Miz Black Crow

Hi Seth! Welcome to the big, weird-ass world of EMS. The first thing, the most important thing: What you're feeling is normal. Being scared out of your eyesockets is absolutely appropriate for your first week on the job, even if you react to it later. You will live with the constant question of, "Am I good enough for this?", at least for the first stretch of your career. That question lingering in your head is how you know you actually care. (The day you become a medic, it gets 10,000x worse, believe you me.) I'm going to cull some of my favorite Laws of the House, from that amazing book The House of God: LAW THREE: At the scene of any cardiac arrest, the first procedure is to take your own pulse. My personal version of this is, whenever I start to get flustered, I take a 5-second "time out", close my eyes, take one good big solid breath in and out, mentally detach from the scene, open my eyes, and reassess the entire situation. LAW FOUR: The patient is the one with the disease. This is another wording of the idea that it's an emergency, but not your emergency. Act accordingly. Also, anyone who says something that spiteful to you on your first week isn't someone who's full of love for what they do. The ones who love their job, teach and nurture. You can, and should (dare I say will?) prove that jerk wrong. And when it all goes wrong and your anxieties get all up in your head, and you can't think straight, remember: This Too Shall Pass. Cry if you have to, talk to whoever you talk to, learn, and move forward. You'll be okay. Honest. PM me if you need anything. ~MBC

Hi everyone! Long time no post. I work full-time as a medic in New York City, and have been looking for a second job, possibly one with a path to a flight career. I've had my eye on a particular hospital in New Jersey that's a) not too far from my home in Queens, and b) hiring per diem medics. There is, however, a catch, or more specifically, a catch-22: --In order to get hired in New Jersey as a medic, you have to have a New Jersey State MICP (Mobile Intensive Care Paramedic) card. --To get an MICP card, you have to get sponsored by a hospital. --For a hospital to sponsor you to get your card, you have to get hired. --To get hired, you have to have an MICP card.... Can anyone see a way out of this loop? I've contacted a couple hospitals, but only ever gotten answering machines for the ALS coordinators, and those calls go into the black holes of Never Been Returned. And no, I don't have a National Registry, and no, even if I did it wouldn't help..... right? If any Jersey medics could let me know what I'm doing wrong here or who to reach out to I'd really, really appreciate it. ~MBC

What's the basis/cause/etiology for the elevated lactate in insulin OD? (And good for him for not having cancer!) Also, in hindsight, horses/zebras. I guess pancreatic CA is the zebra...

I'm on board with pavehawk; this fits very well with a patient I had two weeks ago with a similar presentation and an ultimate Dx of an insulin-secreting tumor (due to pancreatic cancer, which had not previously been diagnosed). An initial BGL of 37 which only goes up to 80 after 50g D50 IVB, and then declines after only 20 minutes, is seriously concerning to me. (And that matches my recent patient PERFECTLY). Time to count the D50s and get an ETA to an OR? Or are Pavehawk and I way off-base?

So. I'm currently in the back stretch of my Paramedic program, that will certify me both as a NYS EMT-P and as a REMAC medic. I'm planning on working 911 in the NYC system, but, here's my question. I'm also considering taking a position per diem at one of the (numerous) transport agencies. Not because I think they're better or worse than working in the 911 system--I'm looking at it as a completely different school of thought in paramedicine (stabilize and run to the nearest 911/trauma/STEMI center vs manage this patient for 2-3 hours between facilities, work with IV pumps and vents, etc). Can anyone provide any relevant information on who's good to work for as a medic in transport? Who carries what drugs, who has more lenient/intelligent/medic-oriented protocols (REMAC vs NYS ALS protocols: who uses what?), who pays well, who actually respects their employees? I spent some time working for one of the above as an EMT, which, I have to say, made me want to shoot myself, but... For the purposes of the poll I removed Presbyterian/New York Hospital as a candidate, since from what I've heard you either have to know someone or blow someone to get in. If there's anyone who knows that *not* to be the case, please, let me know. Oh, and guys? I'm NOT looking to trash-talk transport EMS as a whole. The question is, is it worth my time to work transport instead of 911 overtime? How does it look on resumes in the future? I want to hear from anyone who's worked *as a medic* in txp here in NYC... the good, the bad, the ugly. Wage estimation for brand-spanking-new medics would also be *massively* appreciated. Thanks! ~Miz Black Crow

I thought Barney's was part of FDNY. Guess I was wrong. Sorry! (I TOLD you it wasn't comprehensive )

Going back a ways to the drunk MCIs, you know you're in urban EMS when.... ...the ER nurse pisses off one of your coworkers by yelling at them for bringing a drunk to the nearest ER (this nurse has some attitude issues). So your coworker calls up 4 or 5 other units, goes down to the local shelter, and starts offering free dinners to anybody who wants to go to the hospital. Three or 4 units take 2 or 3 drunks apiece to said ER.... apparently (this was before I was stationed here) it was like the Thanksgiving Day Parade, only with more urine stains and Georgi. Oh, and that nurse doesn't mess with this guy anymore. ...you refuse to drink certain kinds of alcohol (again, Georgi) because you feel like you should be drinking a higher class of liquor than your patients do. ...you're on a first-name basis with half the cops from your local precinct, which has at least 300 officers. ...you work 16 hours and transport the same drunk at least 3 times (Curse you, L.H.!!!! CURSE YOUUUU!) ...you refuse to drive a certain route to the call because you know your "favorite" intox will flag you just to annoy you. ~Miz Black Crow

