triemal04

Wow...bravo on your self-control. Although if that ends up being someone you work with on a regular basis and this continues to be a problem I'd start to think about losing that control around the third time you have to explain yourself. (joking...but not really)

How many times has it been said here that there isn't (or shouldn't be) a separation of care into BLS and ALS levels, just patient care? Sweet bleeding jesus hopping on a crutch, how hard is that to understand? The practise of medicine does not come from a cookbook; there is no single checklist to follow each and every time. Deviations will get made sometimes, and quite often because of how the patient is presenting or what the assessment revealed. With higher levels of knowledge and training most people seem to understand this; it's at lower levels (where cookbook medicine is taught and practised) that it becomes a problem. Especially when those people interact with someone further up the line and aren't willing to learn.

Kudos on doing the right thing and trying to explain why you did what you did; for someone who honestly didn't know any better and was willing to further their knowledge that kind of thing can be priceless. Unfortunately you got stuck with an undertrained, uneducated, cookbook practising asshole. (and for the record, from what you've said about it and making one or two assumptions, I don't see anything that you did that was wrong)

Just wait, there will be a study out soon that will say it's bad! There always is! :roll:

Actually, the couple studies I've read on this say the opposite. (granted that was several months ago but I don't think anything has come out to disprove it) More telling is that the findings in CCR are part of what drove the recent changes to standard CPR; less focus on ventilations and more focus on circulating the blood effectively. Without checking I don't know if their findings have been published yet, but quite a few services in Arizona have been using this for awhile with a fairly large increase in ROSC.

More info:

http://www.ncbi.nlm.nih.gov/sites/entrez?c...f1000m%2Cisrctn

http://web.kshb.com/kshb/pdf/ACurrentOpini...REwy06MCC58.pdf

http://circ.ahajournals.org/cgi/content/full/111/16/2134

Interesting stuff if you actually care about why something works or what may change down the road.

Rid this is mostly for you since the thread (on another site) this was from was locked immediately after I posted this...but since it applies here (especially since we've both said the same things here and in another thread) I thought it might be appropriate; some of it doesn't apply, but a fair amount, mostly towards the bottom, does. Anyone else, please contribute as you see fit. Comments in red are mine.

Originally Posted by Ridryder911

What does "get old" is that EMS does not ever get recognition in comparison to other public safety providers. Don't believe me? Check out your local retirement and benefit packages (if you have one). See what would occur if your EMS partner gets creamed by a drunk driver and then to see if it was a firefighter.

Unfortunately that's true all to often; not always but way to much. The answer to it, (as I've said before) is that EMS workers need to get some kind of organization together to start their lobbying and compete with IAFF in their own game.

If the family gets enough to plant the poor medic in the ground they will be lucky, and the firefighter "dust to dust" will be paraded down the road as will the bill be picked by the locals. Both of them were there for the good of others. Just one of them didn't happen to be "one of the chosen". I am glad that firefighters get great benefits but let's share the pie and we'll even let them keep the glory.

Again, not always true; remember not every firefighter that dies gets any type of parade; the funeral is part of our own tradition, if even that happens. But yeah, it should change and hopefully will. See the above for how.

I am fighting the discrimination against medics. Ironically, EMS is one of the few public safety jobs that actually requires education prior to employment.

Most hire for their physical agility's and then are placed into an academy style training center.

Not so much...while ensuring that a canidate can complete the initial training and actually perform, many physical agility tests are VERY watered down from what they used to be (that's a whole 'nother topic). The most important part is really the interviews...remember, many skills can be taught, but you can't teach someone how to have a personality. And given that we have to live with each other for, on average, a third of our lives while we're working, personality (which includes the ability to learn) is pretty d@mned important. (actually something I'd like to see stressed more in EMS; don't just look at someones credentials but how they interact with people; good indicator for how they'll interact with the public)

I deal with IAFF and associated representatives now on a weekly basis, along with their legislative affairs representatives. So I think I have a little handle other than anecdotal feelings.Maybe better than some, i'll give you that, but not entirely, sorry.

