Leaderboard

Just curious what boots everyone wheres. For the longest time I wore these payless 40 dollar boots, and basically it ruined my feet, my knees and of course my back

I sent the memo to two of the EMS agencies (fire based, as are most around here) where I work. We are attempting to effect a cultural shift for the benefit of our patients. I guess we will see if it takes hold. There is no question that spinal immobilization is painful and anxiety provoking for nearly everyone. Patients often have back pain induced solely by lying on the backboard, pain which resolves not long after removal of the board, but which may prompt imaging in the ED due to pain and tenderness caused not by the presenting injury but by the backboard. We have seen harm in other ways: the demented elderly patient with a ground level fall who becomes more agitated from the pain and restriction of the board, the patient from the MVC with anxiety disorder who panics in the straps, the monstrously obese patient who has the equivalent of another person sitting on their chest and has to fight gravity to breathe. I've summarized below some notes from a presentation I have given on myths in EMS. The bottom line up front is that spinal immobilization on a long backboard has no evidence to support its use, but substantial evidence of harm. It is predicated entirely upon theories of injury that have never been shown. It has been taught dogmatically to EMS providers, nurses, and physicians for 3 decades, though there is now a swell of thought that we should modify the practice. Using a long backboard makes sense when pulling an injured person out of the water, or moving them out of a smashed vehicle, but once on the ambulance stretcher, movement is minimal, even with jarring movements of the ambulance. Being on a hard, slippy surface of a backboard will worsen that movement rather than improve it. The National Association of EMS Physicians is working with the American College of Surgeons on a position paper regarding backboarding. The gist of it is that we should eliminate backboards for anything but extrication. There's a few things I've discovered in the literature: Backboards do a horrible job of immobilizing the spine, and movement is worse on the backboard than on a soft surface that conforms to the patient. Patients who can follow commands can typically maintain stabilization of their own spine without assistance. Backboarding increases mortality in certain trauma patients. Backboarding does nothing to prevent neurological sequelae from spinal injury. Backboarding restricts respiration, which some patients cannot tolerate. Backboarding rapidly leads to skin breakdown and pressure ulcers, even after a short period of time, and is particularly hard on the elderly. I think there are some steps we can take to eliminate some pain and suffering and reduce some unnecessary imaging. Stop transporting patients to the hospital on backboards. Utilize the long spine board only for extrication purposes. Once the patient is extricated, using log roll or lift-and-slide technique, lay the patient flat on the stretcher and leave the c-collar in place. Do not ever immobilize a patient with penetrating trauma such as a gunshot wound or stab wound. Immobilization DOUBLES the mortality rate of these patients. Even with neurologic deficits caused by transection of the spinal cord, the damage is done; additional movement will not worsen an already catastrophic injury. Emphasis should be on airway and breathing management and rapid transport to a trauma center. If patient is being intubated, and manual cervical stabilization is hampering this effort, the neck should be moved to allow securing the airway. An unsecured airway is a far greater danger to the patient than a spinal fracture. Eliminate the "standing take-down" for backboarding patients who are ambulatory after an injury. Place a collar and allow the patient to sit on the cot, then lie flat. Patients who are ambulatory and able to follow commands do a better job of preventing movement of an injured spine than rescuers do. Selectively immobilize (with a cervical collar) only those patients at high risk for spinal injury or with clinical indications of spinal injury. Remove cervical collars on conscious patients that tolerate them poorly due to dementia, anxiety, or shortness of breath. Leaving the collar on and fighting them will encourage more spinal movement rather than less. Clear patients from any spinal immobilization clinically utilizing the spinal clearance protocol. This protocol indicates those patients who may require immobilization: High risk injury (high speed MVC, axial loading injury), focal neurological deficits such as paralysis, intoxication, age <65, and presence of midline bony tenderness of the