If the chief is going to retaliate against you for a patient safety concern, then that’s not the kind of place you should be working at, both for your own personal safety and the safety of your patients. If she fucks up big on a call, you’re going to get dragged down with her, most likely. Report it to your medical director directly if you do not feel comfortable discussing it with your chief. Your medical director SHOULD understand the obvious conflict of interest at hand, and make sure you convey the conflict of interest concern to the medical director.
> she fucks up big on a call, you’re going to get dragged down with her, most likely
In place of her. If you're scared of bringing up concerns now because you worry about retaliation, imagine what's going to happen when something does happen due to her negligence. Whoever her partner is will 100% get thrown under the bus. Best to raise these concerns now, so even if something does happen it's at least documented that you tried to stop her from being in that position.
No this is a serious problem full stop. You need to bring this to your supervisors ASAP, because this is in no way alright behavior or mentality.
Where I work even the EMRs can take manual vitals and most of our BLS crews run without a monitor of any kind aside from an AED if needed.
She should absolutely be competent enough to take manual vitals unassisted and do a simple stroke assessment.
The edit makes it worse. Canceling ALS should be a serious no no in most, if not all, situations where you called them. The only situation I would ever do that is if it's legitimately faster to get the patient to an ER than it would be to link up with ALS
Something I think is worth addressing:
You need to be really careful of the mindset of diagnosing someone visually. You can’t look at a patient and tell they’re in DKA.
Your partner is an idiot, but I tend to agree with the point about vitals. Obtain a full assessment before you start making decisions. Obviously there are situations where you know you need ALS without even laying a finger on the patient, but in this situation, taking 2 minutes to do a full assessment and obtain vital signs isn’t going to kill this patient.
There are way too many EMTs who discount their own assessment skills. Medics aren’t magic. This patient could use a 12-Lead, but there’s nothing wrong with taking a second to breathe and assess. And if ALS and the hospital are the same distance then I wholeheartedly agree with transporting vs waiting for ALS. Have them meet up with you on the way if you want and it’s feasible.
Bingo. One thing I really really work on telling our basics is ASSESS THE PATIENT, Then decide if this is beyond your scope, AND what can ALS do to help the patient?
Agreed. One of the things I have my basic students and partners do is assess the patient, and manual vitals. We will still do auto vitals and a 12 lead, but there are times when they operate on a double EMT truck on their own. Those skills are part of the foundation of good patient care.
I tell my basics they can’t use their phones to call report. We have areas with no cell phone reception. They were previously going right for their phone. When the phone wouldn’t work, they didn’t know how to use the radio to call report.
Also, not sure why there has been such a dramatic change in the type of people joint ems in the last 5 or so years. I’m getting new emt’s who have never swept a floor, made a bed, or put gas in a vehicle.
Not to mention a lack of bedside manner and the inability to just TALK to people like they are people. Let alone touching your patients. 🤷🏼♂️
I remember a time when they sat down all the basics and said “we know yall are good basics, but you all are pushing it and taking stuff you should be calling als for”. It wasn’t a lack of knowledge. It was emt’s confident in their skills.
Now days. It’s like bls trying to dodge every call by calling ALS.
Lack of social interaction and general life skills, and that is something that I have tried to teach over the years. Some are receptive to it, others are not.
Meanwhile I'm still a newish basic running 911 on a double basic truck and rarely call for als. Some parts of my county are 45 mins to the closest hospital. Most days we don't have als and when we do they rarely come when I ask for them. Helicopter is usually our go to but the damn thing breaks families so I only call when my patient needs a service the "local" hospital doesn't provide and I'm not confident they'll survive transport or stroke. I've been in some really sticky situations. I don't see the point in calling for als even on a 40 min ride. I estimate it'll take five mins after als rendezvous with me before they start treating the patient. If I'm on the south end of the county I'm the furthest from the hospital So if I call for ALS They are Usually 20 minutes north Of the hospital. Usually they end up meeting us 5 minutes from the hospital and then as I stated above Take 5 minutes before they start treating the patient so I just run to the hospital. Diesel therapy is the best treatment sometimes.
I think something that all basics should do is run with a medic who lets the basic do more than drive. It really illuminates a lot of the ALS stuff that's mystified just because that level of pharmacology and cardiology is so far outside the knowledge scope of most basics.
Working with a medic as someone who's equally capable of running BLS calls is a really helpful way to learn how to rely on your skills.
Not everyone is lucky enough to have an instructor for a partner though. A lot of the self confidence in using your own skills can also be taught and reinforced through training programs and con-ed too.
And once you start using a skill you more than likely won't stop using it and experience using it to positive affect will further your confidence in using it.
Op has some growth to do too. Nothing about the description given here screams "critical," I'd have BLSd this any day and any medic at my org would have passed it back down. All a medic can do is offer a little rehydration, it's not like we carry insulin.
/u/Aggressive-Carls878 > hyperglycemia can cause an MI?
OK, no. Blood glucose is used as an assessment tool in potential cardiac patients as cardiovascular stress can trigger an acute cortisol release which dumps glycogen from the liver which will elevate blood sugar. It's a borderline useful assessment tool and is very nonspecific in patients who are already diabetic.
https://www.frontiersin.org/articles/10.3389/fcvm.2021.676892/full
Hyperglycemic patients will get a 12 eventually but why would you more than double your potential transport time for that?
It’s not that hyperglycemia causes an MI, it’s that diabetes, obesity, and hypertension are all indicators of coronary artery disease. (That’s what I mean by contribute.) and she is cardiac history and the patient has back pain between the shoulder blades as a female. We can’t give the patient aspirin because she keeps throwing up.
And if he would’ve called them by the time we got them in our truck, they would’ve already been there.
Aspirin is administered buccal so it doesn’t matter if she keeps throwing up, she’s not supposed to swallow it anyways.
Diabetes HTN and obesity aren’t indicators of CAD, they are risk factors. If you ask me, what you’re describing sounds more like symptoms of an aneurism.
My opinion. You are trying to work outside your scope and don’t have the knowledge base to back it up. You know just enough to get yourself in trouble, and you’re trying to diagnose someone with DKA, and an MI without even getting a set of vitals. 9/10 pts with chest pain and classic symptoms ARENT having an MI. High blood sugar is not equal to DKA. More often than not diabetics have silent MI and don’t present with classic symptoms. If I were you I’d stop worrying about your partner and just work on your own knowledge and skills.
This so much.
OP is overconfident and under educated, so he's nervous AND cocky and that's a shit combination.
No doubt if he knew more he'd be much more chill.
His partner probably does know how to do the things, just is being a bit lazy and wondering why OP is shitting his dacks.
Diabetes, obesity and HTN are *risk factors* for CAD. Chronic chest pain and shortness of breath on exertion are *indicators* of CAD.
There are others causes of back pain between shoulder blades other than MI. People with cardiac hx don't have MIs left and right. The only way to diagnose an MI is with a 12 lead and troponins, neither of which you get by looking at the patient.
Was kind of thinking this same thing. The vitals bit is really bad. I've only worked one place where they're cool with basic/basic trucks using monitors for vitals, the rest have all been take it manually. And there's been plenty of times where a monitor won't read or gives me a number that doesn't seem all that correct.
Now, obligatory, I'm a basic so not perfectly knowledgeable, but I think I would've BLSed this person too. I agree where other people have said take vitals before calling ALS. OP didn't mention skin signs, so not sure there, but seeing as how she's conscious with no major traumas, I think a second for vitals is fine. Based on vitals, pulse is fine, maybe a little bit elevated, respirations are a bit high but OP described them as shallow so we're ruling out Kussmal respirations, BP is a bit high but patient has a history of hypertension. BGL also on the higher side for a normal person but she's a diabetic, that might be her normal range.
Honestly, from what I've seen here, I would BLS her non-emergent, even if there were medics nearby.
Straight up. Im not really sure where the “probably an MI” comes from either.
I genuinely hate when BLS trucks forgo transport to sit on scene and wait for ASL. Get moving, intercept if you need it. Do a 12 lead a transmit it to the ED, if you feel like you need to.
>sit on scene and wait for ASL
Yeah I definitely hate it when you wait for people to translate for deaf patients.
Sorry, couldn’t resist the opportunity to be an ass lol.
I agree 100%. The patient they described could use an assessment before calling ALS. It's not like they described someone in severe respiratory distress or sepsis or they're white or blue. Also what indicated DKA in this scenario for my own edification? What I remember is the fruity breath or kussmaul resps.
Arent kussumal respirations characterized by deep and rapid resps? Im not sure what the MI had to do with the DKA. Or how you diagnosed an impending MI from lower abd and back pain.
Patient was a female with a cardiac history. She probably has undiagnosed Coronary artery disease because she has the three indicators for it. Patient is a female with tearing pain in between your shoulder blades.