I have no problem of their involvement, what I do have a problem is their clear intentions of take-over in EMS. Even some of their proposal that it would costs more but "in the long run be better for the community". Their ideologies that they are the only one eligible and qualified is ludicrous. Fire Departments was only involved due to no one would take EMS at the time, not that they had special skills in medicine.

I can't speak for your area, but in some areas in very well may be in the public's best interest to have a fire (or third service would be best) based system...really it's going to depend on a lot. What's true in one area won't be somewhere else.

Again, brief history compare the Fire Services response to EMS even 12 years ago and now. The reason again is fire suppression responses are down (which is good) and to justify existence and personnel one has better have something for them to do.

Same old same old.

Yes, it would be nice that traditional EMS could have the same representation. It is doubtful we will see a lot of activity due to apathy in medics and many EMT's only using EMS as a stepping stone into Fire Service or another profession. As well, it is hard to be motivated after responding to 15 emergency calls a shift and having to work another job to make poverty salary.

Wait...are you saying that EMS workers aren't willing to make some personal sacrifices to better EMS in the US? Interesting. Are you also saying that many don't care what happens to EMS? Very interesting. That aside, I don't have to much sympathy, I'm sorry. If people really want change it's time to stop using fire as the big bad boogyman, step up and start doing something. Honestly, do you always think that fire departments got the things they have now? If you do it's time for you to look at your history. We got these things by going out and working for them, same as EMS needs to do. Yes, it takes time for it to happen, and it won't be fun going up against IAFF, but it can be done. It just needs to start, preferable yesterday.

I am not whining, just want fair shake for those in EMS.

I agree, so do I. But, as I said above and previously, it's pathetic to read threads like this and see people complain about fire departments getting all the glory and perks when very few are willing to go out and try and make changes. Nobody wants to make any sacrifices on their part, they just want the benefits. If you are then good, I truly hope that it helps and that you can get others to do the same, but you are one of the few unfortunately.

Unfortunately I am a pretty bad black cloud when it comes to this type of thing...and it's still one of my least favorite type of calls.

It doesn't change the medical care that I give though, not that I've noticed anyway. What it does make me do is go a little further for the patient on the non-medical side...asking about and contacting any family or friends, staying with them when neccasary...that type of thing. Once they're out of harm's way at least.

That sort of call isn't fun and it's easy to let it get to you, but you can't do that or you'll start making mistakes and doing things differently and wrong. Treat them like any other patient, and, (what has worked for me anyway) until it's over and done become the most emotionless, detached cold bastard you can be. If it's someone you know ignore that and focus only on what needs to be done, not that it's a friend. If it's another cop, firefighter, paramedic, etc do the same.

Makes it much easier.

The 90% (i'm guessing here) probably comes from the annual surveys that JEMS does that tends to show that fire departments have units respond to 90 odd percent of the EMS calls around. Or something like that. Has nothing to do with transport.

Now to the meat and potatoes.

To everyone who is complaining about this, an open question: What are you doing to see to it that videos like this will be shown to be untrue? What are you doing to educate the public about the state of EMS in the US and how it needs to be changed? What are you doing to show the public that EMS needs to be separated from fire? What are you doing to get EMS separated from fire?

I'm sure there are people here who are actively involved in those things and I'll happily shake your hand if we ever meet, but f*ck's sake...if you want to bitch and moan about fire departments here then get off your arse and actually do something to resolve the problem. Otherwise it's just more whining.

I don't see how having a non-transporting unit arrive first is always a bad thing, or even most of time. Unless transport capable rigs have been sacrificed to get the non-transporting units on the road in which case it's completely and utterly f*cked up and wrong.

Even if it really is a placebo effect, that can help some patients...not all, but enough. Assuming that they are able to start the same level of care as the personnel on the ambulance it's still a good thing for those calls when an immediate intervention is needed, or when something we do will really and truly make a difference. Add in that for calls that don't need transport the initial unit should be able to handle it (in a perfect world anyway) and free up the ambulance for the next call and it's still good.

But. If the only reason it's being done is to bring response times down...that's a load of crap. Get more ambulances on the road and response times will drop. It's that simple. If the non-transport unit really can't do anything then it's pointless for them to be on every call, unless more manpower is needed. Unfortunately this seems to be the case more often than not.

