently, the OP was to take this patient back home or wherever, they were never called there; it was a scheduled transfer.
> 
> ...



Good point. When I was working transport we would contact FMS if we felt the patient was not stable unless we had a medic with us.


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## Flight-LP (Aug 26, 2009)

KillTank said:


> On the scene I will only follow a medic or a doctor. In the hospital I will follow a RN or Doctor. I checked my protocall today and it states that In pre hospital care only a Doctor or Medic can control the scene and Only a EMT, Doctor, or Paramedic may give care. The way I look at it... A RN or LVN have a emergency room at there disposal. In the field they don't and are not trained in pre hospital care. The patient was In a clinic the RN is in charge until the Paramedic has begun care on the patient.




Flight nurses???????


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## daedalus (Aug 26, 2009)

I can't imagine what some nurses think of us when we come into a clinic or something acting like this.


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## Akulahawk (Aug 26, 2009)

Flight-LP said:


> Flight nurses???????


Flight Nurses would fall under a different policy than MD/RN at scene. They fall under a "Medical Scene Authority" policy. Usually this refers to ground providers who may be of different license levels, training, or even different agencies. Here's where things get interesting. If a helicopter is dispatched, I have the authority as a Paramedic to cancel their response right up to the point where they make patient contact. 

Transfer of care from a ground to a flight unit is also covered under a transfer of care policy. Normally, in my County, if my patient is unstable (and I'm a non-transport Paramedic), I can not turn patient care over to any other Paramedic. I go to the ER with the patient. I can transfer care to a Flight Paramedic for the purpose of air transport. That means I can also transfer care to a Flight Nurse for the purpose of air transport. 

The point is, Flight Nurses and Physicians are the only providers that can take over command of my scene and care of my patient. Normally though, the Flight RN's aren't called out to the scene unless they're needed and I intend to transfer the patient to them anyway. 

Sacramento's Medical Scene Authority Policy is copied, in part, and highlighted by me:


> Authority for patient health care management in a non-disaster medical emergency shall be vested in that licensed or certified health care professional, which may include a EMT-P, or *other prehospital emergency personnel* at the scene of the emergency, who is most medically qualified specific to the provision of rendering emergency medical care.


Flight nurses are considered "other prehospital emergency personnel" as are EMTs, in the event that only EMTs are on scene.


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## Flight-LP (Aug 26, 2009)

Thank you for the insightful info, but I was directing this towards another individual who has potentially been misinformed or is misperceiving his protocols. 

Yes, they are a different animal all together.


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## KillTank (Aug 26, 2009)

Flight-LP said:


> Thank you for the insightful info, but I was directing this towards another individual who has potentially been misinformed or is misperceiving his protocols.
> 
> Yes, they are a different animal all together.



What does a Flight Nurse have to do with working on the scene at a residence vs a hospital or clinic? I never stated I wouldn't let a Flight Nurse touch my patient. I do not walk into a clinic thinking I'm going to run the show. The nurse knows more about the patient than I do and I rather the nurse assist me. But on the scene of a MVA or a Medical call outside of a hospital or clinic a *RN, LVN, or CNA* will not be allowed to assist according to my local protocols. In fact if a Doctor or another EMS official arrives on scene MY local protocol states I must check for credentials before allowing to take command or assist. A flight Nurse is considered a EMS official and does not take control of the scene, only the patient It will be transporting after the on scene Paramedic or Doctor has handed over care. 

I am not trying to walk over anyones profession or state who is better. Depending on what training you have depends what role you can take in certain situations. Its only common sense.


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## VentMedic (Aug 26, 2009)

KillTank said:


> But on the scene of a MVA or a Medical call outside of a hospital or clinic a *RN, LVN, or CNA* will not be allowed to assist according to my local protocols.


 
There will be exceptions to that also when it comes to home healthcare. The patient with special technology such as VADs, ventilators, access ports, specific meds and/or gases and special needs may have a family member and/or any of the 3 health care workers mentioned at their side who have been specially trained for that patient, their technology and equipment. DO NOT dismiss them because they are not "EMS" and listen to whatever valuable information they have to assist in the care of the patient. That may prevent you from doing harm or killing the patient as you rush in with your book of protocols.


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## Ridryder911 (Aug 26, 2009)

Vent make some important statements but they are not blanket in every state. Flight nurses in many states has no more authority than another state and truthfully RN's are not always deemed higher in control or more authority. As the typical RN does not have the highest level of education in emergency or even critical care.  Just alike prehospital they are under direct or written orders of a physician. 

When a flight crew arrives, they are just a means of transportation to me. No more important or less. They have no more authority in care than I do as ground or as my Paramedics do in fact in prehospital maybe even less. For SCT on IFT I would be sure if nurses are going to be utilized that they check the insurance clause or carry malpractice on themselves as many carriers coverage is only good on hospital territory and not within another medical agency. 

