WANTYNU

Well OK, it might be the Vicodin slowing me down (Ok, Ok, and growing up in the 60’s), but I’m pretty sure your quote reads: “the fact remains that it is a big city culture thing.” Am I wrong to equate Big City (as in my Happy Shining Big Apple) to urban? After all, we got all the stuff a big city needs: Busses that don’t run on time, Taxi drivers (and EMS) that learned to drive in places where life is cheap, overhead and underground trains, lots of noise, oh ya and a Governor that hires hookers…. Come on that has to qualify as “CULTURE”…. -w PS, And for the most part we do TREAT our patients BEFORE transport…

This is not a fair nor accurate statement, I’ve heard plenty of stories of folks in rural systems starting treatment on the bus because they have a long transport and they want to get “the wheels turning” asap. Therefore, I do not believe this “culture thing” is owned solely by urban EMS. In my mind this (long txp times) presents an even stronger argument to start treatment as early as possible. It may be more attention is paid to an urban environment simply because transport times are less, and therefore you have to work more quickly if you are to effect patient treatment, so there is a strong temptation to load and go, and let the ER figure it out. In addition, it might appear logical to someone from outside an urban system, that this would be the preferred method directly because of the short transport to the ER, hence the myth. Another logical argument for the perpetuation of the myth, is folks who do not do something often, are resistant to believe others could or would move quickly and decisively when additional support is close by. As I stated earlier, the only reason for that action would be if the patient presented with a condition that would not benefit from more time on scene, say a knife sticking out their head… Lastly, a cautionary tale of walking an SOB, I know of three cases where the crew that did such, ended up delivering a corpse to the ED… As Always, Be Safe, WANTYNU

This is going draw some attention (If that is your purpose you will have succeeded)... I think the folks you were riding with were not doing the right thing or in that case their jobs. In NYC there is no acceptable reason NOT to treat the patient, unless its a GSW and you're in the ER already, or they're WARM and dead BEFORE you arrived... What I'm saying is don't draw broad conclusions from limited experiences. Don't "reprogram" yourself for the city, you're a paramedic, treat your patient. as always IMHO be safe, WANTYNU

Have the same, helps with parking as well.... -w Oh ya, A WANTYNU magnet on the back (but what did you expect?)

I'm sure this has been posted before, but I haven't seen it here, so maybe so other folks haven't either. I you know of it's previous posting, please don't make a fuss, it's worth it to post again for folks who haven't. Best -w heres the link, not sure why it's not embedding..

Dwayne, If it helps at all I’ve personally gotten to know Jim over the better part of two years now, and I’ve used his tests and guide books for over 5. We “Met” when after I purchased Turbo Medic for my medic refresher, he noticed my email and after going to my primitive attempt to build a website for my wrench, offered out of blue to help me with my website; he was not soliciting business he was genuinely trying to help out one of his fellow EMS who was trying to start a business. Since then I can tell you with great confidence he is a gentleman and all-around good guy who sweats the details, and has tried to create the best learning tool for anyone in EMS. After using his software from EMS Solutions http://ems-safety.com I scored well into the mid 90’s on every test I’ve taken (National, State, and local). IMHO the software creates a solid knowledge foundation for taking any EMS test. I’m sorry if this sounds like a plug, and maybe it is, but it is unsolicited and well deserved, Jim’s site is an excellent resource for anyone who wishes to learn something new or sharpen their mental knives, before cutting into a tough exam… (OK sorry for the PUN… ;-)) however he has created some really good tools. Jim is one of the few people who like myself, is honestly interested in the betterment of the public’s view of EMS and our being looked upon by our colleagues as professionals in the field of emergency medicine. Jim, sorry buddy, I know you like to keep a low profile, but your website deserves some hard earned praise! As Always IMHO, Be Safe WANTYNU

Don’t get me wrong, I carry a (one) clamp as well, I find it good for hanging an IV bag or holding something to as well as closing a sheet, but would never use one on a patient. I was just wondering what RomeViking09’s reason was, and since Kelly clamps (Forceps) are basically just hemostats with a different grip pattern, why the distinction. The field surgery quip was just being obnoxious (sorry). -w