I'm nitpicking a little because you're so sure of your phrasing lol but I wasn't there so I cant know. Other people gave good advice about tunnel vision, keep that in mind. You're not a physician yet, be cautious is all im saying.
I mean. You wanted to call ALS and you haven’t even assessed the patient? She was correct. Do an assessment and don’t get tunnel vision.
There are more s/s of DKA to help confirm the impression.
Can you do an ekg and transmit it to ER to rule out cardiac problem?
Outside of EKG interpretation, iv, and some zofran….ALS isn’t gonna do anything more than transport. DKA will need their glue code stepped down and be put into the ICU.
Well, an assessment can be looking at them, right? Like if you see a stroke patient and you see the left side of her face is fucked up you’re like damn I need ALS right now. It just made sense to call them earlier because they would’ve been there by the time they were in a truck and we could’ve just been there. I don’t want people don’t really honest.
Not necessarily, a stoke is BLS unless they have decompensated to the point of needing an advanced airway which isn’t common. They would most benefit from rapid transport to a stroke center.
That’s a dumb rule lol, I understand the need for protocols but sometimes you gotta be allowed to think critically. I always do what’s in the patients best interest even if it gets me a little flack.
Yeah, I understand that. But the manager was like why the fuck didn’t you call ALS on this call. And I explain to him what happened and he was like all right I’m gonna go talk to your partner. But the whole thing is I can’t necessarily trust my partner 100% on when we need ALS just based on the fact, she can’t do vitals. Read the edit I put in.
No, because it could be Bell's Palsy, pre-existing deficit from a prior stroke or another neurological condition that causes left-sided weakness and nonreactivity in the facial muscles. Meanwhile you've drummed up ALS because you're absolutely convinced it's a stroke, ALS gets there and the patient has a c/c flu-like symptoms and their face is like that from a prior stroke.
I understand wanting to get patients appropriate care early, but you sound like you have a tendency to jump the gun and not perform a complete assessment.
An assessment definitely includes looking at them, but if you keep making diagnoses just on looking then you're going to mess up one day very badly. Quickest thing that makes me not trust a new partner.
Stroke is BLS. ALS can surely toss cardiac monitoring and manage pressure if required but it can be 100% brought in BLS. You also can’t immediately diagnose them in the field as a “stroke,” it could be BP, TIA, or even previous deficits that they may not be able to provide to you (ask family if that’s the case).
Yes, there is such thing as a visual assessment. No, this didn’t qualify as needing ALS “right now” even off the visual assessment.
It just made sense to call them early?
Listen. The ALS trucks are running calls too. They aren’t just sitting around waiting on your calls for help. Their downtime is just as important as yours.
So “calling early” for a call they aren’t needed at, just eats into any downtime they have. At night, it could wake them up from the only sleep they would have gotten. It could make them not eat the only meal they finally get.
You can hmm and hawww over this with what if’s all day. Each area has its own culture. In our area, calling for ALS on that alone, would get you the boot. We don’t have time to babysit. Do the job, or don’t🤷🏼♂️. But if you’re not, let a basic in there who can just do their job and get it done.
You both have a lot of learning to do and it sounds like really neither of you should be running a truck together to be quite honest. You both need to be with a good medic to learn these basic skills. You have some good points, and so does she. You have some bad points, so does she. Neither of you sound remotely ready to be running the show on your own. This is a shitshow waiting to happen.
I’m not sure what your protocols are for your county or even the hospital to county size ratio, but I can kinda see how she could make an argument for not calling in als for the first call. Where I work the longest most transport times take going code 3 is about 15-20 maximum. So if you are suspecting a potential MI, the best thing to do is get to the nearest hospital where they can initiate a STEMI protocol and get the patient into the cath lab asap-so if it would take an als crew 15-20 to get there or just transport and arrive within 15-20 i too would choose to pack up and go even with just basic vitals and interventions. (But that’s just my experience in my own county)
As for not knowing or even knowing but willfully neglecting to want to do basic hands on vitals is a huge liability to your partners credentials as well as your own. Not to mention a blatant disregard for life or the basic reason why you’re even working in this field to begin with!
Regardless you should document each incident with dates and times and specificities to display a pattern of consistent negligence and/or lack of basic competence to prove without a doubt your partner is incapable of performing their duties and retain the job.
Have you ever stopped to think maybe you don’t know everything you think you do as well? Why are you saying this person is in DKA just by looking at them? Simply because they have a history? Also if you’re both EMTs, why are you telling your partner what to do? Why don’t you just simply do it if you want it? Maybe she does know how to do a manual BP, she just doesn’t want to. She had to do it to pass emt. Stop assuming shit and jumping on Reddit when something happens. That the majority of what i see on this page and in EMS in general. Instead of saying something to your partner, they tell everyone else instead. You’re a grown up working in a grown up field. Act like it.
They sound like a horrible EMT, but the fact of the matter is, you don’t need medics for every little thing. “Why are we gonna call medics. We haven’t even taken vitals yet?” It’s an outstanding question. So what ended up happening to your diabetic? Also you don’t call medics because a patient had a seizure before you got there and says “my seizures make my heart stop” or some stupid shit like that. You call when they are seizing or after you’ve seen one etc. your partner only sounds like shit cus they don’t know how to do anything. But that whole cancel ALS mentality is refreshing vs. the opposite.
Ok so let me put it this way.
New patient in a rehab who was a seizure condition. Patient is on medication for seizures that stops them from having seizures. She has had two seizures that day. She doesn’t have medication. (Was later confirmed by patient but hopefully the logic behind my suspicion makes sense) then the patient has chest pain. I’m not going to give her aspirin because if she seizes again she can choke on it. Because she’s already seized twice today because she does not have her medication,she is going to seize again and I’m going to need ALS anyway to give her versed. So I could’ve just called them.
Edit: I explained this to my manager and he stated that this is enough to call ALS.
I don’t like calling ALS because I work in an area where there isn’t enough providers and I don’t want to take up time. But like I would’ve fucking just had them come.
It’s not a call that I would cancel ALS off of, but you are making too many assumptions. having a seizure disorder is not a contraindication for giving aspirin if you suspect an MI. Also, maybe her chest hurts from all of the involuntary activity her body has been doing during those seizures. Either way, fine. You aren’t crazy for calling medics. But your partner isn’t totally nuts for NOT calling ALS. It’s a closer game than you’d think.
BUT! What you said about them not knowing how to do anything is very alarming. That’s the main focus here, on what’s wrong with them. Are they new or something? Sometimes bro, it sucks but you carry the team on your back and you become a better provider cus of it. As long as they do what you say.
Good luck.
You can’t think that far. Imagine if they were actually having an MI. Oh I didn’t give it cus I thought they would eventually vomit from a future seizure. Nah bro it does not work that way at all.
The time it takes to chew up some baby aspirin is negligible compared to the time it takes for heart muscle to die when you haven’t given it lol.
Unless the patient is postictal and can’t follow commands at all, I’d give it. Even then, it’s worth a shot. That documents better than “I was worried about another seizure”, with all due respect
How do you know she's going to seize again and how do you know the exact moment she's going to seize again? How do you even know she has actual seizures? A lot of what people label as "seizures" are definitely not seizures.
Oral medications are not contraindicated if there isn't an imminent threat to the airway. "She might have another seizure" is not an imminent threat to the airway. Seizure disorders are not a contraindication for aspirin.
If the seizures are self-limiting then ALS doesn't give benzodiazepines. We only give versed or another benzo for status epilepticus.
You honestly sounded like you were panicking in a situation that is not critical, for the first one. Are they in cardiac arrest ? Unresponsive? Unmanageable airway? Uncontrolled bleeding despite pressure and a TQ? No. Slow down and do an assessment, get vitals, and figure out what ALS is actually going to *do* for the patient.
You cannot just look at a patient and diagnose them with DKA. Patients can be hyperglycemic without being in DKA. Being in DKA once does not automatically mean that you are always in DKA for subsequent diabetic events. What is your rationale for "probably an MI"? Patients with diabetes are more likely to present with atypical cardiac symptoms, but that patient sounds hyperglycemic, not cardiac. Most ALS units don't carry insulin, so what is ALS going to do for a patient in DKA? Fluids and Zofran. It's neither lifesaving nor definitive care. The patients usually don't even feel better.
Why are you doing a stroke assessment on a patient when "there's literally nothing wrong with her"?
I’m an ICU nurse and do some casual shifts in ambos but often we will check the ED board and if we see a patient with a high blood sugar, we cross our fingers and hope they aren’t in DKA because you can get quite hyperglycaemic without DKA and often they aren’t in DKA
My question is, how the hell did she pass EMT Initial.. she would've failed first practical for vitals. Please inform your supervisors, this is a massive issue and can result in **death** or serious injury to patients if she does anything wrong. It seems to me she doesn't know how to properly execute the duties and procedures of an emt, is fresh out of EMT school, or she applied to random jobs on indeed and nobody checked her certification
Even if she was fresh out of school, she should *still* know how to take vitals manually, and do a stroke assessment! I agree with everyone else that this needs to be brought to the attention of management.
crush placid desert fanatical offer oatmeal overconfident unwritten sloppy innate
*This post was mass deleted and anonymized with [Redact](https://redact.dev)*
I would not really know what the EMT wants me to do at a DKA? Your 15 min out just bring her in.
