fireflymedic

We use the electronic as well, but the drop downs don't allow you to really state what is going on, so we have a space where we can add to the narrative, or allow the computer to generate one based on what we have written. I usually choose to write my own (just personal preference) especially in traumas or complicated cases. Basic transfers I'll let the comp do the work. We have the hammerheads and I love 'em. Only problem we run into is keeping them charged for a full 24 shift. We have to plug them into the inverters on our trucks. Very convenient though. I like 'em. I've used state forms (which I hate, they suck), special order forms the service ordered (those were actually okay) which we used until they went to the electronic which I prefer to any of it. Good times. All a matter of preference.

Cosgro, No offense was implied I was just curious as to how medical directors for other services handled this. We have quite liberal protocols at our service (only one in state outside of critical care ground trucks and flight crews) that are allowed to do surgical crics. We are fortunate to have an excellent medical director. I could not ask for better. he is actively involved and regularly meets with us to discuss changes to our GUIDELINES !!! HEHE. BTW, I do like that word better than protocols. Very approachable and doesn't make QA/QI be a negative thing which I have definitely learned to appreciate. Treats it more like a learning experience rather than punishment. Thanks for the input !

Which is more your choice for premedication and seizure cessation? We carry all three on our trucks and was curious as to the pros and cons of each. It seems if an IV is established, Ativan seems to be the choice (though the down side is the refridgeration issue making it impractical for many services to carry) but if not, Versed is chosen, though some of the older medics tend to go with valium for everything. I know Ativan has a longer duration and protection for seizures than valium, but as far as premedication, I haven't really seen a difference. What are your thoughts.

Our protocols state treat the underlying cause first. However, IF you cannot obtain a line and the patient is actively seizing, I would go for IM or nasal versed or PR valium to stop the seizures, then administer glucagon. Reason being, glucagon can take a bit of time to work as it has to process the glycogen stores in the body. You do not want a patient continuously seizing while you are waiting for the glucagon to take effect. Also, you may run into the problem, especially in alcoholics that they may not have adequate glycogen stored in the body for the glucagon to work effectively. Also, the cessation of seizures may make it easier to obtain an IV and get D-50 in them. Either way, the seizures and the hypoglycemic state have the potential to cause damage, so you would be better off going ahead and giving the benzos while waiting for the glucagon to work, or to establish a line than deciding what to do.

I know several services which having standing orders for fentanyl. Seems to be a well liked drug around here. Morphine is given standing order as well, but I'm not familiar with many services that carry demerol, not to say they don't, I just don't know 'em !

I am wondering if some of this isn't due to not checking the tube placement every time a patient is moved. It still amazes me how easily they can become dislodged. Medic programs in this area have very strong intubation clinicals (you spend lots of time getting to know the anesthesiologists in the area). Plus they teach you how to bag properly (it's amazing how few people actually KNOW how to bag a patient...I thought I did, then I met my preceptor). I would think it a good thing for medics to have to do a routine rotation every year to polish up on skills they don't use that often or confirm their skills. Instead, many times they are left to have a skill unused for sometimes several years, then called upon to use it and it goes badly (example, I watched a service with a former flight medic director who had gotten RSI approved in their protocols, did little training with it, they didn't use it in over two years, then one day needed it, and couldn't get the tube....bad things started happening). Gotta keep those skills up, same goes for basics !

I think 18 would be a reasonable age for a basic (basically an adult), and a minimum of 20 or 21 for a medic. This would be to allow for a good 2-3 years street experience at least a year of which would have to be documented to be considered for medic class. Many states are starting to adopt the experience factor in there, so naturally the age comes with it. Some states (such as tennessee) have psych as part of their selection process. Various schools are doing this as well. More employers are getting the idea too. That can have it's up and downs as well. Needs to be carefully evaluated and parameters set as to the criteria. Like dust said, I think there are some great young medics, that with age will be incredible. Also, I think there are some old timers that are worthless because they 1. either refuse to change how they did it in the old days, or 2. don't choose to be professionals. I don't believe that a standard age should be set, but rather experience as a guide. I think going straight out of basic class into medic (as I have seen many do literally waiting for their basic card to start medic class) should not be allowed under any circumstances, but I've already ranted on that enough. Best idea, go on a case by case basis using 18 as the starting point and go from there.