Shite. Like a lot in US EMS it's something that could work for everyone's benefit if utilized correctly, but currently isn't in most places so it tends to be more for show than anything.

Having a doc that was strictly in-house wouldn't be a bad thing neccasarily (assuming of course that you had a good one who was suitable for the job), but having one that was based out of a local hospital, even if it meant that you had to be associated with it to some extent might not be bad either. It'd probably be easier to get medic's time in the OR if they needed to maintain their intubation skills (which would also be mandatory for the service-12 successful, live intubations per year minimum, no if's, and's or but's), as well as into hospital based case reviews of patients that had care initiated prehospital. Might be easier to get medic's into any classes offered to hospital personnel that they otherwise wouldn't get. I'm sure there could be some downsides, but so far...

James Maietta should be charged with endangerment of public safety officers. The man should have moved down to a bottom floor when he realized he was going to be immobile.

Can you imagine 500 lps of human rolling over you if you were the firefighter at the end of the feet??

Can you imagine the goo left on you after? :puke:

I didn't necessarily mean narcs. We use Tylenol, Toradol, fentanyl, morphine, dilaudid, versed, and valium...Nice to have these options and I understand most don't...I understand your comment, but this patient and those like her would most probably need the pain addressed..with which one..??

Krispy krap you lucky dog. Best I can offer is fentanyl, nitrous and versed. Much better than just morphine but damn...

To be clear, from what got posted in this case the lady more than likely should have gotten a shot of something to help her cope. From your list I'd have gone straight to Fentanyl, backed up with valium/versed to help her relax if needed. And in your situation you may face the problem of having a DSI less than others (or more given the variety of what you carry).

My point is really that, as I said, pain is very subjective and hard to judge when it's not you feeling it. If all you carry to fix pain is a narcotic...you're going to get played by some patients and end up helping to get them their fix when they have no medical need for any narcotic pain killers. Not to say that you should withhold meds from someone who needs them, but there are traits that people tend to display as DSI's, and a lot that I've had whip out the fibromyalgia card awful fast.

I'm guessing that having the ability to give Toradol (long as it's not contraindicated) tends to help deal with drug seekers.

8/10 or 5/10 from someone with chronic pain....treat the pain! :angry1:

This wouldn't be one of the people I've had that told me very calmly and quietly while in no discernable distress that this was 10:10 pain and "worse than I've ever felt it," would it?

Limited info, but what the hell.

If there were signs of a dislocated shoulder or damage to it, then yes, pain management would have been very appropriate. If the lady appeared to be in real pn, then yeah, good idea to give some Fentanyl to her.

But...without having been there, I'm assuming the medic thought something like this: many DSI's often report that they have "fibromyalgia," and given that there is no way to prove/disprove that they have it, it creates a huge problem for anyone who can push or prescribe narcs. I've heard one or two doc's mention that people are often diagnosed with fibromyalgia because they report chronic pain with no apparent cause. The problem there is that it is extremely hard to judge how much pain someone really is in, and often times people seem to get away with drugs that they otherwise wouldn't get (DSI's).

In this case hopefully the medic actually assessed the lady first and then made his judgement, otherwise...that's just not a good idea.

You're right.. I did mean per minute... but math isn't one of my strongpoints either... The place I work at has 45 minute intercepts - with both of us running towards each other... and often, when the helicoptor isn't flying, we have an hour or so after our community hospital care to definitive care.. so long transports are one of the things we do. We don't start amiodarone drips (although we have pumps and will have nitro and heparin drips during these transports) because of the very long half life of amiodarone... as far as what is wrong with what you are doing.. probably nothing.. this is our protocols and are as per AHA recommendations..

Stay safe

Good. My only point was that you don't need the entire amount of amiodarone right there when you start a drip; the rate it goes at is pretty slow and amio generally comes in 150mg vials/ampules, so you're pretty safe; if you need to run a drip, then run it regardless of if you have 150mg or 600mg on hand. As you said, the halflife is pretty damn long also. I'm sure it could happen, but the chances of a drip being started prehospital, and then still be running prehospital 6 hours later are fairly low. Not to say that it couldn't happen though...