The only question I have is why do you carry these, you planning on doing field surgery? -w

Great Rant Ridryder, But the truth is Talk IS CHEAP…. I’ve been saying that for awhile, see my previous posts on this subject, and I’ve asked the question that must be asked before and been ignored. If talk is cheap, HOW MUCH IS ACTION WORTH to you? How much are you willing to spend (and where would you spend it) to see us out of this situation? There are many organizations, but none that have produced any measurable results, should we really join a existing group, or start from scratch? In my opinion, we need a least three things to get going, We need a Group, we need a mission statement that would work as the basis of forming a plan with timeline and definable set of goals, and the biggest hurdle we need MONEY to meet those goals. IMHO, as long as Medic’s in some parts of the country get barely above minimum wage, the last part will be the hardest. Again good post, this is a subject always worth discussing and bringing to the attention to others. Be Safe, WANTYNU

Comment: checked a&ox3 in 5 seconds? This guy/girl? is alert!!! I vote we add 10 seconds to the clock for a realistic mental status check. any seconds?

ACTION: Call for a bus Clock: 00:00:30 Bus ETA : Approx 00:16:00 (lets make this a countdown)

OK I got this idea from my last post to which I tried to convey some simple information in a fun way and the scenario was over analyzed to the point that following posters were no longer on the subject at all. Sort of like a 5th grade game of telephone. It was actually pretty funny, which gave me this idea. The new game is like a combination of “Telephone”, “Clue”, and “Ad-lib” all rolled into one. This seems like a lot of rules but really they’re not. Here are the rules: 1. You may make only one post (take a turn) at a time, after that post, you must wait until at least two people have posted before you can post again. 2. POSTS WILL BE DIVIDED INTO TWO TYPES: 1) ACTION : Patient care/observation / treatments and 2) COMMENT: last post comments (where you can comment on what was done previously); however comments are limited to no more than TWO IN A ROW…. Then you MUST move on to a patient care post after the second comment post. 3. You may add only one comment, patient observation / treatment at a time PER POST. (One scene / patient observation, or one environment change, or patient statement, Med hx, vital sign { i.e. only one HR OR B/P not both}, etc). a). As an example the first post would be you see a patient sitting between two park cars. . The second post could be “There is blood on the ground” OR “ the patient says Help me”, but not both. c). Each post “runs the clock” with time periods between 5 seconds and 2 minutes depending on what action is preformed (making an observational statement “the Patient has a laceration to his/her back = 5 seconds (hey ya gotta look), pulse check = 30 sec, B/P = 20 sec, 12 lead = 2 minutes, IV access = 30 seconds, etc. just be reasonable in your time estimates try not to do a 6 second HR, let’s go with “Best practices” to provide a reasonable standard of care. d). You may state the time it took in your post, or the next poster may give a “Clock” reading adding up all posts to the current post, the clock starts at 00:00 and you add your time to that, COMMENT POSTS DO NOT MOVE THE CLOCK, a clock post does not count as a Pt care or comment post, but does count as a turn. e). Keep in mind the next poster can make a comment post that the previous attempt failed… (i.e. the IV infiltrated) BUT YOU MUST ASSUME THAT THE THIRD ATTEMPT AT THE SAME TREATMENT / PROCEDURE IS SUCCESSFUL, and you can only fail an attempt on a patient treatment AFTER TWO successful procedures (ACTION) have been accomplished. (let’s have fun, but not foil EVERYTHING….) 4. Assume a bus has an eta 15 – 20 minutes ONCE YOU CALL, HOSPITAL IS 1 HOUR…. (Games not fun without some pucker factor…) 5. POSTS MUST ASSUME IN GOOD FAITH THAT THE PATENT IS ALIVE AND CONSCIOUS!!! (of course what is done can change that). 6. YOU CAN NOT PURPOSELY KILL THE PATIENT (I.E. put a tourniquet around his/her neck, give 10mg HD Epi IV bolus etc). 7. If a comment post can reasonably show the previous action will kill the patient (i.e intubation but no BVM following in a reasonable period of time), posting must fall back to the last time the patient was alive, and all treatments preceding the fatal event are nullified. 8. If a new rule needs to be added, it must have two independent “Seconds” to take affect (i.e. two independent people must agree with it). 9. THE RULES ARE NOT HARD AND FAST, but let’s all try to stay to the INTENT of the law, if we can’t abide by the letter of the law. So let’s start: You’re at the local gas station fueling up the units fly car (assume you have anything you would need for patient care in the back, however you cannot transport) when a frantic motorist stops to say they saw a body about 2 miles back. Your conscience gets the best of you, besides it’s in the direction you were going anyway, and you go to take a look …. You arrive to find two legs protruding from behind a tree about 20 feet off the road, you can’t see the patient from this angle only the legs, there is a 4 foot chicken wire fence between you (the road) and the tree. ACTION: You do a 10 second scene safety check. CLOCK: 00:10 Lets have some fun with this. Be Safe WANTYNU