Point well made

Do I qualify here? No radios, pagers, scanners, etc- don't want 'em I do wear EMS boots all the time pretty much (hey, they are steel toed and when I'm not on duty I'm around horses, the steel comes in handy ! ) Alot of my clothing does come from various services I've worked for, fire schools, etc. Hey, I'll take anything (within reason) if it's free. People see me in uniform more than they don't. I work 3 days a week Industrial EMS and 2 days a week for a Fire Dept I am required to have Emergency Services plates on my car to be able to respond to a scene off duty if called in or as a fly car if needed which frequently happens (and helps prevent speeding tickets ). This is a department rule. Is surrounded by a license plate holder that says "thoroughbred breeder" on it.... I do have a small ( 2 inch) star of life and maltese cross in the far corner of my backseat window because I am proud of what I do. I also have a racehorse emblem on the other side though-so enough said there I used to keep my stethoscope on my rearview mirror until I cleaned my car 'cause I could never find the daggone thing if I didn't ! Changed at the farm one too many times after getting off or going to work. And yep, I wear my EMS coat everywhere 'cause it's waterproof and it was FREE ! No service on it though, just a subtle star of life on it. Do I qualify yet?

My partner keeps a tape of Highway to Hell that he pops in when headed to a code..... :twisted:

Our incident wasn't so funny, I only wish it were. In our area, it's common practice, if you see an ambulance on the road coming the opposite way non emergency to flash your lightbar quick and give 'em a howdy from the airhorn. This is especially true with fire companies. My crew was headed back from an early morning fire run (like 3 am) and we saw our second out EMS crew headed out non emergency, so we said howdy. Well, our station is just about a mile from the state police post, and we usually have a pretty good rapport with them and the S.O. as well. As soon as we passed the crew, we flipped our lights off (weren't on more than a second or two) and started heading back to our station. Shortly thereafter, we looked up to see two state pd cars behind us blue lights flashing. We got over out of their way, and they stopped right behind us. We pulled all the way over, and stopped. Two really peeved cops marched up and demanded our driver get out. They lectured him up one side and down the other about trying to impersonate a cop, and pull cars over using fire department vehicles. They proceeded to tell us that was their job not us to pull people over, and that none of us had the skill or training to do so. Our driver listened patiently while we're all sitting there dreading the reports that will be written to both the board of EMS and the fire commission as well as the butt chewing we'll get from our chief. After giving us a stack of tickets a mile high and following us back to the station to talk with our chief (who was now well informed of the situation and getting more pi$$ed by the minute) about what was to be done with us, he let us go. After a brief yelling and screaming match behind the forbidden door of the chief's office, the two troopers emerged looking a smug. Our driver went up and looked at the one trooper and said, "How many arial trucks have you seen trying to pull over cars? Ain't no way I'd try it, I wouldn't do your job if you paid me. Oh that's right you don't ! I do it for free." The cops about died, they then learned he was a new reserve officer with S.O. Needless to say, we were never bothered again, though the practice of saying howdy has been strictly banned in our department as a result.

Cumberland Co- you're a rebel, sorry, especially there ! I'm a northerner by birth, but was kidnapped and transplanted to the south....still getting adjusted ya'll (hehe still am not used to that word yet !) I went back "home" recently and someone actually asked me if they have indoor plumbing and wear shoes in eastern kentucky....oh dear, well, I told them, "it depends on where you live". LOL, sad but true and YOU know it !

I agree with you they should not be done blindly, I am simply commenting that many medics do that (don't get me started down that path again, been there, done that, ain't going there again). As far as the introduction of air to lungs-any unconscious we have automatically gets O2 15 LPM NRB if breathing, if not, they buy a bag and a tube if they don't perk up). So I would say that's kind of an automatic. Perhaps I'm not understanding what you are saying by that. If so, please clarify. Around here, alot of medics go by cookbook medicine and don't understand the rationale for doing what they do. Was just curious if this was situation everywhere. Also, if your assessment reveals an underlying cause, then it is not truly an unconscious/unknown and you divert to the appropriate protocol. Not trying to start a protocol fight, just tryin' to learn and be curious here.

Thing to remember on PCR's is write everyone like you are going to court. Just 'cause you remember it now, doesn't mean you'll remember it 2 years and a thousand patients later. Here's format I use. Unit (who I am) Dispatch (what did they send me out for) Arrival (how did I find them-sitting, laying, etc) Who else was on scene (if applicable fire, police, rescue squad, etc) Damage to vehicle, scene, extrication time (if applicable) Chief Complaint (what they say their problem is) Physical Exam (I list each area airway, skin, heent, pupils, chest, lungs, back, abdomen, pelvis, extremities) Vitals (BP, pulse, respiratory rate - quality I list in lungs) Treatment (what I did for 'em) How we got the patient to the stretcher (walked, stair chair, stretcher, etc) Continuing Assessment (updates to condition, vitals, any other pertinent info) Where we took 'em (hospital, nursing home, home) Who we transferred care to (ER staff, ICU staff, etc) If they had any further complaints addressed prior to delivery to ER (usually is no, 'cause you address that enroute) Medications (if multiple, I write multiple meds-see attatched list-make sure you attatch the list ! ) Past Medical History (only that which is pertinent) ' I've followed this format most of my career and it's served me well. Never gotten QA'd for lack of information and always recieved good response for writing complete reports. Hope this helps you some. Works universally for all run sheets and departments too.