spine. Patients without these findings may be transported without spinal immobilization. Patients who are markedly agitated and confused from head injury may not be able to follow commands with regard to minimizing spinal movement, and combativeness may also be a factor. These patients should remain on a backboard if the crew deems it safer for the patient, and this will be at the discretion of the crew. The above measures will reduce pain and suffering, reduce complications, decrease on scene times, reduce injuries to crews who are attempting to carry immobilized patients, and reduce unnecessary imaging costs and radiation exposure. There is no doubt that our crews will get some push back from the staff at the hospitals. Nurses or physicians may rebuke them for having the patient off the backboard. FD crews should be reassured that hospital staff does not determine their treatment protocols or operational policy, and that any questions can be directed to command staff or to me or to the hospital EMS coordinators. 'zilla, MD Hauswald M,McNally T. Confusing extrication with immobilization: the inappropriate use of hard spine boards for interhospital transfers. Air Med J. 2000 Oct-Dec;19(4):126-7. This was a survey of inter facility transport services. 18/30 interfac transport services immobilized for transfer, even if cleared by sending ER MD Additional 4/30 immobilized unless cleared radiographically No services moved pts to softer surface if known to have injury McHugh TP,Taylor JP. Unnecessary out-of-hospital use of full spinal immobilization. Acad Emerg Med. 1998 Mar;5(3):278-80. 51% reported no neck or back pain at scene of accident before full spinal immobilization 13% not even asked about neck or back pain before full spinal immobilization Haut ER,Kalish BT,Efron DT,Haider AH,Stevens KA,Kieninger AN,Cornwell EE 3rd,Chang DC. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010 Jan;68(1):115-20; discussion 120-1. Twice the mortality rate in penetrating trauma if immobilized (14.7 vs. 7.2%) 0.01% had incomplete neurological injury and underwent fixation Number Needed to Treat: 1032 Number Needed to Harm: 66 Davis, et al: retrospective study of 32,117 trauma patients 2.3% with c-spine injury 10 patients with delayed diagnosis of spinal injury AND permanent neurological sequelae Bottom line: "hidden" spinal injuries which lead to paralysis are extremely rare Gerrelts, et al: Review of 1331 trauma patients 5 patients with delayed diagnosis of cervical injury None with permanent deficit Bottom line: "hidden" spinal injuries which lead to paralysis are extremely rare Platzer et al: 347 with c-spine injuries Of the 18 with delayed diagnosis, 2 had permanent deficit Bottom line: "hidden" spinal injuries which lead to paralysis are extremely rare Hauswald: 5 year retrospective review New Mexico vs. Malaya Malayan medics do not use spinal immobilization The difference: Malayan patients had less frequent deterioration and less overall neuro disability Limitations: Small numbers, different mechanisms (more MVCs in the USA, more falls in Malaya) Neuro decompensation occurs in 5% anyway, despite ideal attention to spinal immobilization. Spinal immobilization raises intracranial pressure 4.5 mmHg Manual In Line Stabilization (MILS) led to failed intubation in 50% after 30 seconds of intubation attempt vs. 5.7% without MILS Gruen, et al: Trauma mortality in 44, 401 patients. 2594 deaths, errors in 64. Failure to secure an airway in 16% of those If spinal immobilization led to a failed airway, then it killed the patient. Santoni: MILS doubles force necessary for intubation Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009 Jan;110(1):24-31. Totten, et al: LBB or vacuum mattress restricted respiration by 15% Bauer, et al: LBB limits respiratory function Respiratory failure is COD in 6% of trauma patients Hauswald: Substantial force required to injure spinal cord Post-injury movement probably not sufficient to injure the cord, even if already partially injured Chan D,Goldberg RM,Mason J,Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med. 1996 May-Jun;14(3):293-8. Perry SD,McLellan B,McIlroy WE,Maki BE,Schwartz M,Fernie GR. The efficacy of head immobilization techniques during simulated vehicle motion. Spine (Phila Pa 1976). 1999 Sep 1;24(17):1839-44. 3 times more likely to develop pain with LBB than vacuum mattress Trunk movement still significant; no method with a LBB eliminates motion Konstantinidis A,Plurad D,Barmparas G,Inaba K,Lam L,Bukur M,Branco BC,Demetriades D. The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J Trauma. 2011 Sep;71(3):528-32. 