Furosemide is good for filling the patient’s bladder, but the patient probably did not call for help filling his/her bladder.

- Rogue Medic

Comments on What About Nebulized Naloxone (Narcan)

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There have been some interesting comments on What About Nebulized Naloxone (Narcan) – Part I.

Let me start with the sarcastic comment that suggest that everyone is opposed to treating patients with heroin ODs (OverDoses).

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Image credit.

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Mike writes –

Why do we even touch the OD patient to begin with? They didn’t call for an ambulance. If they’re breathing, let them stay. They paid for their fix, let them enjoy it.

If a person is not requesting medical help, is breathing adequately, and protecting his airway, how do we justify treating the patient against his will?

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They obviously cannot be helped by any sort of treament program and would never benefit from medical care.

Where does this conclusion come from?

This is something that is completely made up by Mike.

Nobody has suggested anything of the sort.

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Why should feel some sort of responsibility to help these patients? Because they might have families and children? Screw that. They obviously want to die, or at least get high, so what business is it of ours? It’s just like those damn suicidal patients.

More made up nonsense that appears to be designed to allow Mike to feel superior to others.

None of it is true of any of the comments Mike is responding to.

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It’s not like a heroin user has ever been rehabilitated and done something useful with their life.

More examples of an apparently fevered imagination.

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Pulling us away from reading studies and saving real people by figuring out the exact process to get those cardiac saves. Those are the ones we need to focus on. Sure they’re one out of a million, but at least the 76 year old woman we save will get another few years in the nursing home.

Avoiding research is ethical?

In what way does inflicting baseless treatment on patients even come close to being ethical?

But when Mike wants to make up his criticism, we should not be surprised that he also might want to make up his treatments.

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I can’t wait to be as jaded as you guys.

We are not jaded when we are interested in providing informed consent to patients and not treating patients against their will.

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angelo responded to Mike with some clear comments, but Mike replied by just demonstrating his biases.

“I’m just curious what medical condition you think a breathing person who is altered from doing heroin has”

How do you plan on assessing them appropriately when they are unresponsive?

How many of these patients are unresponsive?

The mean GCS (Glasgow Coma Score) was just under 12.

 

An average GCS of 12 is unresponsive?

 

Is Mike’s GCS above 12?

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Is drug dependency no longer a medical condition?

Drug dependency is not something for which I have a protocol.

Drug dependency is not an emergency medical condition.

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Is a heroin overdose an automatic exclusion from any comorbidity?

Why are you assuming comorbidities that require emergency treatment?

Why are you assuming comorbidities that would be ignored?

Why are you assuming that these patients would not be assessed?

Naloxone does not treat comorbidities.

 

Naloxone is not an assessment.

 

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Or, are they just not treated because it is felt that they are not worth the time?

I understand that these can be difficult patients, but sometimes you just need to suck it up and be a damn professional.

What patients are not being treated?

What patients are not being treated appropriately?

Giving a treatment that is not in the best interest of the patient is unprofessional.

Nobody has suggested any unprofessional treatment, but Mike continues to make up unprofessionalism to pretend to justify baseless ranting.

What Mike has failed to understand is that the people commenting here (SubUrbMed, angelo, and Prehospital RN) have been advocating for better treatment of patients presenting with signs of a heroin OD. Mike is the one who is opposing professional behavior.

We need to study ways to provide the best care to our patients.

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What Was the Captain of the Costa Concordia in Charge of

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A lot has been written about the officer in charge of the Costa Concordia when it crashed into Europe, a small continent across the Atlantic Ocean from America. Christopher Columbus once did the reverse. He bumped into America. Except Captain Schettino was not an explorer. He just appears to have been ignoring the problems that mixing ships and rocks tend to produce.

His pulse oximeter machine that goes bing navigation system didn’t tell him that something was wrong, so he appears to have ignored all other assessments.[1]

 

No alarms = Nothing could possibly go wrong.

 

Once help arrived, Captain Schettino appears to have tried to abandon ship before everybody else. It is a simple mistake. The Captain is the first/last to leave the ship, because the Captain is responsible for the lives of the people on that ship – especially when that Captain accidentally gets his ship stuck on a continent.

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Panic is understandable when you are in the middle of the ocean and you fear that you may never see land again.

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“You get back on board! That is an order! There is nothing else for you to consider. You have sounded the “Abandon Ship.” I am giving the orders now. Get back on board. Is that clear?”[2]

At least someone showed up who knew what to do. Coast Guard Captain Gregorio De Falco, who spoke the words above to Captain Schettino.

But maybe it wasn’t Captain Schettino’s fault. Maybe visibility was limited. After all, it was dark and . . . .

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Maybe that part of the coast does not have anything to warn about the shallow water.