This is my final post, as I stated I will not argue about reading from a piece of diagnostic equipment assumed for a scenario to be correctly calibrated, applied and working, that is a discussion without a point. I don't agree, please research what an Arterial line is. -w

FYI at no point was any inference made that suggests the patient did not have a PE, in fact it is implied. I stand by this statement, I will not argue what a A line wave form reading from properly maintained and applied equipment means (this is assumed in the scenario). Here is the answer, -w The following discussion is based on American Heart Association recommendations from 2005. Recent reports of in-hospital CPR document survival rates of 27% in pediatric patients, with 65% of survivors having good neurologic function. In Nadkarni's recent study of in-hospital pediatric cardiac arrest, initial cardiac rhythm was associated with survival in logistic regression analysis. The child described in the vignette had a monitored arrest in the PICU with rescue breaths delivered. After starting 2-person CPR with 15 compressions followed by two breath cycles, optimally an automated external defibrillator (AED) should be applied using either paddles or self-adhering electrodes that fit on the chest wall without touching to assess cardiac rhythm and potentially intervene. AEDs can detect and differentiate “shockable” from “nonshockable” rhythms in children with a high degree of sensitivity and specificity. Adult pads can be used for children who weigh more than 10 kg. Initially, 2 J/kg is recommended, followed by immediate resumption of CPR for five cycles prior to assessing response. Subsequent defibrillation is increased to 4 J/kg, again followed by prompt resumption of CPR and 0.01 mg/kg epinephrine intravenously or intraosseously. If ventricular fibrillation (VF) continues, amiodarone 5 mg/kg or lidocaine 1 mg/kg can be considered. Administration of magnesium sulfate (25 to 50 mg/kg, maximum of 2 g) should be considered for torsades de pointes. Once sudden cardiac arrest occurs, prompt determination of presenting cardiac rhythm is key to potential survival. Asystole is the most common initial pulseless rhythm in pediatric arrest victims. Following initiation of CPR, epinephrine (0.01 mg/kg) should be administered for asystole. (VF) or pulseless ventricular tachycardia (VT) occurs as the first documented pulseless rhythm in approximately 14% of hospitalized children who have a cardiac arrest. The incidence of a “shockable” rhythm increases with age. Defibrillation is the definitive treatment for VF, and survival rates decrease with delays in defibrillation. Survival for victims who suffer pulseless VT or VF is greater than for patients who have pulseless electrical activity or asystole as the first documented arrest rhythm. However, patients who develop VF or VT during ongoing CPR have significantly lower survival. A randomized trial of high-dose epinephrine (0.1 mg/kg) compared with standard-dose (0.01 mg/kg) therapy in children who had cardiac arrest did not show any benefit and suggested that the high-dose therapy may worsen outcome. High-dose epinephrine is no longer recommended to treat cardiac arrest. References: Nadkarni VM, Larkin GL, Peberdy MA, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA. 2006;295:50-57. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/1639121...pt=AbstractPlus Perondi MBM, Reis AG, Paiva EF, Nadkarni VM, Berg RA. A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest. N Engl J Med. 2004;350:1722-1730. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/1510299...pt=AbstractPlus Samson RA, Nadkarni VM, Meaney PA, Carey SM, Berg MD, Berg RA, American Heart Association National Registry of CPR Investigators. Outcomes of in-hospital ventricular fibrillation in children. N Engl J Med. 2006;354:2328-2339. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/1673826...pt=AbstractPlus 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 12: Pediatric Advanced Life Support. Circulation. 2005;112:IV-167 – IV-187. Available at: http://circ.ahajournals.org/cgi/content/fu...24_suppl/IV-167