R/r 911


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## JPINFV (Aug 26, 2009)

Akulahawk said:


> Train of thought writing works for people who know how to do it well.
> 
> As for the other story, without knowing the specifics, I'd have to guess that the crew did put their certificates in jeopardy for what they did. If that patient had an adverse outcome, that would have required ALS intervention en-route, I would imagine that the end result might easily have been different for both the Paramedic and the EMT crew. There's a lot more that I could probably go into, but without knowing more, including OC EMS protocols, I'm going to hold off. Personally, I think they were probably very lucky that they retained their certs.



As someone who's worked in OC and had to deal with this exact situation (question to the OP: Anaheim fire, female medic?), the fire department is supposed to transport with the company that called them. Period. Now my view on this is that if fire wants to transfer, then fine, what ever. I personally don't care which ambulance the patient goes with and I'm not there to impress the medics. Which company should transport is above my pay grade and I'm not going to get into a fight on scene. It simply isn't worth my time. There was a letter sent out by the old county medical director stating that this shouldn't happen.


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## JPINFV (Aug 26, 2009)

jgmedic said:


> Hmm...maybe the paramedics knew they type of shenanigans your company has pulled(like BLS'ing obviously ALS patients, or arguing about transports on scene, in front of patients)



You obviously don't know OCEMS that well. There are no paramedics with private companies and the current plan in place basically dilutes them down to an EMT with a monitor and an IV. It's essentially BLS or call 911.


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## JPINFV (Aug 27, 2009)

rescue99 said:


> I'll absolutely argee; this BLS crew was over zealous, under trained and pretty darned disrespectful of their patient's welfare as a whole. There is no doubt a person will worsen when he's constantly asked "ya sure ya don't feel sick", by what is perceived as a medical professional. Don't need 1000 words to say...wow, get a little more skill under yer belts there kiddo.



Welcome to Orange County, California.


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## JPINFV (Aug 27, 2009)

To the OP:
 Protip for calling for paramedics in Orange County. When you're on the line with 911 (and, yes, since paramedics were only fire based, every time I requested paramedics I did so through the 911 system) make sure you identify that you are Pacific/Lynch/Shoreline/etc ambulance company and need a paramedic response. Make sure you identify that you have an ambulance and will meet the paramedics in your ambulance (and plan on being at the ambulance when they arrive). If you do so (and do it professionally and with tact), the contracted 911 ambulance company won't always be dispatched.


To the 'OMG, a NURSE can't tell me anything' crowd:

Fun fact: It's better to work with other health care providers than against them. Just because you're 'in control' doesn't mean that they don't know more about 'your' patient than you do.


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## VentMedic (Aug 27, 2009)

Ridryder911 said:


> When a flight crew arrives, they are just a means of transportation to me. No more important or less. They have no more authority in care than I do as ground or as my Paramedics do in fact in prehospital maybe even less.


 
That being said, the flight crew does have the final say in what is best for the patient when it comes to flying. There should be no arguing about care when it comes to the safety of the patient and THE CREW. If that patient is too heavy and we can not safely drop a crew member or conditions do not allow us to fly to scene or a certain hospital that the ground crew believes best but we have a safer alternative, there should not be a peeing contest that jeopardizes that air crew. If that patient is combative with a TBI, we will sedate and intubate with or without the ground crew's blessing when that patient is in our care and before we take off. We also don't transport dead patients as one that is coding at scene will probably not even be a good organ procurement candidate. Tissue and whatever can be taken later at the ME's. We didn't just fly to the scene because we were bored and just thought it sounded like a good call on the scanner to go to. Time can also be a concern as we may be looking at weather conditions to return safely. I've flown to ground scenes where the crew has been on scene for 30 minutes and have yet to establish as IV or even make an effort to package because they didn't think the patient needed anything but yet called for a helicopter. Communication and coordination should be about what is best or safest for the patient and not whose ego might get a little bruised or for the convenience of the EMS provider. 



Ridryder911 said:


> For SCT on IFT I would be sure if nurses are going to be utilized that they check the insurance clause or carry malpractice on themselves as many carriers coverage is only good on hospital territory and not within another medical agency.
> 
> R/r 911


 
Yes this has been an issue for years until hospitals started establishing their own transport personnel that can just take the patient in their own ambulance (or contract truck) or will be covered when they have to get into a truck to provide care. At the also may not release a patient to a "CCT" if they appear to be clueless when they come for the patient unless one of our transport staff accompanies or another team can be arranged. For Peds, most hospital will now go with a dedicated team and/or with the guidelines from the AAP. For neonates, Florida has specific guidelines as to who can transport and now which facility/Medical Director is in charge of making crew arrangement for transport. 