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Was he trying to play chicken with the lighthouse?

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The ship ran aground and sank as much as it could sink without burrowing into the ground. The ship is resting on the sea floor, but the ship is big enough that most of the ship is still above water. As big as the ship is, the land that the Captain plowed into is big enough to dwarf the ship in this picture – and the ship is huge. 4,000 people living on the ship. 4,000 people can fill a small town.

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There are two main types of dangerous –

1. Those who don’t worry about anything, because they do not understand what is dangerous.

2. Those who panic about everything, because they do not understand what is dangerous.

Captain Schettino appears to have been both. He casually ran his ship aground and apparently killed several people. He followed this by panicking and attempting to flee from his ship, which could cause his crew and passengers to panic and could lead to much greater loss of life.

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Being in charge means being responsible for practically everything.

Being in charge means setting an example for everyone else.

Being in charge means that even if something was out of your control, you accept responsibility for it.

Later, an investigation can determine how much blame should be placed on each person.

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Footnotes:

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[1] Costa Concordia: Why navigation might ‘fail’ and other cruise ship questions
Christian Science Monitor
Whitney Eulich, Staff Writer
Article

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[2] Costa Concordia’s tale of two captains: the ‘hero’ and the ‘coward’
Italy is enthralled by two captains involved with the Costa Concordia. Coast Guard Capt. Gregorio De Falco is a hero to many. Capt. Francesco Schettino, not so much.
Christian Science Monitor
By Philip Pullella
Reuters
January 18, 2012
Article

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Inexcusably Low Pay, Hypoxia, and Assessment

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On EMS Office Hours most recent show, Jim Hoffman, Josh Knapp, Bob Sullivan, and I discussed several topics –

January’s Rapid Fire Show | Refusals, Cameras and Perception

Why does EMS pay so little for such dangerous work. This year, EMS is rank as the 6th most dangerous job in America, but many people have to work several jobs just to be able to afford to have the paychecks cover the bills.

The other topic on the show was about whether a hypoxic patient can be permitted to refuse treatment and/or transport. Are we required to treat a number on the pulse oximeter, or are we supposed to assess our patient appropriately to determine if the patient has the capacity to make informed decisions.

What do you think?

Go listen to the podcast.

Articles discussed in the show

EMS1.com article on cameras and bystanders.

EMT the worst job? According to this article, it’s #6

Rogue Medics take on refusals and hypoxia. Be sure to read the comments posted here as well.

The Medic Madness post that motivated Tim to bring the discussion to his blogosphere.

Also check out the FreeEMSTalk audio on hypoxia Tim noted during the show.

The last link is at Free Emergency Medicine Talks, which is an excellent collection of emergency medicine presentations. The talk on hypoxemia is nice and short, but will change how you look at measurements of oxygen.

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Ten Things Only Bad Managers Say

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This is not a continuation of If the Banks Ran EMS, but in the same vein. These are things that we do in EMS that we should not do, or that we should do better.

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If you don’t want this job, I’ll find someone who does.
. . . Good managers realize that to get and keep great people, they have to move past the dollars-and-cents transaction and let people own their jobs. . . . Lousy managers, on the other hand, love to remind employees that it’s all about the transaction: “You work for me.”[1]

The approach of, Just get it done, and don’t let patient care or ethics get in the way of getting it done. Yes, it is a business, whether run by a government as a third party, or as a part of a fire department, or by a private company or by a hospital – good business practices are important, but the patient is the reason for the organization.

Just get it done, means “We don’t care about quality, only about job completion.” This is the motto of the lowest common denominator. I passed the entrance exam = I am all that I need to be. I got it done!

If Enron had avoided resorting to Just get it done, they would probably still be in business and their employees would still have money to retire with.

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I don’t pay you to think.

If you demonstrate that you are good at thinking, then my bosses will realize that I am not good at thinking.

Thinking is extremely important in EMS.

EMS without thinking employees is just a taxi service, but even taxi drivers need to think.

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I won’t have you on eBay/ESPN/Facebook/etc. while you’re on the clock.

Down time is important.

The manager who insists that you be alert and awake and doing something, just so the manager doesn’t feel that he is wasting his money, does not understand EMS – even a little bit. Research is showing that we should be building naps into the day. We need to eliminate those who are more concerned about appearances than about job performance.

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I’ll take it under advisement.

Fancy words, that nobody uses except when trying to look smart, but the message is still – I don’t pay you to think.

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Who gave you permission to do that?
. . . People who obsess about hierarchy and permission and grade levels and the like are people you’d be better off avoiding, especially in relationships that give them power over your life and career.

I would rephrase this as – You can’t do that!

My response is. “Then it didn’t happen.”