Okay gang, Here's a question for everyone out there. As I understand it, the general consensus for unconscious unknown protocol (at least in my area) is Narcan, D-50, and thiamine. Now I understand the reasoning behind it (narcan-opiate overdose, D-50-hypoglycemia, thiamine- help with absorbtion of D-50 especially in alcoholics), but I don't understand the reasoning for just giving each blindly hoping one will work as is often done around here. Frankly, I don't see the reason for it at all. A good patient assessment will tell you if the patient (can we say D stick anybody?) is hypoglycemic thus ruling out the D-50 and thiamine, and pinpoint pupils will give you the indication for narcan (plus any bystander info if they are so inclined or if you happen to get lucky - or FF). What I'd like to know is how many of you all maintain this protocol for unconscious unknown and what are your feelings on it? If that's not your protocol what is yours?

JPIN : I agree with you completely in the fact that you should know why you are giving the care you are giving. That goes for anything, splinting, oxygen, albuterol, or valium. You should be able to tell me why you are giving the drug, what it should do, what side effects can occur and the indications why and why not to give it. This is basic knowledge that anyone should know before being allowed to touch anything. And yes people, contrary to the almighty belief O2 is a drug. It requires a physician's prescription to obtain (don't know what's up with the O2 bars-WTF?) I would like to see the basic program extended to about a year in length. I think 3,4 months is hardly enough to adequately cover the care one will need to give on an ambulance. Around here, the turnover rate is so high, you cannot depend on always having a "veteran" to pair the partner up with. The demand for EMS people is so great you have many students literally waiting to get their basic results so they can start medic class with nothing more than 10 hours of ER or ambulance ride time and a minimum of 4 patient contacts (most of which I might add are nursing home transfers). There are a few programs which do additional ride time that exceeds the state requirement such as mine did, but those are few and far between. I recently started riding students, and I am amazed at the lack of knowledge. The sad thing is, I know they will be on a truck somewhere within just a few weeks of the time they spent with me (usually they ride two or three weeks before testing). When they get on a truck, they have no clue how to treat a patient, and the oh crap factor is extremely high. I had one student which rode with me (already graduated just waiting for results) that literally walked off a scene after seeing an accident saying, "this ain't how it was in the book ! This is BAD !" (guy vs cop cruiser, cruiser 1, guy 0). I think basic class is too easy and the requirements need to be increased, especially for those riding on an ALS truck. You may just be driving, but you'll be asked to spike bags, get out drugs, set up intubation equipment, etc. My department does a great class for new basics called "Medic Assistance". It's really helpful, we run them through alot of the scenarios dealt with and actually play it out at our training facility. They say they feel alot more prepared. Plus, after class, they all spend time on the ambulance riding and perfecting skills before they are allowed to test. We turn out some really nice basics too. They will make excellent medics some day. Few realize it is one way in the book, and then very, very different on the street. The rules still apply, just in a different format. Have to learn to adapt. If working with a college service or rescue squad allows them to develop their skills in taking vitals, starting IV's, whatever. Then by all means do it. The more education we can give, the better professionals we will have. After all, most drunks in college I knew had great veins. Good sticking education :twisted: Later