In Vfib/pulseless Vtach, bolus dose of 300mg IVP. Other arrythmias (patient has a pulse) bolus dose of 150mg IV over 8 - 10 minutes.

In Vfib/pulseless Vtach, post resuscitation care the drip is 900mg in 500ml, 1 mg/hour for the first 6 hours, 0.5 mg /hour the next 18

- that's what the hell for

Not to be rude or anything but...1mg/hour for 6 hours is only 6mg. .5mg/hour for the next 18 is only 9. I'm guessing what you meant was 1mg/min, but hey, I've always hated math so maybe I'm wrong.

Not to mention that even with my longest transport I won't be seeing a patient for 6 hours. I'm sure there are places like that out there, but generally speaking...there aren't many, and a lot don't seem to be ALS. Point being there is nothing wrong with mixing 150mg of Amiodarone into 50cc of D5W (or 100cc) and running it in at 1mg/min. Gives you 2.5 hours to get them to a hospital.

Any problems with that?

Zippy you don't have a relative in the US who goes by NREMT-B do you? Because the two of you sound an awful lot alike.

CPAP does burn through and O2 cylinder pretty fast, (some systems more so than others apparently), but it is most definitely worth it. Since it's been introduced here it's kept me from having to intubate several pt's that I would have had to awhile back.

It has made me a lot more conscious of what the levels are in my O2 cylinders; generally speaking once our main tank (M) drops below about 800psi I start looking to change it. Same goes for the D-tanks we carry. If you can switch out your tanks at a higher level (especially if you run a lot of respiratory calls) then start doing that, and if you know you're going on a transfer involving CPAP, get a fresh tank and several spare D's.

Trust me, having CPAP on the car, even if it makes for a bit more work, is very much worth it.

The trauma termination protocol is for extended extrication times only. For most other trauma resuscitations, rapid transport is called for.

You work trauma codes? Really? Even in systems that still transport dead people, I thought that most had realized that the ROSC in trauma was something like .07% and let them be.

I issued a challenge a while back for someone to provide an example of just one private company that offers good pay, good working hours, good retirement, good equipment, and interestingly, to date no one accepted the challenge. I have never, NEVER, seen a private company that could remotely compare to most local government or fire based services. Given that you feel empowered to state that xgldcrossemt's post was "entirely wrong" I figure you are up to the challenge.

Ahhh...wipe your eyes, m'kay? I'm not even sure why you're so pissy about this. Does the pay at a private ambulance service suck? Yeah, quite often. Does it always? Nope. In fact sometimes it can be downright decent. Maybe not on the east cost, but over here...

AMR-Portland...starting wage I couldn't tell you, but after 2 years it's about $18/hr with anything over 8 hours straight being time and a half.

Mercy Flights (yes, they are ground based too)...don't know about now, but when I was looking at them starting pay was around $17 or 18/hr.

Cal-Ore Lifeflight (and still ground based)...less, but not by much from what I remember.

Murder Death...annual pay of about 38K to 60K, without overtime.

Now, are all of these payrates great? Not really. Are they better than some places that pay next to nothing? Yes. Does this mean that saying that pay for privates sucks isn't entirely accurate all the time (like I said above)? Yes. Are third-services the way to go? Sure. Does this change anything that I've said in either post? Nope.

Now tell me again, why are you bitching?

Maybe this post will be way out of line here, but had to weigh in on this topic. Some people "might" be "happy" working in private EMS, but lets face it, the pay sucks, the hours are crappy(usually 12 or 14 hour shifts, as opposed to 24's) and the benefits are nil. All this talk about cutting the fire dept "fat" is not gonna happen. Individual municipalities post levys and citizens vote. I would say most people would like to have their ambulance ride paid for through their taxes, and not get a huge bill from a private company. In my honest opinion(and this is just my opinion) people in private EMS that bash the fire service are pissed off because for whatever reason they cant get in. Too many times you have been on scene and a fire medic made you feel like a second class citizen. Your just the private ambulance EMT that no one will recognize as the hero. Choose you own destiny. Be what you will, but for god sake, it boils down to patient care. I thought thats why we did this work.