I reread the initial post and under my first impression there was NO air ambulance available, having access to one makes for a different scenario. Although 50 minutes is a long time, in all reasonable scenarios, safely lifting a object off a victim would take a minimum of 15 minutes (and that’s saying all rigging was ready to go BEFORE the accident) more likely 30 minutes with everything going just right. Fair to say 15 – 30 minutes before patient extraction is completed. Now your patient is on long board with bleeding controlled and your air transport is 20 – 35 minutes out. Under this scenario it makes no sense to start a two hour ride, when waiting for air transport with a shorter ETA that ultimately equates to a faster delivery to treatment time, during which you are of course building upon your previous patient treatment, warming, treating for shock, up through application of a tourniquet (if required and allowed or advised by telemetry). This makes sense except for the intercept, which would be a zero sum gain, when held against the logistics as stated above. Still, if there is no air transport, I stick to my original post, and in either scenario transportation of the patient is the highest priority. -w

"Suddenly, his arterial waveform flattens, and he becomes unresponsive. " This means no cardiac output, No cardiac output = no breathing. So far treatment is appropriate, what is the MOST appropriate next step? -w

LMAO, this has gotten surreal, I was waiting for the “Saw his legs off with some barbed wire found at the site” answer. But I just can’t wait any longer, I’ve been to a number of conventions / trade shows and have always joked it would be the worse place to have a medical emergency…. This thread has just proven that point. Dwayne said it 4 posts back, everybody has ASSUMED the worse or this or that (I don’t mean to dis folks here), there were a few good answers based on assumptions, and this is after all one of the ways we learn, however NONE that suggested wait were remotely correct (I really hope that’s clear by now). Let’s break it down: You know it’s cold, you know the Pt is in great pain. And yes Virginia there is NO air support. Answer: (A) Transport How about adding some info? Say our Pt has gone AMS? Answer: (A) Transport How about change in vital signs? Say tachycardia (because he’s already bleeding out by that rod underneath that punctured his femoral artery with the ground soaking up his blood, that you can’t see)? Answer: (A) Transport Drop in B/P?, Change in pain?, Skin signs? You can now assess his feet (pluses or not, motor / neuros or not)? Answer: (A) Transport Anything else you can think of? Answer: (A) Transport In fact let’s say the crane breaks down and now you can’t extract him? This would depend on the medical telemetry support you have and whether or not you can keep him warm until you can get him out in one piece, and your local laws, but remember the hiker that got trapped by a bolder and had to cut his arm off to escape? Someone said it earlier, Life over limb. Bottom line, you’re the medical person on the scene, your patient has an injury, it’s your job to get him as stable as you can and onto definitive medical care with as little delay as possible. I once had a teacher put it this way, it doesn’t matter what you face, you job is simple, ASSESS and then TREAT, how complicated you make it is up to you. As always IMHO Be Safe, WANTYNU

The following was presented by a Dr. who works with our Critical Care Group. A 10-year-old boy is in the PICU for evaluation of cardiomegaly. He was well until 1 week ago, when he had a flulike illness. Over the past 2 days, he has experienced shortness of breath when lying flat and dyspnea on exertion. Laboratory studies have been ordered to evaluate for myocarditis and cardiomyopathy. Echocardiography shows globally diminished function but no structural defects. Currently, the boy is receiving intravenous diuretics, an infusion of milrinone (0.5 mcg/kg per minute), and oxygen via nasal prongs. Suddenly, his arterial waveform flattens, and he becomes unresponsive. The nurse calls for assistance and begins cardiopulmonary resuscitation (CPR) with bag-mask ventilation with supplemental oxygen. Of the following, the MOST appropriate next step is to A. administer 0.1 mg/kg epinephrine (1:1,000) intravenously B. administer 0.01 mg/kg epinephrine (1:10,000) intravenously C. attempt defibrillation with 2 J/kg D. determine the cardiac rhythm E. secure the airway with an endotracheal tube Answer to follow. Be Safe, WANTYNU