As for places to work: Transcare operates the EMS for the following hospitals (that I know of, there may be more). As someone said earlier, they should be avoided like the plague; I worked for them as BLS in transport. They fire people at the drop of a hat, have no benefits to speak of, and are totally non-unionized (and even anti-union). They run: -Beth Israel -Mt Sinai -North General -NYU -Bronx Lebanon -Montefiore -BI King's Highway As evil as they are, they *can* be a good stepping stone. TC requires 6 months experience in 911, as a volunteer, or as one of *their* txp EMTs before they'll VAX you to 911 there, but that's less time than most places. Hospitals that run decent, unionized, voluntary 911 services: -Roosevelt and St Luke's (same company, different locations) -St. Vincent's (apparently they're really good to work for) -Lenox Hill -Presbyterian (including Columbia, Cornell in Manhattan and Community in Bk) -LICH. However, LICH is losing their EMS licenses and shutting down the ER as far as I've heard... this may just be a rumor. Check with them. -Lutheran, which has a kickass ER -Staten Island University Hospital I've left out all of Queens because I admittedly know nothing about the borough. This list is not comprehensive and I have no idea who's hiring and who isn't. Any of the above voluntaries will want at least a year on an ambulance and/or probably (unfortunately) a year in 911. You can always try the ubiquitous FDNY, of course, but I heard something about a hiring freeze and I hear the waiting list is over a year long anyway. Good luck! ~Miz Black Crow

Usually I just start off with "Why did you call 911 today?" (though in IFT I was MUCH more humor-oriented at contact). Once I've done 75% of my assessment, history questions and figured out that this person is stable, depending on what I can get of their personality through their answers I'll make some jokes. Always small things, like when they ask what they're signing (HIPAA stuff): "Sign here, sir/ma'am. This is just saying we're not going to run down the street screaming your social security number, though I used to have a LOT of fun with that at parties before they made it illegal." When loading, particularly on a stretcher: "Thank you for flying [company] EMS, please keep your arms and legs inside the stretcher [or Ambulance] until arriving at our destination, which will be [hospital]. Our anticipated altitude will be 0 feet; any variation on this will result in me getting fired. Please observe the no smoking sign and try to enjoy your flight." Works even better when I'm driving (which is rare), since I'll say it right before I jump out the back doors and close them. Especially with younger patients close to my age range (between 15 and 30) I've discovered that as long as you don't say anything offensive or making fun of the patient themselves, laughter really can be the best medicine--minor injuries, SOME EDP's (i.e. the 20 year old girl getting kicked out of the shelter for backtalking to the staff who really isn't very EDP at all) will get the full force of my terrible sense of humor. Sometimes this is a great way to distract people from their pain, as well; joking or just talking about them, their job, my job, whatever..... Though this doesn't work for peds with me, I can't talk to them for the life of me.... I couldn't talk to kids when I WAS a kid. I have a better knack for humor than for simplifying things, I suppose. But it's all on a case-by-case basis; I don't joke with anyone even remotely dangerous or who seems like they have no sense of humor. PHILISTINES! ~Miz Black Crow

Jinx, saying "there's a lady present" is no excuse to start or stop jackassery. I don't see ladies or men on this forum; I see EMTs and Paramedics. You should know that. Secondly, YOU'RE going to talk about anyone ELSE making idiotic remarks?! Have you read ANY of your own posts? If you want to stay an EMT with your head up your poop chute (not sure if the term I really want to use is okay here) then that's all fine and dandy. Your posts have pretty much proven that you have neither the basic education nor the will to see things beyond a CFR's (yes, I said it, live with it) "scoop and scoot" perspective. Whether your skills are enough to salvage your ability to perform work as an EMTB or not I can't say, but please... until you get a smaller ego and a bigger brain... DONT GO TO MEDIC SCHOOL. Whatever system you work in, if a medic with as big an ego as yours and as narrow a view on EMS as yours showed up on my job, I'd close the doors and transport myself. I'd probably save a life. Actually, DO go to medic school. You need a slap in the face with medical realities and the Giant Fish of Testing. ~Miz Black Crow PS: Thanks, Jinx, you already got one forum thread closed. PLEASE leave this one alone. EVERYONE ELSE: Back on topic with something witty and beyond my education, please?