When starting out, I was in class with a teacher who told me #1 girls had no business being in fire and ems, #2 no girl had ever passed his class. I was given the hardest way to go of anyone in my class. I was the youngest (have been for every service I've worked and still am), given what everyone told me was the worst preceptor, and told to have fun. I quickly found out why my preceptor had the reputation he did. He expected excellence from his students. Half A**ing it wouldn't cut it with him. You were expected to know what was going on and why. Other students praised how easy they had it with their preceptors while I often came home frustrated wondering if I would ever know enough. If I didn't know my drugs, I spent the first part of my day writing drug cards until I knew them. He would pull out a drug and ask me, "what's this do, dose, side effects, reversal agent, indications, contraindications". Many times, even on long boring transports I would be quizzed. I'll never forget my first one (I was a BRAND new basic student) and we were in the ambulance with a guy going for a routine transfer. I took vitals, checked everything, and settled in to do my paperwork. We got to the hospital, unloaded our patient who had slept most of the trip, and were hanging out behind the ambulance talking with another crew. He asked me, "what did you miss?" I thought through everything and couldn't think of anything really. Then he told me think how the patient breathed when he slept. I thought back, he had sleep apnea. Yes, my preceptor was tough on me as was my instructor but I was just as determined to make it. I have tremendous respect for my preceptor and still ask him about things to this day. He really pushed me to have great assessment skills, listen to my patients, and most importantly treat them not what I see on a monitor or elsewhere. I still think my instructor was a jerk, but I proved him wrong. Out of my class, half of them ended up quitting by the end of their basic ride time, a quarter quit partway through the series for different reasons, and out of a class of 25, 6 of us graduated. I'm now getting students (basics mind you) to ride with and I am applying for my instructor's card and yes, I'm tough on them, but I also keep an open mind and remember when I first started. I answer any questions and try to find answers if I don't know. I think my education was invaluable and I only hope I can provide that to others. Frankly I think the path to EMS is too easy. One must remember, these are HUMAN lives we are dealing with here, not mannequins. If we don't treat them right, they die. Hard but cruel lesson to learn. Some weeding does need to occur to get good professionals in this job.

There was an article some time ago (several years I believe like '02 or '03) in JEMS regarding this very topic. It was a school which had a similar set up to what you are proposing and it received a very positive response from both the public (as it significantly freed up county ambulances) and also the school. The school featured was somewhere in Kansas. I went to a school that despite the incredible fire/ems/police program they had there did not feature this. However, several of us did volunteer with the local rescue squad while going through school to get the experience and decide if this was what we really wanted to do. It also allowed for first responders to see if they wanted to further their education in the EMS world or pursue something else. My school would have greatly benefited from having a campus based EMS service especially for athletic events or on the dreaded weekends (ie lots of drinking involved). The local service was often overloaded with calls and sometimes an ambulance would have to be called all the way from the other end of the county to respond, often taking nearly half an hour. Dust, I greatly respect your credentials and experience, however, I am troubled by the negative view you do have of basics and those of a lower level in general. Remember, we all had to start somewhere. There was a time when you didn't know anything as well, and someone had to teach you. I think the basic level is a great place for people to get started (though I think the addition of IV skills should be added to the curriculum nationwide to allow for fluid boluses, admin of D 50, and first round cardiac drugs). I feel basic should actually be a mix between the current basic and intermediate level. Several states are progressing this direction, and a few have even fazed out the basic level entirely (ie Tenn and Georgia-must be IV cert or intermediate to work on an ambulance). I had a vast range of experiences in EMS before deciding to pursue the career full time. I believe all contributed to strong assessment skills and will make me a better medic for it. It all falls back to BLS before ALS. If all the fancy toys fail, you can still keep a person alive using BLS methods. Are they superior? Not by any means, but only be as aggressive as you need to be. The majority of runs you go on can be managed BLS anyway and really don't require a medic. It is the "really big and bad ones" that will and in that case, they are usually flown out. As far as requiring a degree in the field, sure I'm all for it, if it actually meant something. But as was the case for me, I took a bunch of classes not even remotely pertaining to EMS or Fire to get a degree which I will never use again. A & P, bio, english and math, all very applicable and helpful though. Perhaps have a "focused" degree option? I think that would be a better resolution that just a general degree from a college that says you took a bunch of worthless classes and just happened to get your certification or license in the process. Did you ever think that perhaps the average burnout rate in our profession is 5 years because we pressure newcomers straight into being a medic and they really don't have time to see if this is what they want to do? Even as basics, the required 10 hours of ride time is hardly enough to know (my school required an additional 150 hours as a basic before testing-almost half of my class quit after that realizing this is not what they thought it was). I think bringing in better professionals who have better training (ie more clinical and ride time) would be of benefit rather than a piece of paper. Just a thought to think about Dust.