Poor pay for privates...sometimes, but not always. So you're wrong there.

24 hour shifts being better...sure, if the call volume isn't to high. But if you run 10 calls in a 12-hour shift then you run how many in a 24? Wrong again.

Ambulance ride paid for by taxes...holy hopping crap on toast, what kind of fantasy land do you live in? In 2 states there is one fire department that I know of that does not charge residents for transports. And this is in an area that is mostly fire-based EMS. Once again...wrong.

Nice post. Pretty much entirely wrong, but nice reading just the same. About the only thing that was accurate was that it does come down to patient care and patient care only.

Just my 2 cents, so bear with me. Can it be beneficial to work as a basic before becoming a paramedic? Sometimes. Can it be detrimental? Sometimes. Should it be required to be a basic for X number of months before starting medic school? Maybe sometimes. Should that happen always? No. Confused yet? Good. Welcome to the wonderful world of EMS education in America.

The "skills" and so-called education that an EMT-Basic recieves is lacking and extremely minimal. I think pretty much everyone can agree on this, as well as agree that everything that a basic is taught in class is covered again in paramedic school in much greater detail, and during the internship those skills will actually be performed. So if that's the case, why should someone have to be a basic before a medic? Short answer, they shouldn't. There is no special knowledge or training that an EMT-Basic receives that a paramedic doesn't. So scratch that.

The field experience that the average basic get's isn't going to be much better. With the state of EMS today I'm going to go out on a limb and say that the majority of basic's are employed in some form of interfacility transport work; not all, and maybe not a majority, but a very, very large percent. What kind of experience will someone gain doing that for a year or two? None for the most part. So it's pointless to go out and do it. Add in that some people seem to learn to ignore what their patients are saying because "it's just another transfer, so who cares," and if anything it can be harmful for their future. For those lucky enough to work for a 911 ambulance service it can be a bit of a different story, if they're really lucky. They will be able to see what happens in the field versus a classroom and get some introduction to what people look like in various stages of extremis, so that's not bad. But given their lack of education and training, mostly what they'll be doing is watching and driving. Is that bad? Not really, and it can be beneficial. But it shouldn't be a requirement. The caveat to that is if someone is lucky enough to work as part of a 3-person crew (don't laugh, they are out there). The opportunities for more exposure to patient care is there but again, no reason that this should be a requirement.

Going through medic school isn't just class work; the internship and clinicals are a huge part of it and often the most beneficial to people; all the knowledge in the world won't help you if you can't perform an assessment and actually think while doing a skill. And honestly, this is really the only reason that having prior experience as a basic might be beneficial. I know from a lot of the (younger) people that I've seen that many have problems talking to their patients when they first start. Simply talking to them, not figuring out what the problem is (though the lack of communication doesn't help) can be the hardest thing that is done. Learning how to do that, and how to do it in a way that allows you to do your job can take awhile. Throw in learning how to perform your skills/assessment in a less controlled environment, and problems can easily arise. Of course, all it takes to overcome those problems are time and effort on the part of the intern and their preceptor. Which is where the problem comes in, since many internships are very short. If you can remove part of what needs to be learned (how to talk to an very proud 85-year old WW2 vet who can't stand snot-nosed little pukes like you without pissing him off more) then the rest will come much more easily. So in this case, having some prior experience as a basic (assuming that you did have to talk with a patient) can definitely help and make things easier.

Of course, extending the length of the field internship would be a much better way to solve that problem, but for some reason I just don't see that happening. I guess for me the bottom line is different for everyone. If your internship only runs 200 odd hours and you're an introvert who hates to talk to strangers...you need to learn how somehow, and preferably do it before your internship. If you can speak comfortably with anyone...not so much. Same goes if your internship lasts for months and months and months and months and months...but unfortunately not many do. The answer to this will really vary from person to person AND program to program; and that is how it'll stay until there is a set standard from EMS education in the US that is way above what it is today.

Anyway, enough rambling for now. Cheers.

BTW, I have a Master's degree, yet wasn't able to go and get a job in Oregon because I didn't have such AS in paramedicine courses like "Medical Terminology", "CSIM", and "Radio Skills"...wow, that pretty much blew my mind.