101 blunt trauma patients with c-spine injuries 87% had “distracting” injuries: rib fractures, lower and upper extremity fractures 4% had no tenderness on c-spine All 4% had bruising and tenderness of anterior chest Bottom line: "distracting injuries" are largely a myth. Horodyski M,Conrad BP,Del Rossi G,DiPaola CP,Rechtine GR 2nd. Removing a patient from the spine board: is the lift and slide safer than the log roll? J Trauma. 2011 May;70(5):1282-5; discussion 1285. Del Rossi G,Horodyski M,Heffernan TP,Powers ME,Siders R,Brunt D,Rechtine GR. Spine-board transfer techniques and the unstable cervical spine. Spine (Phila Pa 1976). 2004 Apr 1;29(7):E134-8. Del Rossi G,Rechtine GR,Conrad BP,Horodyski M. Are scoop stretchers suitable for use on spine-injured patients? Am J Emerg Med. 2010 Sep;28(7):751-6. Epub 2010 Feb 25. Log roll creates unacceptable motion Lift and slide technique creates less motion Scoop stretcher may be better as well J Trauma. 2009 Jul;67(1):61-6. Motion of a cadaver model of cervical injury during endotracheal intubation with a Bullard laryngoscope or a Macintosh blade with and without in-line stabilization. Turner CR, Block J, Shanks A, Morris M, Lodhia KR, Gujar SK. Source Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA. turchris@med.umich.edu Abstract BACKGROUND: Endotracheal intubation in patients with potential cervical injury is a common dilemma in trauma. Although direct laryngoscopy (DL) with manual in-line stabilization (MILS) is a standard technique there is little data on the effect of MILS on cervical motion. Likewise there is little data available regarding alternative airway techniques in this setting. This study compared intubations with and without MILS in a cadaver model ofcervical instability. We also used this model to compare intubations using DL with a Macintosh blade versus a Bullard laryngoscope (BL). METHODS: Complete C4-C5 disarticulations were surgically created in 10 fresh human cadavers. The cadavers were then intubated in a random order with either BL or DL with and without MILS. The motion at the unstable interspace was measured for subluxation, angulation, and distraction. RESULTS: MILS did not significantly affect maximal motion of this model in any of the three measures using either DL or BL. There were no clinically significant differences in maximal median motion in any of the three measures when comparing the two blades. However, there was significantly more variance in the subluxation caused by DL than by BL. CONCLUSIONS: We were unable to demonstrate any significant effect of MILS on the motion of an unstable cervical spine in this cadaver model. The BL appears to be a viable alternative to DL in the setting of an unstable lower cervical spine. Ann Emerg Med. 2007 Sep;50(3):236-45. Epub 2007 Mar 6. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Manoach S, Paladino L. Source Department of Emergency Medicine, State University of New York-Downstate and Kings County Hospital Center, Brooklyn, NY 11203, USA. seth.manoach@downstate.edu Abstract Direct laryngoscopy with manual in-line stabilization is standard of care for acute trauma patients with suspected cervical spine injury. Ethical and methodologic constraints preclude controlled trials of manual in-line stabilization, and recent work questions its effectiveness. We searched MEDLINE, Index Medicus, Web of Knowledge, the Cochrane Database, and article reference lists. According to this search, we present an ancestral review tracing the origins of manual in-line stabilization and an analysis of subsequent studies evaluating the risks and benefits of the procedure. Allmanual in-line stabilization data came from trials of uninjured patients, cadaveric models, and case series. The procedure was adopted because of reasonable inference from the benefits of stabilization during general care of spine-injured patients, weak empirical data, and expert opinion. More recent data indicate that direct laryngoscopy and intubation are unlikely to cause clinically significant movement and that manual in-line stabilizationmay not immobilize injured segments. In addition, manual in-line stabilization degrades laryngoscopic view, which may cause hypoxia and worsen outcomes in traumatic brain injury. Patients intubated in the emergency department with suspected cervical spine injury often have traumatic brain injury, but the incidence of unstable cervical lesions in this group is low. The limited available evidence suggests that allowing some flexion or extension of the head is unlikely to cause secondary injury and may facilitate prompt intubation in difficult cases. Despite the presumed safety and efficacy of direct laryngoscopy with manual in-line stabilization, alternative techniques that do not require direct visualization warrant investigation. Promising techniques include intubation through supraglottic airways, along with video laryngoscopes, optical stylets, and other imaging devices.