I personally haven't seen much of the show advertisements, just one quick blip, and I thought, here it goes again. I did watch rescue me for a bit (but lovely scheduling prevents that now), and I do admit I was a fan of third watch, but not for the reasons one may think. I liked it because it actually showed that some people have a life outside of this profession, that this is not all there is. Yes they got quite carried away with some of their treatments, and exciting stuff was happening every two seconds, and all that, but it also showed they were human and made mistakes and that they had to live with those mistakes. I have yet to see a show acurately portray that side of fire/ems. Now as far as the out of control personalities, well, there is much of that which does go on in EMS. I know of several medics personally which I have worked with that were fired and lost their license for things like using drugs outta the sharps box, inappropriate actions in the back of an ambulance (enough said there), and even had a medic from the first service I worked for that killed his 8 month old child. This job puts a stress on us that we don't realize some times. It's a sad but true thing. I've been in this profession for 5 years this month in various roles. I've worked industrial medicine, occupational health, at racetracks, fire departments, and transport services. I've seen alot in those 5 years, but not nearly as much as I know many others have. I've learned alot, but I know there is still a whole lot more to learn by a long shot. The one thing I am tired of seeing on tv though is the whole GOD complex that every medic on tv seems to have. They are the best, they always get it right, and there is no state board to kick their butt when they do wrong, no dreaded QA when they want to know why you did something you knew was right, but they didn't like, and the struggle to balance a family, full time job, and trying to work usually two jobs to make a living. All the fire/ems/pd people on tv can live (quite well I might add usually) on one job. I'd like to see that happen in real life. As far as the tee shirt thing, that's at the bottom of the list. Yes it's not the most professional thing, but there are worse things. Around here there is a large volunteer fire base which makes first response as well as many off duty people who respond due to the rural area. I thank God every day for them, I've had them show up in their pajamas before, and frankly I didn't care. Our departments policy is polo shirts and BDU's until 7 pm (we don't wear the blue shirts due to us looking too much like the local cops it has caused major issues at scenes before) and tee shirts from 7 pm to 7 am. Our polos are blue with only the department logo on them. No patches at all. We are a joint fire/ems service (do rotating shifts 6 months on fire, 6 on EMS). And despite being a country service, we do a large volume of calls for the area and we are expected to always be clean, tidy, and professional acting. Bottom line is despite our best efforts, the public has the image that we don't treat the patient, we are simply a means of transport (had a gentleman tell me once, why don't you put my wife in the truck and drive to where they can actually do something for her. I used to do this job, I know it's all you do-mind you he was about 70). He and the public didn't realize how far our profession had progressed. We need to focus on educating the public, and not depend on some tv show to do it for us. Good care and professionalism will get us farther than publicity through a tv show ever will. Not law, just simply my two cents. Later.

I was extremely curious about this as well. When I was going through class, three of the services we were to do our ride time with were participating in the study. I actually called northfield labs with a bunch of questions, which I have to say, they were more than gracious about taking their time to answer. They gave me additional resources to look up with both the positive and negatives on it (I'd have to find the list, if I do, I'll post it), but overall it has gotten good reviews around my area IF the protocols are followed for administration of it (it seems some problems have occurred in contraindicated patients). I think this is the same as any new med or whatever, in the end one must decide if it actually provides a benefit. Around here it definitely does as the transport times can sometimes be long, and due to the landscape frequently choppers can't fly. Also, in the event of a negative reaction to the polyheme, true blood is NEVER withheld ! This is completely contrary to what some people think, once you get it, it does not mean that you will not receive blood at all, for our area, it was during transport only. If additional blood was needed, it was given at the hospital. We've seen great results from it. Also, in most areas where they are doing the study, they had a public education meeting which featured a lab person from northfield, a local medical director of the study from a trauma center, the directors of the EMS/Fire services participating, and the public. The public is given the option of not participating, they wear a wristband (very similar to the DNR idea) stating they do not wish to participate in the study. If you want good information, contact northfield and a local med director who is supervising the study (northfield can provide that info for you). Hopefully this will show further postitve results and be an assett to services everywhere !

My service really did have someone hit a deer with the buggy, tie it to the top of the ambulance and bring it back to the station (yes they called themselves 10-7-out of service while doing this) and yes, we had venison stew for dinner and it was good. Enough said there Worked for a service that had a 4x4 ambulance. Was really jacked up, had to run and jump to get up into it. Very comical for my partner to watch, scared patients half to death ! Was most helpful though in really rural areas when we got stuck in flooded creeks !

I work in a predominately white rural service on the back of our ambulances, they all have stickers in the window that say "Say no to racism" - don't ask..... Above our gas tank, someone as a joke took a permanent marker and wrote DIESEL ONLY DUMMIES on a piece of tape, yeah and the next day, went to fill the buggy up and guess what ? Guy put UNLEADED in the tank ! (not my partner, gas station attendant, then told us to run the thing that it would be fine....uh yeah) Our engines and buggies all have on the side 9/11/01- all gave some, some gave all (which I actually like, reminds me why I get in that truck each day)