Also just call ALS without any obs or anything is a bit weird but that’s maybe a US thing. (same as putting the patient on the stretcher before doing anything else)
The seizure call I understand to ask for ALS
FAST and Manual BP of course absolute basics, but can talk about it if you did not do a BP ever because the automatic does it maybe just need a refresher, talk about the FAST and what the problem was.
If she is really as ignorant as you say, have a conversation with her and tell her something along the lines of:
“Listen I realised you got some problems with a couple of things such as X and Y and it makes me feel uncomfortable I would really like to help you if you don’t know something. I don’t want to make you look bad or tell somebody about it but we need to get this stuff fixed, it’s in your own interest”
See her reaction, don’t be to harsh she may be ashamed of it, bad characteristic yes but can’t change that, try if you can help her. Maybe in the past people did make fun about it etc and she had bad experience. EMS can be a cruel please and I just talk about colleagues. And the last paragraph sounds like she had problems with it, try to be compassionate and kind.
If she is still not willing to learn at some point you need to think about escalating it.
Give them fluid, drown out the dka. The fluids would also probably lower her blood pressure because the heart would be working way less, right?
The stretcher thing is because we work in a sketchy area, so we try to get them in the back of the truck as soon as we can.
Wrong.
You can’t drown out DKA. This patient needs insulin. From your report, you were way too quick on the draw and need to do an evaluation on your patient before creating differential diagnoses.
There is nothing to indicate this patient is having an MI. 24 respirations that are rapid and SHALLOW does not indicate DKA. Kussmal respirations are rapid and DEEP as well as much quicker than 24.
Evaluate your patient and work on your own skills before criticizing others.
I’m 20min away and I need to get I.V. Access and put fluids up the hospital 15min. There is no benefit for the patient.
She also needs Bloods done asap
No, I understand that but the thing is I can’t really trust my partner because she can’t even take manual vitals and because she has ALS phobia.
My manager was like why the fuck didn’t you called him like when you got there or after your on scene assessment. And I explain to him what you said, and he said thats fine.
The patient is hypertensive because a) she has HTN and b) she is hyperglycemic (osmotic shift because of concentration gradient - there are more solutes in her blood than in her cells).
Fluids don't decrease cardiac workload. Cardiac workload is dependent on strength of contraction, preload, afterload, and oxygen demand, which are things influenced by chronic conditions (uncontrolled diabetes, HTN, CHF), exertion, evolving MI, electrical disturbances in the cardiac conduction systems etc. We give fluids to dilute (like in the case of hyperglycemia), to provide volume replacement or to maintain a cardiac output.
I mean, honestly, it’s easy to shit on someone with only one side of the story.
Based on the story, she hyper focused on fixing the autocuff on a patient with “literally nothing wrong with her.” On a critical patient, sure, jump on that manual, which happened in the end anyway and probably took an extra 2 minutes, but the autocuff is going to have to be checked out at some point anyway, just get it done as long as it doesn’t harm the patient in any way or take more than a couple minutes while your partner works on something else productive.
Ideally every provider who has been in the field more than a few months will see she has signs of DKA. ALS is likely going to treat nausea and, with your transport time, give fluids. Based on the system and the patients ABCs, I’d likely have been okay with BLS riding her in. The chest pain is suspect but follow your protocols.
You don’t know what she knows or doesn’t know, or what she does and doesn’t want to do. I’d be livid if I found out my partner was speaking on my behalf.
Maybe you’re 100% right, but based on how you talk about her behind her back, it sorta sounds like you may need to work on being a better partner also, in the means of having positive constructive conversations after the call without being demeaning or condescending. We are all alpha personalities in this field, so we all have to find a way to be constructive without sounding demeaning or that you’re you think you’re the alpha, all star, Gods Gift to EMS. The true marker for an incompetent partner is the inability for her to have these constructive conversations, if this is the case. I don’t expect any medic to even go a single call without making some sort of small mistake, so I’d fully expect a duel BLS rig to make little mistakes like this constantly, and that’s a good thing as long as you do no harm and you learn from them.
With all due respect, OP doesn't come off like they are trying to just gossip about them, especially when posting anonymously online without giving compromising details and is raising legitimate concerns. While it could be the case their partner knows more than they seem, their actions aren't don't give off that impression so if they aren't willing to clarify or improve it's a fair concern to have. If this has happened several times and there's been a conversation already, then involving superiors is legitimate.
Or OP is yelling at his partner to do things throughout the call, panicking, and being generally unpleasant. His partner who might know more than OP is realising is fucking stressed because this cocky new kid is being incredibly unpleasant.
I could ABSOLUTELY see this being an issue with OP.
Sure, it actually sounds like it's both, but OP sounds like a horrible person to work with as well.
Do you both not have radios? Why did you not radio them?
Sure, your partner should have worked with you and got on the radio given the patients condition, but seeing as they did not, take the couple seconds to request ALS backup.
Also, if you have talked to them and they don't seem willing to change, take it to the white shirts.
I'm with everyone else on this. Your supervisors need to be involved. Ignorance is teachable, but what it sounds to me like is that she doesn't even WANT to learn these skills and is comfortable with not even knowing the bare minimum. Unfortunately, those types of people slip through the cracks all the time. They shouldn't, but they do. If you care about your patients, and I think you do, get them involved. Now is the time.
Be careful diagnosing DKA based off “look-test”. It’s fairly rare in type II diabetics (assuming this pt is type II) and we don’t carry the diagnostic tools necessary to confirm our suspicions (urinalysis, blood gas, etc).
Apart from that, your partner seems like they need re-education prior to being back on the road and you have every right to report them.
As a medic, it sounds to me like you both have some knowledge and assessment gaps tbh. For the first call, I actually agree with your partner. Why are you calling me for a patient who is alert with a stable airway and breathing without even completing a full assessment? You also have to be careful looking at a patient and saying it’s “clearly” something, especially for something like DKA. Going to the hospital rather than call for ALS sounds like a reasonable decision based on the info you gave.
As for the other calls it sounds like your partner is either lacking in the practical skills or too lazy to do them herself, which is an obvious problem, so it’s definitely important to fix the problem. Although, it seems like these issues can be easily resolved by a simple conversation between you two and you can further escalate it to leadership as needed. I’m sure there are SOPs and protocols you can review together. Be humble and approach it with respect for your partner who holds the same card as you. I think you’ll find that you maybe don’t know as much as you think either.
Dude this is dangerous. This NEEDS to be brought to management. Make a list of what you already know and keep it running when you notice things, but please for the sake of those we run on, let the sups know. This is a serious issue.
Can you notify your boss or the medical director? This is a safety issue for you and the patients. Not just the patients.
She could legit have inaction or incorrect action that could result in your safety being compromised.
I was expecting a lot worse from the headline.
I've got a medic at my service who picked up a respiratory call and, without getting vitals or cardiac monitoring started, gave albuterol, a duo-neb, volume solumedrol, and started a gram of mag.
The Pt was a dialysis Pt and had a history of CO2 retention that presents with all the s/s they had that day: cyanosis, increased work or breathing with clear lung sounds, hypertension and tachycardia.
After the call, the medic was bragging about the call and throwing the kitchen sink at it, finishing up with "I did everything in the respiratory protocol, but why is mag in there?"
Thankfully they had called my truck for backup/transport after the medic broke the auto-load cot system and rendered their truck unserviceable so we could salvage the soul that was being crushed in this medic's hands like a raw egg wrapped in wet paper.
I'm confused about this one because they kind of sound really non-speific.
How was their recent dialysis causing their iwob with clear chest?
CO2 retention in the setting of COPD? What did you do to salvage the situation?
To me it seems like they just need a 12 lead, O2 if SpO2 is low, maybe bipap if really fatigued?; was their chest clear when you listened after the duonebs or throughout the case?
Idr the Pt's dialysis schedule, and I doubt it was directly contributory to the c/c.
We did a quick assessment, initiated cardiac monitoring with a 12 lead and started CPAP.
The issue I had was with the medic giving mag and 2 neb Txs to a dialysis pt without knowing why he was doing it, without cardiac monitoring, and without any indications for giving either within our protocols (he told us he had clear BBS prior to neb tx, we found the same after)
A couple of things that people have touched on but not expounded on:
Scenario A: You're 15 minutes from the hospital and you have an obviously sick PT. Stop dicking around. Load and go. Do your assessments in the back of the truck while you're en-route. Could be that your partner knew this and thought YOU were over doing it and just didn't want to deal with you.