This is the proposed rewrite of the neonatal transport section in the EMS statutes. It eliminates the "ALS and BLS" terminology which is not appropriate for neonates or critical care medicine and it defines the training and control of the medical directors. 

https://www.florida-air-medical.org...oposed RuleNeonatalInterfacilityTransfers.pdf


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## Akulahawk (Aug 27, 2009)

Ridryder911 said:


> Vent make some important statements but they are not blanket in every state. *Flight nurses in many states has no more authority than another state and truthfully RN's are not always deemed higher in control or more authority*. As the typical RN does not have the highest level of education in emergency or even critical care.  Just alike prehospital they are under direct or written orders of a physician.
> 
> When a flight crew arrives, they are just a means of transportation to me. No more important or less. They have no more authority in care than I do as ground or as my Paramedics do in fact in prehospital maybe even less. For SCT on IFT I would be sure if nurses are going to be utilized that they check the insurance clause or carry malpractice on themselves as many carriers coverage is only good on hospital territory and not within another medical agency.
> 
> R/r 911


This makes an excellent point... Field Providers: if you're going to have any interaction with flight crews, make sure you know the policies in effect for these instances. Flights that are IFTs do not normally fall into the prehospital arena, so they're an entirely different animal. 

As to the insurance issue, hospital staff that go on transports should carry malpractice insurance anyway. If you, the field provider, have any substantial assets... it should be an excellent idea as well for you to have this insurance.


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## Akulahawk (Aug 27, 2009)

VentMedic said:


> That being said,* the flight crew does have the final say in what is best for the patient when it comes to flying. There should be no arguing about care when it comes to the safety of the patient and THE CREW. If that patient is too heavy and we can not safely drop a crew member or conditions do not allow us to fly to scene or a certain hospital that the ground crew believes best but we have a safer alternative, there should not be a peeing contest that jeopardizes that air crew*. If that patient is combative with a TBI, we will sedate and intubate with or without the ground crew's blessing when that patient is in our care and before we take off. We also don't transport dead patients as one that is coding at scene will probably not even be a good organ procurement candidate. Tissue and whatever can be taken later at the ME's. We didn't just fly to the scene because we were bored and just thought it sounded like a good call on the scanner to go to. Time can also be a concern as we may be looking at weather conditions to return safely. I've flown to ground scenes where the crew has been on scene for 30 minutes and have yet to establish as IV or even make an effort to package because they didn't think the patient needed anything but yet called for a helicopter. Communication and coordination should be about what is best or safest for the patient and not whose ego might get a little bruised or for the convenience of the EMS provider.
> 
> 
> 
> ...


I'm glad Florida is getting going on the neonate stuff. Clarity is always a better alternative to confusion... 

As to the flight crew... I'm of the opinion that if it's unsafe to fly the patient but the patient still needs that level of care after the flight crew arrives... guess what? The flight crew is more than welcome to use my truck for transport instead of the egg-beater. I will be happy to assist them as I know where everything is... in my truck, but they're in charge. Also, if the patient is going to be flown... I'm going to do my best to ensure that the patient is ready for the flight team to transfer to their litter and can be packaged for flight easily.


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## Shishkabob (Aug 27, 2009)

I know a few people on flight crews, and they all say essentially the same thing:

On an IFT, the nurse is in charge.  On a field 911 call, the medic is in charge.  Each has their own specialty in medicine, and they work off of eachother to get the job done.


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## VentMedic (Aug 27, 2009)

Akulahawk said:


> This makes an excellent point... Field Providers: if you're going to have any interaction with flight crews, make sure you know the policies in effect for these instances. Flights that are IFTs do not normally fall into the prehospital arena, so they're an entirely different animal.


 
Do you remember a statement concerning a Sacramento Paramedic made a couple years ago by CA's EMSA director?




> Jennifer Hardcastle, a nurse and spokeswoman for the air ambulance company, said there have been no complaints or concerns about patient care involving Parker. Aristeiguieta (_EMSA Director Dr. Cesar Aristeiguieta_) agreed, adding that flight paramedics typically work as a team with a flight nurse and "the nurse really runs the show."


 
http://www.sacbee.com/paramedics/story/117393.html


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## Akulahawk (Aug 27, 2009)

The statement I made was a general one... but I believe I've met Nurse Hardcastle. In any event, with REACH, while the RN/EMT-P team works as a team, there's never been any question that the RN runs the show... and I've been familiar with them since about 2000-2001, and had the opportunity to run at least one call with them. I'm much more familiar with other programs... that run RN/RN and I've run probably 50-100 calls with that type of prehospital team. No question they're in charge. But flight crews are a different animal.


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## medic_texas (Aug 27, 2009)

VentMedic said:


> Do you remember a statement concerning a Sacramento Paramedic made a couple years ago by CA's EMSA director?
> 
> 
> 
> ...