I'm just writing because I'd like to know how you guys as EMTs deal with death on the job, and in your personal lives. I was just laying here doing some thinking about death. I'll start by saying I am 20yrs. old and have never lost anyone yet in my life. (Family, friends, etc.) The reason I'm thinking about it is I was in California for 2 weeks and my last night there (last Friday) I went with a family member who was alone to put her dog to sleep. I never seen anything really besides bugs die (if that even counts), and yet I watched them kill a dog who was suffering with cancer right in front of me. Was it sad sure, I even helped her take the 40pd dog home and bury it. I didn't cry or anything, but it was sad cause she was hysterical & that dog just lost it's life. I think I hid my emotion and tried to "stay strong" which idk if that's good. Before I ask the questions I have for you guys, I also want to say I didn't even know what to say to my aunt. (lady who lost her dog) or comfort her really I kept asking "are you ok?" I mean obviously she wasn't... Though she kept saying she was. So now to my questions. How do you guys deal with deaths on the job? Do you cry on scene if someone dies? Maybe a young kid. Have you cried on scene? Are you allowed to cry or tear up anyways... on scene or in the back of the ambulance when dealing with patients? These are just some questions I have and hope you guys don't mind sharing your thoughts. And if you'd like you can talk about how you deal with deaths in your personal life if it's different than on the job. Also, I just read this book and one of the quote I read in there said: "Death is not a tragedy. It's a certainty." "indeed, there are tragic circumstances surrounding many deaths. Some die too young. Some seem totally senseless. Some deaths negatively impact the lives of many people. The circumstances of death can be quite tragic, but death itself is not tragic. It is as much a part of life as is birth." It just left me thinking. Thanks for reading.. And thanks for any time reading and responses you may have. -Kyle