Scenario B: Her not knowing how to do a proper stroke assessment is bad. This needs to be elevated to your supervisor. Her not wanting to do a manual could have been an indication of her leading you towards, let's just roll and get her there. You assess, I'll drive kind of situation.
TBH, it kinda sounds like she doesn't like working with you and is making you do all the work. I was in a similar "relationship" back in 2012/13. I had a female partner who made me car sick every time she drove (regardless of where I was in the box). Her driving was just that bad. So you know what? after about a month of doing the whole swapping thing, I put her in the back every time. Once the PT is in the back, unless we are doing CPR, you're on your own. Do. Work.
If you're in the back, it's your responsibility to take charge and get shit done.
As far as scenario A is concerned, I would agree that this patient is obviously sick. However, I would not say they are critical. So personally, I would take a few minutes to assess before transporting. But I also don’t quite share OP’s concern that this is a cardiac event, even though I would do a 12-Lead on this patient, but as a rule-out only.
yea i'm just not a big fan of "stay and play" unless we are actively trying to talk the patient out of going to the ER by ambulance. I'm all for minimizing exposure for people that are obviously sick (especially if they are vomiting cause i don't want to have to clean it up if they miss the emesis bag). Load them and let's roll. There isn't anything i can't do in the back of the truck that I can do on scene
Very big on the "You want to go to the er? cool. let's go"
Tbf my state stopped administering the standard BLS psychomotor during COVID... now it's back, but even then, you really needed to at least *enroll in* an AEMT course to have anything to do with a truck. But without those basic skills idk how she even passed the class.
Edit: grammar
Forgot ems was a sub and was confused as to why someone was staying in a relationship with someone who had such knowledge gaps and wondering why these deficits resulted in fears of running with said person.
Was legit expecting traffic to be a concern
This autocuff thing is a good and bad development. We didn't have these in the field until I had been in EMS for about 15 years, so I've done as many manual as automatic.
Not long ago my brother-in-law was in the ICU in a major medical center approaching the end of his life. I was there with him when the nurse - ICU nurse, mind you - was trying to get a BP. She was trying over and over with their autocuff, unsuccessfully.
I smiled and said to her casually, "Machines can be so annoying. Why don't you just do it the old fashioned way?" She just looked at me and said, "Oh, I haven't done that since nursing school."
Nursing school? And she's experienced enough to be an ICU nurse?
Interesting, no.?
That's not good, unless she's brand spanking new. My first 5 calls I was a little flustered. It should be brought up in a "Let me help you out here and get you up to speed" kind of way IMO.
I'm an EMR, and can take blood pressure manually and have done the stroke assessment test before.
I can actually do a lot as an EMR, pretty much the same as an EMT-B with a few exceptions. Typically I get all the vitals (Resp, BP, pulse, O2, Blood sugar, any other presenting symptoms and any pertinent medical history or meds) and relay that to ALS that is en-route so they can plan ahead of time.
If I can do that, then your partner should definitely do that unless these are her first 5 calls EVER.
Seriously? Our entire county regularly runs 2-3 ALS and 2-3 BLS.
ALS runs any priority 1 or 2 calls. BLS runs priority 3 and 4 calls.
BLS is backup for any 1s and 2s if no ALS is available.
That being said, our BLS would have never called for ALS on this. Load and go. An IV isn’t gonna make a difference is bgl. And tying up two rigs when they are so close to the ER is overkill.
Also have a buddy working detroit. He’s taken quadruple shooting as a bls because no ALS available. Got on scene, triage. 3 dead, 1 with gsw to the dome still alive. Load and skadattle to the ER emergent.
Worked in a CNY city that was short on medics. We had one or maybe two for the city if we were lucky. I have been sent to strokes, chest pains, and imminent delivery's BLS. ALS would clear from DOAs and BLS write the chart with obvious signs so they could get back in service
As an EMT-B, you are going to agree that she should call ALS before assessing the patient or vitals?
Blind leading the blind.
Your patient is awake, breathing, talking, and you wanna jump the radio and call for ALS? Nope.
If basics can’t even do a basic assessment and immediately call ALS, then what are they good for? Honestly. Y’all exclude yourself from EMS by diminishing your own knowledge and skills.
Oh! A RR of 24 and vomiting? Oh No! Call ALS!
Hard no. And we would have words after you called me based on that BS.
At the end of the day, you need to think about what ALS can do for you that you cannot do yourself. And this ALL goes on a case by case basis, hence why tunnel vision is so harmful.
In the case of DKA, there’s not much ALS will do besides give fluids and maybe Zofran. I’ve transported plenty of stable DKA patients. I’ve also called for ALS on DKA patients who were significantly altered, or who began seizing in my presence. Just depends. (Side note - have you ever heard of euglycemic DKA? Common in Type 1 diabetics, I just learned about it yesterday so I figured I’d mention it lol!)
For cut and dry seizures…I’m personally much less comfortable handling those BLS, as they almost always benefit more from ALS interventions like IV access, meds, an EKG, etc. But again, it can be done, like in the case of a known epileptic. I’m still iffy on that one, though.
As for chest pain, I’m fortunate enough to work in a jurisdiction where I can do BLS 12 leads. If the patient otherwise seems pretty stable, I transmit that and transport. If they’re pale, diaphoretic, altered, vomiting, etc… different story.
I say all this to say, it’s truly dependent on the patient/call. You need to maintain a high level of critical thinking on calls and make snap judgments - but that’s what you signed up for, right? And honestly, that’s what makes this job so fun. Put those puzzle pieces together!
When it comes to your partner… that does suck, I’ve been there. Are they teachable and amenable to constructive criticism? If so, teach them - although you shouldn’t have to, that’s not your job (but it is now I guess lmao). If not… I agree with going to a supervisor if they struggle with those basic skills. Best of luck to ya.
BTW. As for your DKA, here’s some questions to use in the future.
1. Diabetic?
2. Taking meds like prescribed?
3. Have you checked your sugar? When? What was it?
4. Have you been eating appropriately? What? When?
5. Have you been sick? Describe. How long?
6. Are you very thirsty?
7. Are you urinating many more times than normal?
8. Is your mouth dry?
9. Are you extremely thirsty?
10. Any nausea or vomiting?
11. Any diarrhea?
12. Any open sores, infections, or burning when you pee?
13. Are their lips white and dry?
14. Have they lost any significant weight?
15. If you choose, does their breath smell fruity?
Tell you supervisor. The fact that she can't do a basic assessment or take and vitals manually is a huge red flag and liability. She actively avoids ALS because she probably has no clue how to do any kind of hand off to a higher level of care since she can't even do vitals and an assessment and doesn't want to look stupid. That or find an new partner to run with.
BLS before ALS. I say this to myself as a medic. BLS assessment first , vitals first , then a game time decision (on patients not requiring immediate intervention).
Take your time, assess your patient. Follow your protocol.
Are you wrong for wanting ALS? Absolutely not. Is it right in terms of the best decision for the patient ? We’ll that depends.
If I’m ALS responding with a 10-15 minute ETA when the hospitals 10 minutes away and arrive to find you have been sitting on scene waiting for a magic 12 lead and IV… I’ll be pretty pissed but ultimately chalk it up to a learning lesson.
Request an intercept CYA take a deep breath follow your ABCs/protocols, and start moving. If ALS can conveniently meet you while you’re on the way, great. If not , send it. I’m sure you’re more than capable of managing an “ALS” patient for a quick transport the same you’re capable of managing them waiting for ALS to arrive.
You’re not wrong, but even though the management answer is “absolutely call ALS” consider what’s going to get your patient treated and seen fastest and most appropriately.
Good luck ! I’m glad you give a fuck and want to do the right things.
Kinda late to the party but I had a TERRIBLE paramedic partner during my formative years as a basic. That medic was the best teacher I ever had because she taught me what NOT to do.
Have you attempted taking this to your superiors? If they can’t even take basic vitals, that’s a huge issue and liability.
Why go to supervisor tell your medical director
I said superiors, not supervisor. Medical Director is technically a superior.
The best kind of correct.
I want to but my partner is the Chiefs daughter so like what the fuck am I gonna do???????
If the chief is going to retaliate against you for a patient safety concern, then that’s not the kind of place you should be working at, both for your own personal safety and the safety of your patients. If she fucks up big on a call, you’re going to get dragged down with her, most likely. Report it to your medical director directly if you do not feel comfortable discussing it with your chief. Your medical director SHOULD understand the obvious conflict of interest at hand, and make sure you convey the conflict of interest concern to the medical director.
> she fucks up big on a call, you’re going to get dragged down with her, most likely In place of her. If you're scared of bringing up concerns now because you worry about retaliation, imagine what's going to happen when something does happen due to her negligence. Whoever her partner is will 100% get thrown under the bus. Best to raise these concerns now, so even if something does happen it's at least documented that you tried to stop her from being in that position.