If it can’t be done, then by definition it could not have happened.

 

It is better to ask for forgiveness, than to ask for permission.

 

This is best when combined with the best treatment for 90+% of our patients –

 

Benign neglect.

 

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Drop everything and DO THIS NOW!

This isn’t something that only bad managers say, but when it is said often, that is a sign of a manager who cannot manage his own priorities. I forgot about this important thing, but now it is your problem.

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Don’t bring me problems. Bring me solutions.

A nice slogan on a coffee cup. The coffee is to be sipped, while the employees manage themselves, because an idiot incapable of solving problems is not a manager.

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Sounds like a personal problem to me.

Part of being a manager is being a referee on personal matters, when they begin to interfere with the job. Having a manager say Stop it, is probably not going to resolve something that became a big problem without the help of the manager. Having somebody objective listen to both sides is important. It may not work, but it is important to at least document attempts to resolve this before firing someone.

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I have some feedback for you … and everyone here feels the same way.
. . . —until a co-worker mentions that your lousy manager said the same thing to her. Poor managers need to throw in a few dozen extra “votes” with their barbs, just to keep employees off guard.

… and everyone here feels the same way?

I have some feedback for you … and the check is in the mail.

I have some feedback for you … and I swear it’s true.

What does that extra irrelevant bit add?

Intimidation.

You are all alone.

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In these times, you’re lucky to have a job at all.
. . . in an era of more than 9 percent unemployment is the same as saying, “I can’t believe you manage to stay in that 90 percent of the population that is working.”

Not as lucky as the bad manager, who relies on the greater ignorance of others to appear to be competent.

Good business practice includes good management. If we find ourselves using these tactics, we should consider the example we are setting. We are not addressing real problems, just pretending to do something. The best management is by example. Set an example that the employees want to emulate.

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Footnotes:

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[1] Ten Things Only Bad Managers Say – Nope, it’s not just you. These jerks are out there
Bloomberg BusinessWeek
Corporate Provocateur
September 23, 2011, 3:09 PM EDT
By Liz Ryan
Article
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Bad FDNY EMS Decisions

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The city’s ambulance fleet is equipped with high-priced GPS – but paramedics still rely on time-consuming paper maps to get to and from emergencies.

That’s because the global positioning systems are designed only to let the FDNY keep track of the rigs, not provide directions on the ground.[1]

Why would anyone want to spend $10,000 for GPS (Global Positioning Satellite) navigation that only gives latitude and longitude?

GPS prices have come down since these were purchased and requirements for this kind of use are different from those for a personal vehicle.

But –

What is the purpose of GPS navigation that does not navigate?

How many people know how to read a map? I am referring to the under 30 year old people. So many have grown up with GPS, that they have never learned to read maps. True, video games often have maps that should develop this skill to some extent, but it doesn’t seem to work that way.

I think that map reading skills are important, but when I need to get someplace unfamiliar in a hurry, GPS can be very helpful. When I run into problems with detours or stopped traffic, GPS can help me get around the problem. How much did I pay for my GPS? Nothing. I have a phone with internet access. Is that a solution for EMS? Not really.

I like riding a horse, but I use a car to get to work. Just because something does work, doesn’t mean that it is the right tool.

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“It allows us to know the exact location of all units at any given time so we can send the closest ambulance.”[1]

If the crew on that ambulance is not familiar with the area, how does that help?

I have worked in cities where the signs are often not there. I have worked in rural areas, where everyone has a rural route or they just make up their own street number. A paper map does not help much in these situations. A GPS location from dispatch directly to the ambulances GPS would speed things up on the calls to unfamiliar locations.

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It lets the Fire Department know where its 236 ambulances are at any given moment – and city officials say it’s cut 30-plus seconds off response time since being installed.[1]

In other words, it is a $10,000 electronic babysitter that does nothing to help crews get to the call sooner. This only helps dispatch locate the closest unit faster.

This is not good management.

I used to work for people with a similar attitude. They frequently would tell people –

You are not paid to think.

It certainly wasn’t IBM.

Anybody who wants EMS to avoid thinking is asking for trouble.

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“They need to listen to the people in the field, actually doing the job, for what needs to change,” said Vincent Variale, president of the Uniformed EMS Officers Union.[1]

Maybe the employees come up with 10 bad ideas for every good idea. Is it worth it to miss out on that one good idea, just for the time savings or the ego massage of staying above the lowly street workers?

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I wonder what The Social Medic will write about this.

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Footnotes:

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[1] Ambulances have GPS, but only to track their location; must use paper maps for directions
by Jonathan Lemire and Alison Gendar
NY Daily News
Thursday, February 10th 2011, 4:00 AM
Article

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