Hello There Everyone! My name is Andrew. I am an EMT-B In NYS. I've been in this business for Four years (I'm Most likely a baby in some of your eyes), three as a certified EMT. I Work in a very, very high call volume (total near 90,000 calls per year for the company). I look foreward to interacting and getting to know Y'all. -Brotherlog63 (If you come to work and dont learn something new, you should most likely rethink what you are doing or how you are acting.)

Just wanted to stop in a say HI. My name is Jason and I'm 25. I have currently applied to school to become a paramedic. My goal is to do both paramedic and firefighting. Been wanting to do this so I finally applied and now working towards my goal! Super excited and cant wait!

Hi, I have been an EMT for about 2 years now, but have not gotten a job with which to use my knowledge/skills during that time. I' am moving to Portland very soon, and plan on applying with a few companies in and around that area. But here is my question: will I be hired, or even interviewed if I have no experience? I have been out of the game for a while, and before heading out to the field, I would like to refresh myself, or practice, before my first day. Will an ambulance company...be ok with this? I believe I could be a valuable asset, but could use some (extra) training before working. Should I get into an EMT refresher course, and then apply? Or, apply, and mention my concerns with the company/agency? I'm a little lost. Thanks!

Hello! Thanks for reading this post. What do you think it will cost to start an EMS Company in Maine? I haven't taken basic classes yet, but I'm starting in September. I'd like to work my way to become a paramedic before I started my own company, but that made me want to look into it early. I'd like to provide emergency services, non-emergency services, and special event stand-by. I'd like to get a smaller building, with at least 2 bays, I have a building in mind if its still for sale then. (Not sure about the price.) For vehicles, I'd like to have 2 or 3 ambulances, a wheelchair accessible van, and a paramedic car. Saying that - I've found ambulances that are around the 10k range for sale. I'm not sure how much the equipment would be? But I know some of it can be very expensive. ----------------------------------------------------------------------------------------------------------------------------- Questions I'd really like answered: A good start up cost for the company to have out of my own pocket? What kind of employees I should have and how many? ( Basic, Inter, Paramedic, Dispatch, Etc.) A fair price to charge for ambulance services? On average how much would it cost to stock 2 ambulances, and a paramedic car to start with? ( Ball park estimates are good) How to get contracts with insurance companies and hospitals? ___________________________________________________________________________________ I have some financial plans, and I know starting an ambulance company can be very costly, and its not just something to jump into. I read about having a business plan, such as having an: executive summary, funding requirements, current market conditions, management backgrounds, company strengths, company weaknesses, financial analysis and investor return analysis. How would I set out a business plan like this? I'm not sure what is the best way to start out with this. So any help or tips and prayers would be great! Thank you! - Mike. References: For how to start an EMS company: http://mdonner.net/ems_article.html http://www.ehow.com/how_6684639_start-ambulance-company.html Gear sites: http://www.511tactical.com/ http://www.galls.com/home Ambulance sale sites: http://ambulancetrader.com/ These are some sites I've looked at, if you have any kind of comment or recommendations for any of these or other sites that would be great! Thanks!

Not sure if this is the right section for this seeing as I'm new to the site. If you have seen my introduction you'll know my situation and for those who haven't, I just recently applied to a community college to become a paramedic. My question is, does anyone know any good sites/apps/videos/ or books I can use to help study up before I get started up and enrolled into college. I'd like to have a head start seeing it's not going to be quite and easy road. Looking to gain as much knowledge now as I can to help understand things for once I start school. Thanks -Jason

Well, just when I think I am getting good I get presented with this: I am sure many of you will have no problem, but it as my first one, so it took like 10min beore I knew wtf I was working with..... 81 y/o female. aprox 140lbs, sudden onset chest pain while sitting drinkng tea with husband. Pain = 10/10, crushing, radiating to lower back. Nausea 10/10.... dry heaving like crazy Pale-grey, diphoreic, good turgor. No distal edema, JVD present. Complains of SOB Pulse 112 BP 74/58 Bilateral. Sp02 98% Afebrile ECG = unremarkable. Sinus tach, narrow QRS, no T,ST changes History: Spondylitis (Kyphosis noted).

Welcome brother! Keep us updated if you need anything or have any questions!

Hi there, I am in an instructor work-group to find out what other EMS instructors are requiring for clinical rotations at the Advanced EMT level. I would also be interested in any type of documentation that you have on this subject. I have Googled the subject with limited results. You help is greatly appreciated.

Maybe thoracic aneurysm/disection? Bilateral radials present?

From what I gathered by surfing around the net, even if you live on one of those compounds things are still fairly strict to muslim law. The dress code may be a bit more casual but not by much, especially for women. With that being said, I've talked to a couple guys who really enjoy it out there with their families.One guy even compared the compound he and his family stayed on to living in San Diego. Not too shabby sounding to me

It seems there is some aggreeance among the posters that I may have jumped to a defensive stance a bit hastily. Though, I don't fully agree with this assessment, I do acknowledge that my view on something isn't always the correct one. I took your comment as shot at my character, Island, which is something I'll defend fiercly. I apologize to anybody I may have unknowingly rubbed the wrong way. Consider panties officially unbunched. Oh, and Oreos over Chips Ahoy any day of the week, Captain