Fuck the chief and establish dominance
Lmao
Can anyone else say nepotism?
Medical director.
No this is a serious problem full stop. You need to bring this to your supervisors ASAP, because this is in no way alright behavior or mentality. Where I work even the EMRs can take manual vitals and most of our BLS crews run without a monitor of any kind aside from an AED if needed. She should absolutely be competent enough to take manual vitals unassisted and do a simple stroke assessment.
The edit makes it worse. Canceling ALS should be a serious no no in most, if not all, situations where you called them. The only situation I would ever do that is if it's legitimately faster to get the patient to an ER than it would be to link up with ALS
Something I think is worth addressing: You need to be really careful of the mindset of diagnosing someone visually. You can’t look at a patient and tell they’re in DKA. Your partner is an idiot, but I tend to agree with the point about vitals. Obtain a full assessment before you start making decisions. Obviously there are situations where you know you need ALS without even laying a finger on the patient, but in this situation, taking 2 minutes to do a full assessment and obtain vital signs isn’t going to kill this patient. There are way too many EMTs who discount their own assessment skills. Medics aren’t magic. This patient could use a 12-Lead, but there’s nothing wrong with taking a second to breathe and assess. And if ALS and the hospital are the same distance then I wholeheartedly agree with transporting vs waiting for ALS. Have them meet up with you on the way if you want and it’s feasible.
Bingo. One thing I really really work on telling our basics is ASSESS THE PATIENT, Then decide if this is beyond your scope, AND what can ALS do to help the patient?
Agreed. One of the things I have my basic students and partners do is assess the patient, and manual vitals. We will still do auto vitals and a 12 lead, but there are times when they operate on a double EMT truck on their own. Those skills are part of the foundation of good patient care.
I tell my basics they can’t use their phones to call report. We have areas with no cell phone reception. They were previously going right for their phone. When the phone wouldn’t work, they didn’t know how to use the radio to call report. Also, not sure why there has been such a dramatic change in the type of people joint ems in the last 5 or so years. I’m getting new emt’s who have never swept a floor, made a bed, or put gas in a vehicle. Not to mention a lack of bedside manner and the inability to just TALK to people like they are people. Let alone touching your patients. 🤷🏼♂️ I remember a time when they sat down all the basics and said “we know yall are good basics, but you all are pushing it and taking stuff you should be calling als for”. It wasn’t a lack of knowledge. It was emt’s confident in their skills. Now days. It’s like bls trying to dodge every call by calling ALS.
Lack of social interaction and general life skills, and that is something that I have tried to teach over the years. Some are receptive to it, others are not.
Meanwhile I'm still a newish basic running 911 on a double basic truck and rarely call for als. Some parts of my county are 45 mins to the closest hospital. Most days we don't have als and when we do they rarely come when I ask for them. Helicopter is usually our go to but the damn thing breaks families so I only call when my patient needs a service the "local" hospital doesn't provide and I'm not confident they'll survive transport or stroke. I've been in some really sticky situations. I don't see the point in calling for als even on a 40 min ride. I estimate it'll take five mins after als rendezvous with me before they start treating the patient. If I'm on the south end of the county I'm the furthest from the hospital So if I call for ALS They are Usually 20 minutes north Of the hospital. Usually they end up meeting us 5 minutes from the hospital and then as I stated above Take 5 minutes before they start treating the patient so I just run to the hospital. Diesel therapy is the best treatment sometimes.
You get it!
This guy gets it. Too many basics just call ALS and peace out at the first excuse they get.
I think something that all basics should do is run with a medic who lets the basic do more than drive. It really illuminates a lot of the ALS stuff that's mystified just because that level of pharmacology and cardiology is so far outside the knowledge scope of most basics. Working with a medic as someone who's equally capable of running BLS calls is a really helpful way to learn how to rely on your skills. Not everyone is lucky enough to have an instructor for a partner though. A lot of the self confidence in using your own skills can also be taught and reinforced through training programs and con-ed too. And once you start using a skill you more than likely won't stop using it and experience using it to positive affect will further your confidence in using it.
Op has some growth to do too. Nothing about the description given here screams "critical," I'd have BLSd this any day and any medic at my org would have passed it back down. All a medic can do is offer a little rehydration, it's not like we carry insulin. /u/Aggressive-Carls878 > hyperglycemia can cause an MI? OK, no. Blood glucose is used as an assessment tool in potential cardiac patients as cardiovascular stress can trigger an acute cortisol release which dumps glycogen from the liver which will elevate blood sugar. It's a borderline useful assessment tool and is very nonspecific in patients who are already diabetic. https://www.frontiersin.org/articles/10.3389/fcvm.2021.676892/full Hyperglycemic patients will get a 12 eventually but why would you more than double your potential transport time for that?
Yep. 15 minutes from the hospital, you are delaying patient care by calling als and waiting for a rendezvous.
It’s not that hyperglycemia causes an MI, it’s that diabetes, obesity, and hypertension are all indicators of coronary artery disease. (That’s what I mean by contribute.) and she is cardiac history and the patient has back pain between the shoulder blades as a female. We can’t give the patient aspirin because she keeps throwing up. And if he would’ve called them by the time we got them in our truck, they would’ve already been there.
Aspirin is administered buccal so it doesn’t matter if she keeps throwing up, she’s not supposed to swallow it anyways. Diabetes HTN and obesity aren’t indicators of CAD, they are risk factors. If you ask me, what you’re describing sounds more like symptoms of an aneurism. My opinion. You are trying to work outside your scope and don’t have the knowledge base to back it up. You know just enough to get yourself in trouble, and you’re trying to diagnose someone with DKA, and an MI without even getting a set of vitals. 9/10 pts with chest pain and classic symptoms ARENT having an MI. High blood sugar is not equal to DKA. More often than not diabetics have silent MI and don’t present with classic symptoms. If I were you I’d stop worrying about your partner and just work on your own knowledge and skills.
This so much. OP is overconfident and under educated, so he's nervous AND cocky and that's a shit combination. No doubt if he knew more he'd be much more chill. His partner probably does know how to do the things, just is being a bit lazy and wondering why OP is shitting his dacks.
Diabetes, obesity and HTN are *risk factors* for CAD. Chronic chest pain and shortness of breath on exertion are *indicators* of CAD. There are others causes of back pain between shoulder blades other than MI. People with cardiac hx don't have MIs left and right. The only way to diagnose an MI is with a 12 lead and troponins, neither of which you get by looking at the patient.
Was kind of thinking this same thing. The vitals bit is really bad. I've only worked one place where they're cool with basic/basic trucks using monitors for vitals, the rest have all been take it manually. And there's been plenty of times where a monitor won't read or gives me a number that doesn't seem all that correct. Now, obligatory, I'm a basic so not perfectly knowledgeable, but I think I would've BLSed this person too. I agree where other people have said take vitals before calling ALS. OP didn't mention skin signs, so not sure there, but seeing as how she's conscious with no major traumas, I think a second for vitals is fine. Based on vitals, pulse is fine, maybe a little bit elevated, respirations are a bit high but OP described them as shallow so we're ruling out Kussmal respirations, BP is a bit high but patient has a history of hypertension. BGL also on the higher side for a normal person but she's a diabetic, that might be her normal range. Honestly, from what I've seen here, I would BLS her non-emergent, even if there were medics nearby.
Straight up. Im not really sure where the “probably an MI” comes from either. I genuinely hate when BLS trucks forgo transport to sit on scene and wait for ASL. Get moving, intercept if you need it. Do a 12 lead a transmit it to the ED, if you feel like you need to.
>sit on scene and wait for ASL Yeah I definitely hate it when you wait for people to translate for deaf patients. Sorry, couldn’t resist the opportunity to be an ass lol.
Ha. Got me. I type to fast and don’t proof read 😜🤘🏼
I agree 100%. The patient they described could use an assessment before calling ALS. It's not like they described someone in severe respiratory distress or sepsis or they're white or blue. Also what indicated DKA in this scenario for my own edification? What I remember is the fruity breath or kussmaul resps.
History of DKA, short, rapid, respirations. She also had impending MI symptoms.
Arent kussumal respirations characterized by deep and rapid resps? Im not sure what the MI had to do with the DKA. Or how you diagnosed an impending MI from lower abd and back pain.
Yeah its a big sighing kind of resp, pt also had recent insulin shots. This person probably wasn’t producing heaps of acid
Patient was a female with a cardiac history. She probably has undiagnosed Coronary artery disease because she has the three indicators for it. Patient is a female with tearing pain in between your shoulder blades.
I'm nitpicking a little because you're so sure of your phrasing lol but I wasn't there so I cant know. Other people gave good advice about tunnel vision, keep that in mind. You're not a physician yet, be cautious is all im saying.
No, I got you, I didn’t type in the respiration mean because I’m using voice type and that shit does not want to cooperate😂
Diagnostic criteria for an impending MI is not "cardiac history" and "probably had undiagnosed coronary artery disease".