Wow. You have a master's. Good for you. Takes a lot of work to get that. Now out of curiosity, what is that degree in? I hope it's at least somewhat related to the medical field, otherwise you're blowing so much smoke it's embarrassing.

As for the courses...you probably also left out A&P 1,2,3 EMS intro, rescue, biology, chem, and unless your tacky little "radio skills" was communication (ie how to write a chart without looking like an idiot) that too. Along with some others. Lots of others.

Oregon (along with Kansas and maybe somewhere else now) requires EVERY paramedic who was certified after 1999 to have an associates degree. Doesn't matter where you come from. Does that mean that there are no medic mills in Oregon? Yes. Does that mean that people have to really want to be paramedics and be willing to put in the time/effort? Yes. Does that mean that the standards are higher? Yes. Does this help to enforce those standards? Yes. Does that mean there are fewer mother-may-I systems? Yes. Does that mean that an Oregon paramedic is trained in more than just monkey skills? Yes. Are all these things good? Hell yes. And hopefully this is how it'll be nationally in the future. (if I'm really lucky it'll happen in my lifetime...I hope)

If you don't like that, that's really just to bad. There's plenty of other states out there with minimal requirements to become a paramedic, feel free to go there. (california is just to the south) Personally, I'd rather stay somewhere where it is required to get an actual education before you go out and start treating people in the the street.

/rant.

All levels are required to complete the same educational standard in order to be licensed in the state. (you must hold NREMT with required cards--medics must have a degree as of last June)

With that, I do not see what the problem is between who is providing the service, as long as the regulatory body is performing as they should (so far, this is the case).

If you meet the standard, fine--if you do not---Thanks for playing--don't let the screen door hit your behind on the way out.

Beautiful. Nice to know that another state has got off their ass and done a little something to move forward. Now if we could just improve it from 3 out of 50 states to 50 out of 50...

Part of the problem that I have with volunteers (and specifically volunteer medics) is their experience level. With basic's I've learned not to have much in the way of expectations, and honestly, with what they can do that doesn't bother a whole lot anymore. But with paramedics...unless they work professionally somewhere, the thought of someone providing ALS care to a patient at the paramedic level when they see maybe MAYBE 100 patients a year scares me. And I have seen what can happen when you have someone like that around...not pretty in any way, shape, or form. Increasing the educational standards is great, but if you haven't had to perform any advanced skills or critical thinking for 2 months and are suddenly faced with someone having a true emergency...not good. People tend to forget things if they aren't doing it fairly regularly.

I hope you got the guy to buy you a lottery ticket.

The basics!!! Alot of times paramedics get focused on their ALS skills and forget about a simple BLS skill. If you are a good medic and like to teach your EMT partner what is actually going on they will see some things that you miss. If you have to ask the question how can an EMT save a paramedic then you haven't been in the field long enough or you have a paragod complex.

Or he's just a paramedic who never forgot what the basic skills are and when they're needed. Something you have a problem with maybe?

the fire dept in this great state do not have all their people trained in such areas, where as ALL ambulance rescue officers do have to be fully trained in each area that is set out for them.

Slightly off topic, but can you explain that a bit better? Do you mean that each person is fully trained in each area you mentioned above, partially trained in all, or trained in one specific area only?

But you know what I learned more than anything? That the individual is more important than the theory, and there is *no* absolute that says you are going to behave with X amount of maturity at Y age because of Z physical reasons.

Just saying. You can't just throw out "human development" and a chapter from a book and assume that it explains maturity differences for individuals you've never met, or even those you have met...

Wendy

CO EMT-B

Sure there's no absolute. Hell, for most things, including medicine, there aren't that many absolutes. But your first paragraph was right; while not all 16 year olds may be immature and not emotionally/mentally developed, many, many are. It's like most things; we base what we do off the largest common denominator. And in this case, most 16 year olds aren't ready to be running EMS calls, especially as the primary. Is that unfair to some out there? Sure. Is that just a part of life though? Yep. And right or wrong, it is a lot easier to make a blanket rule like, "the minimum age to participate in EMS is 21" than to selectively weed out those rare individuals who are truly prepared at a young age.