Oh man, I remember that!  That comment pissed a lot of people off, lol.  

I think we all know what should happen on a 911 call if a nurse is on scene. My point was generally speaking about the scenario posted by OP; an IFT and 2 people jumping around and getting everyone all excited and wanting to turn a IFT into a "code 3 to the hospital".


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## Sasha (Aug 27, 2009)

Linuss said:


> I know a few people on flight crews, and they all say essentially the same thing:
> 
> On an IFT, the nurse is in charge.  On a field 911 call, the medic is in charge.  Each has their own specialty in medicine, and they work off of eachother to get the job done.



Really? When I have the opprotunity to talk to flight crews at my hospital, the trauma center, and the boondock hospital, they all tel me the same thing. They work as a team, regardless of which call it is.


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## VentMedic (Aug 27, 2009)

medic_texas said:


> Oh man, I remember that! That comment pissed a lot of people off, lol.
> 
> I think we all know what should happen on a 911 call if a nurse is on scene. My point was generally speaking about the scenario posted by OP; an IFT and 2 people jumping around and getting everyone all excited and wanting to turn a IFT into a "code 3 to the hospital".


 
My point was also about the other medic scenario and the fact this is in California.  That in itself gives things a weird twist.   The county thing, the state scope, Paramedic utilization and the reasons Flight RNs and MICNs are utilized just makes this state a little different .


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## VentMedic (Aug 27, 2009)

Sasha said:


> Really? When I have the opprotunity to talk to flight crews at my hospital, the trauma center, and the boondock hospital, they all tel me the same thing. They work as a team, regardless of which call it is.


 
A team may still have someone who is of a higher medical level. If a physician flies he/she is part of the team but now has the ultimate responsibility with the exception being for the resident in training who may be there to observe for the first few flights. 

Each brings to the team a different set of expertise but it also depends on how the statutes and the agency policy are worded for various situations. If you read the job description on the flight help wanted boards you will notice that for the RN it will state "to supervise the Paramedic". This can shy away some applicants who may not want the responsibility so it is often made clear up front.


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## medic_texas (Aug 27, 2009)

Lots of good points being made here. The comment about California is really true (and I may take a travel gig in the Sacramento area this spring). 

I'm on my phone, at work, waiting on people. Don't ya just love that?


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## VentMedic (Aug 27, 2009)

medic_texas said:


> Lots of good points being made here. The comment about California is really true (and I may take a travel gig in the Sacramento area this spring).


 
I do travel assignments primarily in the Bay area.  It has been a big step back in time both in the hospitals and viewing their EMS situations.  I would say 10 - 15 years backward for the hospitals and about 25 - 30 for EMS.


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## medic_texas (Aug 27, 2009)

VentMedic said:


> I do travel assignments primarily in the Bay area.  It has been a big step back in time both in the hospitals and viewing their EMS situations.  I would say 10 - 15 years backward for the hospitals and about 25 - 30 for EMS.



Oh crap, that doesn't sound too good.  No wonder they pay so well


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## KillTank (Aug 28, 2009)

VentMedic said:


> There will be exceptions to that also when it comes to home healthcare. The patient with special technology such as VADs, ventilators, access ports, specific meds and/or gases and special needs may have a family member and/or any of the 3 health care workers mentioned at their side who have been specially trained for that patient, their technology and equipment. DO NOT dismiss them because they are not "EMS" and listen to whatever valuable information they have to assist in the care of the patient. That may prevent you from doing harm or killing the patient as you rush in with your book of protocols.




Didn't I mention outside of the clincal and hospital a couple times already? Go back and re-read my thread. I think I remember mentioning that "I RATHER LET A RN ASSIST ME BECAUSE THEY KNOW MORE ABOUT THE PATIENT THAN I DO."
I will do what ever I want with my book-o-protocols thank you very much.


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## VentMedic (Aug 28, 2009)

KillTank said:


> *Didn't I mention outside of the clincal and hospital a couple times already?* Go back and re-read my thread. I think I remember mentioning that "I RATHER LET A RN ASSIST ME BECAUSE THEY KNOW MORE ABOUT THE PATIENT THAN I DO."
> I will do what ever I want with my book-o-protocols thank you very much.


 
This is outside of the hospital. We have our own CCT truck and quite often if one of our patients with serious technology requires transport to or from home, we have the capability of doing that. 

You have also given the reason we do provide this service.


> I will do what ever I want with my book-o-protocols thank you very much.


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## KillTank (Aug 28, 2009)

VentMedic said:


> This is outside of the hospital. We have our own CCT truck and quite often if one of our patients with serious technology requires transport to or from home, we have the capability of doing that.
> 
> You have also given the reason we do provide this service.



Your point?


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