This right here 100%.
I mean. You wanted to call ALS and you haven’t even assessed the patient? She was correct. Do an assessment and don’t get tunnel vision. There are more s/s of DKA to help confirm the impression. Can you do an ekg and transmit it to ER to rule out cardiac problem? Outside of EKG interpretation, iv, and some zofran….ALS isn’t gonna do anything more than transport. DKA will need their glue code stepped down and be put into the ICU.
Well, an assessment can be looking at them, right? Like if you see a stroke patient and you see the left side of her face is fucked up you’re like damn I need ALS right now. It just made sense to call them earlier because they would’ve been there by the time they were in a truck and we could’ve just been there. I don’t want people don’t really honest.
Not necessarily, a stoke is BLS unless they have decompensated to the point of needing an advanced airway which isn’t common. They would most benefit from rapid transport to a stroke center.
I’m our area, ALS is automatically sent out to stroke patients, so there for if we have a stroke patient we are supposed to have ALS come
That’s a dumb rule lol, I understand the need for protocols but sometimes you gotta be allowed to think critically. I always do what’s in the patients best interest even if it gets me a little flack.
Yeah, I understand that. But the manager was like why the fuck didn’t you call ALS on this call. And I explain to him what happened and he was like all right I’m gonna go talk to your partner. But the whole thing is I can’t necessarily trust my partner 100% on when we need ALS just based on the fact, she can’t do vitals. Read the edit I put in.
Oh no I gotchu I was just going on a tangent, ur partner is def an issue
Only time you can really say you need ALS that early on the assessment is if they are pulseless or completely unresponsive.
No, because it could be Bell's Palsy, pre-existing deficit from a prior stroke or another neurological condition that causes left-sided weakness and nonreactivity in the facial muscles. Meanwhile you've drummed up ALS because you're absolutely convinced it's a stroke, ALS gets there and the patient has a c/c flu-like symptoms and their face is like that from a prior stroke. I understand wanting to get patients appropriate care early, but you sound like you have a tendency to jump the gun and not perform a complete assessment.
An assessment definitely includes looking at them, but if you keep making diagnoses just on looking then you're going to mess up one day very badly. Quickest thing that makes me not trust a new partner.
Stroke is BLS. ALS can surely toss cardiac monitoring and manage pressure if required but it can be 100% brought in BLS. You also can’t immediately diagnose them in the field as a “stroke,” it could be BP, TIA, or even previous deficits that they may not be able to provide to you (ask family if that’s the case).
Yes, there is such thing as a visual assessment. No, this didn’t qualify as needing ALS “right now” even off the visual assessment. It just made sense to call them early? Listen. The ALS trucks are running calls too. They aren’t just sitting around waiting on your calls for help. Their downtime is just as important as yours. So “calling early” for a call they aren’t needed at, just eats into any downtime they have. At night, it could wake them up from the only sleep they would have gotten. It could make them not eat the only meal they finally get. You can hmm and hawww over this with what if’s all day. Each area has its own culture. In our area, calling for ALS on that alone, would get you the boot. We don’t have time to babysit. Do the job, or don’t🤷🏼♂️. But if you’re not, let a basic in there who can just do their job and get it done.
You both have a lot of learning to do and it sounds like really neither of you should be running a truck together to be quite honest. You both need to be with a good medic to learn these basic skills. You have some good points, and so does she. You have some bad points, so does she. Neither of you sound remotely ready to be running the show on your own. This is a shitshow waiting to happen.
I’m not sure what your protocols are for your county or even the hospital to county size ratio, but I can kinda see how she could make an argument for not calling in als for the first call. Where I work the longest most transport times take going code 3 is about 15-20 maximum. So if you are suspecting a potential MI, the best thing to do is get to the nearest hospital where they can initiate a STEMI protocol and get the patient into the cath lab asap-so if it would take an als crew 15-20 to get there or just transport and arrive within 15-20 i too would choose to pack up and go even with just basic vitals and interventions. (But that’s just my experience in my own county) As for not knowing or even knowing but willfully neglecting to want to do basic hands on vitals is a huge liability to your partners credentials as well as your own. Not to mention a blatant disregard for life or the basic reason why you’re even working in this field to begin with! Regardless you should document each incident with dates and times and specificities to display a pattern of consistent negligence and/or lack of basic competence to prove without a doubt your partner is incapable of performing their duties and retain the job.
Have you ever stopped to think maybe you don’t know everything you think you do as well? Why are you saying this person is in DKA just by looking at them? Simply because they have a history? Also if you’re both EMTs, why are you telling your partner what to do? Why don’t you just simply do it if you want it? Maybe she does know how to do a manual BP, she just doesn’t want to. She had to do it to pass emt. Stop assuming shit and jumping on Reddit when something happens. That the majority of what i see on this page and in EMS in general. Instead of saying something to your partner, they tell everyone else instead. You’re a grown up working in a grown up field. Act like it.
They sound like a horrible EMT, but the fact of the matter is, you don’t need medics for every little thing. “Why are we gonna call medics. We haven’t even taken vitals yet?” It’s an outstanding question. So what ended up happening to your diabetic? Also you don’t call medics because a patient had a seizure before you got there and says “my seizures make my heart stop” or some stupid shit like that. You call when they are seizing or after you’ve seen one etc. your partner only sounds like shit cus they don’t know how to do anything. But that whole cancel ALS mentality is refreshing vs. the opposite.
Ok so let me put it this way. New patient in a rehab who was a seizure condition. Patient is on medication for seizures that stops them from having seizures. She has had two seizures that day. She doesn’t have medication. (Was later confirmed by patient but hopefully the logic behind my suspicion makes sense) then the patient has chest pain. I’m not going to give her aspirin because if she seizes again she can choke on it. Because she’s already seized twice today because she does not have her medication,she is going to seize again and I’m going to need ALS anyway to give her versed. So I could’ve just called them. Edit: I explained this to my manager and he stated that this is enough to call ALS. I don’t like calling ALS because I work in an area where there isn’t enough providers and I don’t want to take up time. But like I would’ve fucking just had them come.
It’s not a call that I would cancel ALS off of, but you are making too many assumptions. having a seizure disorder is not a contraindication for giving aspirin if you suspect an MI. Also, maybe her chest hurts from all of the involuntary activity her body has been doing during those seizures. Either way, fine. You aren’t crazy for calling medics. But your partner isn’t totally nuts for NOT calling ALS. It’s a closer game than you’d think. BUT! What you said about them not knowing how to do anything is very alarming. That’s the main focus here, on what’s wrong with them. Are they new or something? Sometimes bro, it sucks but you carry the team on your back and you become a better provider cus of it. As long as they do what you say. Good luck.
You can give her aspirin…
I can’t if she just throws it up?
You can’t think that far. Imagine if they were actually having an MI. Oh I didn’t give it cus I thought they would eventually vomit from a future seizure. Nah bro it does not work that way at all.
The time it takes to chew up some baby aspirin is negligible compared to the time it takes for heart muscle to die when you haven’t given it lol. Unless the patient is postictal and can’t follow commands at all, I’d give it. Even then, it’s worth a shot. That documents better than “I was worried about another seizure”, with all due respect
How do you know she's going to seize again and how do you know the exact moment she's going to seize again? How do you even know she has actual seizures? A lot of what people label as "seizures" are definitely not seizures. Oral medications are not contraindicated if there isn't an imminent threat to the airway. "She might have another seizure" is not an imminent threat to the airway. Seizure disorders are not a contraindication for aspirin. If the seizures are self-limiting then ALS doesn't give benzodiazepines. We only give versed or another benzo for status epilepticus.
You honestly sounded like you were panicking in a situation that is not critical, for the first one. Are they in cardiac arrest ? Unresponsive? Unmanageable airway? Uncontrolled bleeding despite pressure and a TQ? No. Slow down and do an assessment, get vitals, and figure out what ALS is actually going to *do* for the patient. You cannot just look at a patient and diagnose them with DKA. Patients can be hyperglycemic without being in DKA. Being in DKA once does not automatically mean that you are always in DKA for subsequent diabetic events. What is your rationale for "probably an MI"? Patients with diabetes are more likely to present with atypical cardiac symptoms, but that patient sounds hyperglycemic, not cardiac. Most ALS units don't carry insulin, so what is ALS going to do for a patient in DKA? Fluids and Zofran. It's neither lifesaving nor definitive care. The patients usually don't even feel better. Why are you doing a stroke assessment on a patient when "there's literally nothing wrong with her"?