I am back and hopefully can clear some of this up: First, a mmol is commonly called a millimole. A millimole is 1/1000 of a mole just like a milligram is 1/1000 of a gram. In other words 1000 mmol equals one mole. If I have one mole of Carbon 12, I would have 12 grams. However, if I had one mmol of Carbon 12, I would have 12 milligrams. With that, we commonly use mmol as a concentration. The common dimensions will be mmol/litre of mmol/l. In other words, how many mmol do I have in a liter of solutions, typically water when talking about biology. Next, mEq is cammonly called milliequivalent. As you may have guessed a mEq is simply 1/1000 of an Eq. However, what exactly is an Eq? Well, if you remember mmol is simply a measure of mass. However, mEq takes something else into consideration. Specifically, Eq is a way of measuring something about the chemical reactivity of the substance you are measuring. The formal definition of an Eq is either the amount of a substance that will supply one mole of Hydrogen ions in an acid-base reaction or the amount of substance that will supply one mole of electrons in a REDOX (reduction-oxidation) reaction. Historically, different definitions have been used; however, let us simply stick with this line of thinking. Now that we have at least some sort of understanding of what these terms are looking at, let me give you a couple of conversions formulae: To convert mmol to mEq you take the amount of mmol * by the "valence" and then divide by a litre since we are typically measuring in mEq/litre. What is the deal with "valence?" Valence is simply the charge on the ion we are discussing. However, we do not care about the sign of the charge, only it's magnitude. For example Na+ and Cl- have exactly the same "valence." In this case, the valence would be one. If you had Ca++, the valence would be two and so on for all the different ions. Let us say you have 1 mmol/litre of Na+ and you wish to convert to mEq/litre. Simply plug and chug: 1 mmol of Na+ * Valence of 1 over a litre or 1 mEq/litre. That's easy, just remember when dealing with ions that have a higher valence, you will have a different conversion. For example, take 1 mmol/l of Ca++. This would convert to be 2 mEq/l because Ca++ has a valence of two. The basic answer to why we need to consider valence revolves around the fact that Eq and mEq are looking at the ability for one substance to chemically interact with another substance. An easy way to see where this becomes relevant is to take the simple case of Na+Cl-. In a perfect world, one mmol of Na+ will perfectly react with one mmol of Cl- to form one mmol of Na+Cl-. In other words, these substances ionically react on a 1:1 basis. Therefore 1 mmol/l of these substances equate to 1 Eq/l because of the 1:1 reaction. However, if you have Ca++ and Cl-, you would need two Cl- for every one Ca++. Therefore the valence of Ca++ becomes quite relevant. Does that make sense?

Thanks a lot to both of you above for your responses. I like hearing what you guys have to say, and for me I feel that talking to people would most Lillkely be my coping method. When I talked about crying I was meaning more like shedding a tear. Not break down crying. I was thinking how someone would go about controlling their emotions EMT wise while dealing with certain deaths, but you guys I think pretty much helped me understand that. I now understand that as an EMT the people on scene who may be all frantic about a death, or maybe just a bad trauma are counting on you guys to be together mentally to help a patient the best you can. They have time to focus on the injured/deceased person which can probably add to the emotions, while you guys are probably so busy trying to help someone, keep everyone calm, and do your job right that it makes sense you may block everything out and then actually reflect on things later when things are calm. Thx for the replies.