Thanks Dust, once again you jump in with a (in my tiny mind) an extremely insightful observation, to paraphrase there is not a single “Organization” to date that has done a positive thing for EMS as a whole. And I will put forth that the ones in existence today, actually cause harm. They use up precious resources (TIME, MONEY, PEOPLE) and are mostly run by bloated bureaucratic egotists, who’s only interests seem to be based on self promotion. Time to start over and build from scratch? From day one I have tried to buy advertising space on this board, but there are kinks that still need to be worked out, so in the absence of a workable solution, I have just given money. I would like to clear up a misconception here, I have given money but don’t have a lot of it, in fact my little budding startup of a company is completely funded from my own pocket. So before anyone dismisses out of hand my giving over hard earned cash to this site as “disposable income” don’t, it comes with the same pain and choices of self denial that we all must go through before reallocating precious funds. I chose to give to this site not for personal gain as some have implied, but because it has great merit and greater potential. I personally don’t think a forum can or should replace or even fill in for professional organization, but growing though advertisement and booths at major EMS shows is a good idea (keep in mind the tables are not cheap). Great things have been started by grassroots efforts, from funding for local playfields to changes in federal laws, we should never underestimate the power we have, and further we must ignore the naysayers who say change can’t take place. As always IMHO Be safe, WANTYNU

Good point, much better than slowly rotting your lungs out of your chest. -w

Never mind I just heard smoking is bad for your health. I guess that would put being blown up in the same category.... -w

I'm just guessing here, but maybe because its A POLYMER WAX MIXED WITH SOLVENTS.... Ah Duh, anyone got a light for my cigarette while I clean this carburetor over this open bucket of gasoline.... -w

OK, everyone PLEASE STOP!!!!! What a waste of bandwidth, Dust Devil may indeed come off as an insulting, obstinate, and overly opinionated (and those are his positive points… kidding). And he is the last person on this board that needs defense, but it should also be noted, he is also involved, insightful, and intelligent, so the majority of his posts add a positive contribution to this site. I digress; this thread was about his INTERVIEW… An INTERVIEW…., HE WAS ASKED FOR HIS OPINION by EMS Solutions, ASKED, so first he was FREE TO SAY ANY DAMN THING HE PLEASED. Second, I listened to the interview, and don’t know what all the fuss is about, to my “Yankee” ears he was thoughtful, and well balanced in his OPINIONS, and was not in the LEAST self promoting, nor degrading to others. It is obvious some posters here have a giant chip on their shoulders (and no my shoulder has bashed rotator cuff, so don’t look at me). At first IMHO, this post was to alert the folks that might want to know and to maybe rib DD on his 15 minutes of fame. Now it seems as an poorly veiled attempt at the fulfillment of some sort of vendetta, with no point what so ever. I’m sorry to the EMT-B’s that think they’ve been disrespected in some way, but on average a Paramedic receives 10 TIMES the base education of a EMT, and as well must continue ADVANCING that education for as long as they hold their card, SO THERE IS NO COMPARISON HERE, get over it. With that in mind, in just about every system you MUST BE AN EMT BEFORE you become a medic, so for the majority of us, we were there too, but more than a few have forgotten their roots. It’s no secret I work paid EMS, and for the most part (it’s not a perfect world) BLS and ALS work as a TEAM, and for the most part I have great respect for my coworkers. There will always be an imbalance between advanced anything and basic, that’s after all the point of advancement, so some may move ahead (pick you category), and others remain. I apologize for this rant, but I am truly disgusted by the infighting and blatant immaturity that sometimes occurs on these forums. As Always IMHO, Be Safe, WANTYNU

LMAO, very nice. -w

Actually I just screwed up my shoulder on a job.... -w