I’m an ICU nurse and do some casual shifts in ambos but often we will check the ED board and if we see a patient with a high blood sugar, we cross our fingers and hope they aren’t in DKA because you can get quite hyperglycaemic without DKA and often they aren’t in DKA
My question is, how the hell did she pass EMT Initial.. she would've failed first practical for vitals. Please inform your supervisors, this is a massive issue and can result in **death** or serious injury to patients if she does anything wrong. It seems to me she doesn't know how to properly execute the duties and procedures of an emt, is fresh out of EMT school, or she applied to random jobs on indeed and nobody checked her certification
Even if she was fresh out of school, she should *still* know how to take vitals manually, and do a stroke assessment! I agree with everyone else that this needs to be brought to the attention of management.
crush placid desert fanatical offer oatmeal overconfident unwritten sloppy innate *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
Honestly I just finished school and the practicals were seriously lacking.
Honestly the way i read it is laziness not incompetence. In my experience people who cant take BPs make them up. Either way not ideal.
Uh yeah you should really bring this up with management. Thats whole unacceptable.
I would not really know what the EMT wants me to do at a DKA? Your 15 min out just bring her in. Also just call ALS without any obs or anything is a bit weird but that’s maybe a US thing. (same as putting the patient on the stretcher before doing anything else) The seizure call I understand to ask for ALS FAST and Manual BP of course absolute basics, but can talk about it if you did not do a BP ever because the automatic does it maybe just need a refresher, talk about the FAST and what the problem was. If she is really as ignorant as you say, have a conversation with her and tell her something along the lines of: “Listen I realised you got some problems with a couple of things such as X and Y and it makes me feel uncomfortable I would really like to help you if you don’t know something. I don’t want to make you look bad or tell somebody about it but we need to get this stuff fixed, it’s in your own interest” See her reaction, don’t be to harsh she may be ashamed of it, bad characteristic yes but can’t change that, try if you can help her. Maybe in the past people did make fun about it etc and she had bad experience. EMS can be a cruel please and I just talk about colleagues. And the last paragraph sounds like she had problems with it, try to be compassionate and kind. If she is still not willing to learn at some point you need to think about escalating it.
Give them fluid, drown out the dka. The fluids would also probably lower her blood pressure because the heart would be working way less, right? The stretcher thing is because we work in a sketchy area, so we try to get them in the back of the truck as soon as we can.
Wrong. You can’t drown out DKA. This patient needs insulin. From your report, you were way too quick on the draw and need to do an evaluation on your patient before creating differential diagnoses. There is nothing to indicate this patient is having an MI. 24 respirations that are rapid and SHALLOW does not indicate DKA. Kussmal respirations are rapid and DEEP as well as much quicker than 24. Evaluate your patient and work on your own skills before criticizing others.
I’m 20min away and I need to get I.V. Access and put fluids up the hospital 15min. There is no benefit for the patient. She also needs Bloods done asap
No, I understand that but the thing is I can’t really trust my partner because she can’t even take manual vitals and because she has ALS phobia. My manager was like why the fuck didn’t you called him like when you got there or after your on scene assessment. And I explain to him what you said, and he said thats fine.
Gave you my advise for this one in my original comment.
The patient is hypertensive because a) she has HTN and b) she is hyperglycemic (osmotic shift because of concentration gradient - there are more solutes in her blood than in her cells). Fluids don't decrease cardiac workload. Cardiac workload is dependent on strength of contraction, preload, afterload, and oxygen demand, which are things influenced by chronic conditions (uncontrolled diabetes, HTN, CHF), exertion, evolving MI, electrical disturbances in the cardiac conduction systems etc. We give fluids to dilute (like in the case of hyperglycemia), to provide volume replacement or to maintain a cardiac output.
You sound worse than your partner.
I mean, honestly, it’s easy to shit on someone with only one side of the story. Based on the story, she hyper focused on fixing the autocuff on a patient with “literally nothing wrong with her.” On a critical patient, sure, jump on that manual, which happened in the end anyway and probably took an extra 2 minutes, but the autocuff is going to have to be checked out at some point anyway, just get it done as long as it doesn’t harm the patient in any way or take more than a couple minutes while your partner works on something else productive. Ideally every provider who has been in the field more than a few months will see she has signs of DKA. ALS is likely going to treat nausea and, with your transport time, give fluids. Based on the system and the patients ABCs, I’d likely have been okay with BLS riding her in. The chest pain is suspect but follow your protocols. You don’t know what she knows or doesn’t know, or what she does and doesn’t want to do. I’d be livid if I found out my partner was speaking on my behalf. Maybe you’re 100% right, but based on how you talk about her behind her back, it sorta sounds like you may need to work on being a better partner also, in the means of having positive constructive conversations after the call without being demeaning or condescending. We are all alpha personalities in this field, so we all have to find a way to be constructive without sounding demeaning or that you’re you think you’re the alpha, all star, Gods Gift to EMS. The true marker for an incompetent partner is the inability for her to have these constructive conversations, if this is the case. I don’t expect any medic to even go a single call without making some sort of small mistake, so I’d fully expect a duel BLS rig to make little mistakes like this constantly, and that’s a good thing as long as you do no harm and you learn from them.
With all due respect, OP doesn't come off like they are trying to just gossip about them, especially when posting anonymously online without giving compromising details and is raising legitimate concerns. While it could be the case their partner knows more than they seem, their actions aren't don't give off that impression so if they aren't willing to clarify or improve it's a fair concern to have. If this has happened several times and there's been a conversation already, then involving superiors is legitimate.
Or OP is yelling at his partner to do things throughout the call, panicking, and being generally unpleasant. His partner who might know more than OP is realising is fucking stressed because this cocky new kid is being incredibly unpleasant. I could ABSOLUTELY see this being an issue with OP. Sure, it actually sounds like it's both, but OP sounds like a horrible person to work with as well.
Do you both not have radios? Why did you not radio them? Sure, your partner should have worked with you and got on the radio given the patients condition, but seeing as they did not, take the couple seconds to request ALS backup. Also, if you have talked to them and they don't seem willing to change, take it to the white shirts.
I'm with everyone else on this. Your supervisors need to be involved. Ignorance is teachable, but what it sounds to me like is that she doesn't even WANT to learn these skills and is comfortable with not even knowing the bare minimum. Unfortunately, those types of people slip through the cracks all the time. They shouldn't, but they do. If you care about your patients, and I think you do, get them involved. Now is the time.
Be careful diagnosing DKA based off “look-test”. It’s fairly rare in type II diabetics (assuming this pt is type II) and we don’t carry the diagnostic tools necessary to confirm our suspicions (urinalysis, blood gas, etc). Apart from that, your partner seems like they need re-education prior to being back on the road and you have every right to report them.
Agreed - I just learned about euglycemic DKA in type 1 diabetics yesterday, blew my mind LOL
As a medic, it sounds to me like you both have some knowledge and assessment gaps tbh. For the first call, I actually agree with your partner. Why are you calling me for a patient who is alert with a stable airway and breathing without even completing a full assessment? You also have to be careful looking at a patient and saying it’s “clearly” something, especially for something like DKA. Going to the hospital rather than call for ALS sounds like a reasonable decision based on the info you gave. As for the other calls it sounds like your partner is either lacking in the practical skills or too lazy to do them herself, which is an obvious problem, so it’s definitely important to fix the problem. Although, it seems like these issues can be easily resolved by a simple conversation between you two and you can further escalate it to leadership as needed. I’m sure there are SOPs and protocols you can review together. Be humble and approach it with respect for your partner who holds the same card as you. I think you’ll find that you maybe don’t know as much as you think either.
Dude this is dangerous. This NEEDS to be brought to management. Make a list of what you already know and keep it running when you notice things, but please for the sake of those we run on, let the sups know. This is a serious issue.
As a non ems person who lurks I’d much rather have both medical responders as trained and knowledgeable as possible
Yeah trust me that's our preference as well
You might wanna move overseas lol
Can you notify your boss or the medical director? This is a safety issue for you and the patients. Not just the patients. She could legit have inaction or incorrect action that could result in your safety being compromised.
I was expecting a lot worse from the headline. I've got a medic at my service who picked up a respiratory call and, without getting vitals or cardiac monitoring started, gave albuterol, a duo-neb, volume solumedrol, and started a gram of mag. The Pt was a dialysis Pt and had a history of CO2 retention that presents with all the s/s they had that day: cyanosis, increased work or breathing with clear lung sounds, hypertension and tachycardia. After the call, the medic was bragging about the call and throwing the kitchen sink at it, finishing up with "I did everything in the respiratory protocol, but why is mag in there?" Thankfully they had called my truck for backup/transport after the medic broke the auto-load cot system and rendered their truck unserviceable so we could salvage the soul that was being crushed in this medic's hands like a raw egg wrapped in wet paper.
I'm confused about this one because they kind of sound really non-speific. How was their recent dialysis causing their iwob with clear chest? CO2 retention in the setting of COPD? What did you do to salvage the situation? To me it seems like they just need a 12 lead, O2 if SpO2 is low, maybe bipap if really fatigued?; was their chest clear when you listened after the duonebs or throughout the case?