Kyle, death is a part of life, but for anyone in this field, it is a FREQUENT part of our life. We see all manners of death- stupidity, tragedy, accidents, natural aging, disease processes. Some people can completely shut down their emotions and seemingly not be affected. I think those folks are few and far between. For most of us, it clearly depends on the circumstances. Your response can range from a "Gee, that was too bad", to "Oh my gawd, why did this infant have to die!" When my kids were little(infants), I went through a stretch where I saw 6 dead infants in a month- mostly SIDS, but a couple were homicides and accidents. I was almost afraid to go to work. That was tough- I kept envisioning my own kids. You go home, hug the kids a little tighter, and be thankful they are OK. You get through it. There is no right or wrong way to deal with it, as we each develop our own coping mechanisms based on our own personalities and our psychological make up. You are young, which means in many ways you are at a disadvantage- your lack of experience personally dealing with death can be a problem. It also can be a golden opportunity to start off on the right foot. You are doing the right thing- asking questions, looking for advice. Take what folks tell you, realize the good and bad of what you hear, and then adapt these ideas to make them your own. Until you begin to amass the experiences on your own, it's all you can do. How we deal with the death of a patient also depends on where we are at emotionally. If we are having our own personal issues, you may not be able to cope quite as well as other times. Sometimes the strangest calls get to you. Maybe you form an immediate bond with a family member and empathize with them more than usual for some reason. The thing is, DURING the call, you need to shut out the emotions and do your job. Sometimes that is easier said than done, but you have no choice. We are called to help someone because we CAN do something about a situation, and falling apart during a call won't help anyone. I worked with a girl- good medic, with plenty of experience. Saw plenty of death and dismay. One call we had was an elderly man who suddenly arrested at home- nothing unusual. I noticed my partner was not doing well during the call- slow, confused, tentative, needing to be prompted to do her work- totally out of character. The man died, and afterwords, I asked her what was wrong and why she was out of sorts. She broke down and cried, and told me that her grandfather had just passed away last week, and the emotions suddenly spilled out. It happens. Afterwards you can sit back, reflect on the call, critique your actions, and deal with any associated emotions that surface. Bottom line is now is the best time to examine this idea- better to develop POSITIVE coping skills, then later on when things start to catch up with you and you turn to negative behaviors. Figure out what works for you, and start working on those skills now- they take time to develop. Some folks turn to religion, others to meditation, others take vacations to remote, quiet, peaceful places to clear their heads. Others get relief from just talking about things with coworkers. Others like to keep a separate group of friends who have nothing to do with the business. Everyone is different, and what works for me may not work for you. Good luck.

Hey buddy. Everyone deals with death in there own way. Im 20 as well and have dealt with quiet a number of patients who have passed away, fortunately most of which were palliative care patients but unfortunately I have been involved with death at motor vehicles accidents, sudden death in ED and so on. Theres no easy way about it but in the end everyone has to die, its a fact of life, some die young, some die old. No one can stand here and tell you how to feel, how you will react or how to deal with your feelings because everyone is different. Unfortunately living in a small community your more than likely going to know or know of most of the people who die so it makes it a little harder. I was involved in the care of an adolescent patient who was transferred from a tertiary facility in the city for palliative care management post failed excision of a brain tumour which had metastasised. He arrived at us fully alert and orientated, for pain and symptom management, he was with us for 4 weeks, in that 4 weeks I became pretty close with him and his family (being a similar age I guess it was easier to bond and get along). He ended up being on infusion of morphine, metaclopramide and midazolam. I ended up having to give him so much medication he was pretty sedated and unresponsive which was extremely hard for his family. We he past away we just supported the family, offered reassurance and what not… When I got home I spent 2 hours sitting on the floor of the shower crying, just my way of dealing with it I guess. Youll never get use to death but you develop ways to deal with it both at the scene and once the situation is over. Theres nothing easy about seeing people who have past away in car accidents, helping the ambos extricate the body, patients who come into ED and crash and even palliative care patients who are expected to die. Youll always remember the first deceased person you see. Its easy to forget about your welfare and state of mind, sometimes it takes a while for the adrenaline to wear off or youre busy looking after everyone whos around you and forget about what your feeling and when you get home it all hits you at once. Its important to talk about what youre feeling with someone you trust, work colleges or peer support and look out for symptoms of PTSD. I wouldnt recommend crying in front of everyone, sometimes youre the only one who isnt hysterical and people really appreciated someone of sound mind hanging around to offer support. Of course you tear up on the odd occasion but breaking down into a complete crying fit would not be recommended. EDIT - I forgot to mention anger! After some jobs you doubt your self and you often find yourself flashing back on how you could have improved or done something different. This is such a common occurrence for us, on the odd occasions I’ve beaten myself up over things I could have done better. The fact is sometimes little mistakes happen but what done is done and you live and learn. On some patients there injuries are just incompatible with life and despite your best efforts things don’t always have a positive outcome. Hope this helps