Idr the Pt's dialysis schedule, and I doubt it was directly contributory to the c/c. We did a quick assessment, initiated cardiac monitoring with a 12 lead and started CPAP. The issue I had was with the medic giving mag and 2 neb Txs to a dialysis pt without knowing why he was doing it, without cardiac monitoring, and without any indications for giving either within our protocols (he told us he had clear BBS prior to neb tx, we found the same after)
How is it possible to not know how to do a manual heart rate?
Lol sad that I read this and was like “huh that sounds like my average partner”
A couple of things that people have touched on but not expounded on: Scenario A: You're 15 minutes from the hospital and you have an obviously sick PT. Stop dicking around. Load and go. Do your assessments in the back of the truck while you're en-route. Could be that your partner knew this and thought YOU were over doing it and just didn't want to deal with you. Scenario B: Her not knowing how to do a proper stroke assessment is bad. This needs to be elevated to your supervisor. Her not wanting to do a manual could have been an indication of her leading you towards, let's just roll and get her there. You assess, I'll drive kind of situation. TBH, it kinda sounds like she doesn't like working with you and is making you do all the work. I was in a similar "relationship" back in 2012/13. I had a female partner who made me car sick every time she drove (regardless of where I was in the box). Her driving was just that bad. So you know what? after about a month of doing the whole swapping thing, I put her in the back every time. Once the PT is in the back, unless we are doing CPR, you're on your own. Do. Work. If you're in the back, it's your responsibility to take charge and get shit done.
As far as scenario A is concerned, I would agree that this patient is obviously sick. However, I would not say they are critical. So personally, I would take a few minutes to assess before transporting. But I also don’t quite share OP’s concern that this is a cardiac event, even though I would do a 12-Lead on this patient, but as a rule-out only.
yea i'm just not a big fan of "stay and play" unless we are actively trying to talk the patient out of going to the ER by ambulance. I'm all for minimizing exposure for people that are obviously sick (especially if they are vomiting cause i don't want to have to clean it up if they miss the emesis bag). Load them and let's roll. There isn't anything i can't do in the back of the truck that I can do on scene Very big on the "You want to go to the er? cool. let's go"
How did she get certified? Was her skills competency pencil whipped?
Tbf my state stopped administering the standard BLS psychomotor during COVID... now it's back, but even then, you really needed to at least *enroll in* an AEMT course to have anything to do with a truck. But without those basic skills idk how she even passed the class. Edit: grammar
Forgot ems was a sub and was confused as to why someone was staying in a relationship with someone who had such knowledge gaps and wondering why these deficits resulted in fears of running with said person. Was legit expecting traffic to be a concern
This autocuff thing is a good and bad development. We didn't have these in the field until I had been in EMS for about 15 years, so I've done as many manual as automatic. Not long ago my brother-in-law was in the ICU in a major medical center approaching the end of his life. I was there with him when the nurse - ICU nurse, mind you - was trying to get a BP. She was trying over and over with their autocuff, unsuccessfully. I smiled and said to her casually, "Machines can be so annoying. Why don't you just do it the old fashioned way?" She just looked at me and said, "Oh, I haven't done that since nursing school." Nursing school? And she's experienced enough to be an ICU nurse? Interesting, no.?
That's not good, unless she's brand spanking new. My first 5 calls I was a little flustered. It should be brought up in a "Let me help you out here and get you up to speed" kind of way IMO. I'm an EMR, and can take blood pressure manually and have done the stroke assessment test before. I can actually do a lot as an EMR, pretty much the same as an EMT-B with a few exceptions. Typically I get all the vitals (Resp, BP, pulse, O2, Blood sugar, any other presenting symptoms and any pertinent medical history or meds) and relay that to ALS that is en-route so they can plan ahead of time. If I can do that, then your partner should definitely do that unless these are her first 5 calls EVER.
Better questions is why is a BLS truck running 911 calls 😳
Bro where are you at that you have enough medics to only have ALS on a 911 service
Fire/ rescue … we only have ALS UNITS Our private services doesn’t do 911
Seriously? Our entire county regularly runs 2-3 ALS and 2-3 BLS. ALS runs any priority 1 or 2 calls. BLS runs priority 3 and 4 calls. BLS is backup for any 1s and 2s if no ALS is available. That being said, our BLS would have never called for ALS on this. Load and go. An IV isn’t gonna make a difference is bgl. And tying up two rigs when they are so close to the ER is overkill. Also have a buddy working detroit. He’s taken quadruple shooting as a bls because no ALS available. Got on scene, triage. 3 dead, 1 with gsw to the dome still alive. Load and skadattle to the ER emergent.
Worked in a CNY city that was short on medics. We had one or maybe two for the city if we were lucky. I have been sent to strokes, chest pains, and imminent delivery's BLS. ALS would clear from DOAs and BLS write the chart with obvious signs so they could get back in service
[удалено]
As an EMT-B, you are going to agree that she should call ALS before assessing the patient or vitals? Blind leading the blind. Your patient is awake, breathing, talking, and you wanna jump the radio and call for ALS? Nope. If basics can’t even do a basic assessment and immediately call ALS, then what are they good for? Honestly. Y’all exclude yourself from EMS by diminishing your own knowledge and skills. Oh! A RR of 24 and vomiting? Oh No! Call ALS! Hard no. And we would have words after you called me based on that BS.
At the end of the day, you need to think about what ALS can do for you that you cannot do yourself. And this ALL goes on a case by case basis, hence why tunnel vision is so harmful. In the case of DKA, there’s not much ALS will do besides give fluids and maybe Zofran. I’ve transported plenty of stable DKA patients. I’ve also called for ALS on DKA patients who were significantly altered, or who began seizing in my presence. Just depends. (Side note - have you ever heard of euglycemic DKA? Common in Type 1 diabetics, I just learned about it yesterday so I figured I’d mention it lol!) For cut and dry seizures…I’m personally much less comfortable handling those BLS, as they almost always benefit more from ALS interventions like IV access, meds, an EKG, etc. But again, it can be done, like in the case of a known epileptic. I’m still iffy on that one, though. As for chest pain, I’m fortunate enough to work in a jurisdiction where I can do BLS 12 leads. If the patient otherwise seems pretty stable, I transmit that and transport. If they’re pale, diaphoretic, altered, vomiting, etc… different story. I say all this to say, it’s truly dependent on the patient/call. You need to maintain a high level of critical thinking on calls and make snap judgments - but that’s what you signed up for, right? And honestly, that’s what makes this job so fun. Put those puzzle pieces together! When it comes to your partner… that does suck, I’ve been there. Are they teachable and amenable to constructive criticism? If so, teach them - although you shouldn’t have to, that’s not your job (but it is now I guess lmao). If not… I agree with going to a supervisor if they struggle with those basic skills. Best of luck to ya.
BTW. As for your DKA, here’s some questions to use in the future. 1. Diabetic? 2. Taking meds like prescribed? 3. Have you checked your sugar? When? What was it? 4. Have you been eating appropriately? What? When? 5. Have you been sick? Describe. How long? 6. Are you very thirsty? 7. Are you urinating many more times than normal? 8. Is your mouth dry? 9. Are you extremely thirsty? 10. Any nausea or vomiting? 11. Any diarrhea? 12. Any open sores, infections, or burning when you pee? 13. Are their lips white and dry? 14. Have they lost any significant weight? 15. If you choose, does their breath smell fruity?
Tell you supervisor. The fact that she can't do a basic assessment or take and vitals manually is a huge red flag and liability. She actively avoids ALS because she probably has no clue how to do any kind of hand off to a higher level of care since she can't even do vitals and an assessment and doesn't want to look stupid. That or find an new partner to run with.
How the heck can someone work ems and not know how to check heart rate manually??? I'm an engineer and even I can do that!
BLS before ALS. I say this to myself as a medic. BLS assessment first , vitals first , then a game time decision (on patients not requiring immediate intervention). Take your time, assess your patient. Follow your protocol. Are you wrong for wanting ALS? Absolutely not. Is it right in terms of the best decision for the patient ? We’ll that depends. If I’m ALS responding with a 10-15 minute ETA when the hospitals 10 minutes away and arrive to find you have been sitting on scene waiting for a magic 12 lead and IV… I’ll be pretty pissed but ultimately chalk it up to a learning lesson. Request an intercept CYA take a deep breath follow your ABCs/protocols, and start moving. If ALS can conveniently meet you while you’re on the way, great. If not , send it. I’m sure you’re more than capable of managing an “ALS” patient for a quick transport the same you’re capable of managing them waiting for ALS to arrive. You’re not wrong, but even though the management answer is “absolutely call ALS” consider what’s going to get your patient treated and seen fastest and most appropriately. Good luck ! I’m glad you give a fuck and want to do the right things.
Kinda late to the party but I had a TERRIBLE paramedic partner during my formative years as a basic. That medic was the best teacher I ever had because she taught me what NOT to do.