JPINFV, please see the first post in this topic. Didn't you just counter your own argument? Immunocompromised patients, ESPECIALLY those with a background in healthcare, are (or are made to be) VERY aware of the ramifications that illness has on their body, their reactions to disease and infection, and the possibilities regarding their ability to continue working. What you just said boils down to, 'it's the provider's choice, knowing the impairment that their body has and its lessened ability to fight infection of any kind, whether or not to continue working with the sick and injured.' I could choose to juggle fire for a living, knowing fire can burn. If I get burned doing it, it was my choice to make, not anyone else's. If my skin is extra-flammable for some reason (say, for example, bathing in alcohol and diesel fuel is some new treatment for acne), and I choose to do it anyway.... IT'S STILL MY CHOICE. In the end I'm not going to have anyone to blame except myself if I catch on fire and burn to cinders in the street. However, it's not the risk to the provider that we've been discussing; it's the risk to the patient. Which, until someone finds hard scientific data on providers exposing patients to the provider's blood or BBPs, I'm going to write off as "negligible" and move along. ~Miz Black Crow

We love you Dwayne! Jinketsu, I agree that the EMT-B is a good and useful level that has its place, especially in inner-city areas with high trauma rates and fast transport times. But you have to acknowledge the (sometimes exceedingly short) limitations of our training and education. I don't understand a HUGE amount of what gets discussed on this forum; that's half of why I read it. It's also why, when I have even the slightest doubt about a patient's stability, I get on the radio and ask for some medics, even if it turns out I didn't need them and they do no interventions on my patient at all. Knowing your skills doesn't make you a great provider, it makes you a great drone. Ask yourself WHY the medics' assessments takes "twice as long" as yours; they're probably asking things that you didn't or covering things that you missed. I know I always wince and go "why didn't I ask that?" when ALS assesses one of my patients. Be willing to learn from those who know more than you. It will make you a better provider. Guaranteed. ~Miz Black Crow

Jinketsu, not all systems are the same. In some cases, it really does take 20+ minutes to get to the nearest facility, which may not even be a definitive care center. You're saying you have a short average transport time, and that's great. That means that in your particular system, BLS can be a little more independent and slightly less reliant on their ALS backup, because the ER is never more than 10 minutes away (I'm guessing; I don't know your system). Some people don't have that option. Triple the transport time; in that case, are you REALLY comfortable with that patient who's in chest pain? What about if their blood pressure starts dropping a little? I know I wouldn't be. That aspirin may help a little, and that nitro may reduce a little of the pain for now, but that's nowhere NEAR the care that can be given by ALS providers. I ALWAYS ask for medics for anyone complaining of chest pain, because if nothing else I trust my medics. I want to be dead sure that my patient is getting the care that they need. Also, even if your transport may be 10 minutes, what about triage time? Your urban EMS system most likely has waiting times before you even hit triage; even then, they have to run the EKG, tap the vein, run the line. How long have you stood waiting in the ER, when you could have gotten ALS to do the same thing, covered your own butt in case the pt deteriorates during txp, and have a better diagnosis than ROMI? Are some ALS providers arrogant? Of course they are. Some EMTs are too--you made a fairly arrogant statement yourself. Don't mistake an ability to provide a better diagnosis and better prehospital care for arrogance. Not every system is made on a cookie-cutter; the needs of the community dictate the EMS system (or at least in an ideal world they do). Your protocols may be different from mine, but I don't mess around with feeling like I can run a cardiac call by myself. I know better. ~Miz Black Crow (edited for clarity)

*hangs her head in protocol-shame* The only reason to give O2 via NC is if the pt is unable to tolerate an NRB.... That's also partially because BLS doesn't get O2 saturation, blood glucometry, we don't even *think* about combitubes.... Hell, my company is too cheap to give their *ALS* glucometry.... This is a large part of why I'm going to medic school when I can afford it, because at this rate I can't afford not to. ~Miz Black Crow

BEorP: If the patient is age 35 or over or anyone of any age with a cardiac hx, I am mandated to give aspirin unless it is contraindicated. There is no wiggle room in my protocols for clinical judgement, on a BLS level (EMT-, nor is there a "contact medical control for orders" clause. Hence why I was expressing my dismay with the protocols. Can you say "exacerbation of acid reflux"? Be safe! ~Miz Black Crow

First of all, I apologize for unclear wording, I guess my tiredness got the best of me. No, I'm not a "cookbook EMT." I'm running the list of my non-traumatic CP protocols. Do I give everyone with a cold or an upset stomach aspirin? OF COURSE NOT. I was just pointing out what the protocols were on a BLS level in my area, and saying that if I follow my protocols as written I have no choice but to give ASA. There is no stipulation to contact medical control for permission NOT to give it, but that doesn't mean I haven't picked up the phone or that I won't continue to. I'm inexperienced, not stupid. I was also pointing out that I would much rather be safe than sorry with this particular patient. ~MBC

Side note from the BLS provider: Where I am, the protocol this patient would fall under would be "Non-traumatic CP", where technically by protocol I am required to give ASA to someone who's been coughing for 3 weeks straight and has worsening CP on inspiration/expiration and the lung sounds like you're listening to a puddle of cowpies, or to the guy who has acid reflux who calls at least twice a week for chest pain. My protocol states "Chest Pain", not "Cardiac-related CP". Why on EARTH would I NOT give ASA to this pt unless s/he meets the ABCD's of ASA contraindications? By my book, ASA, ask for medics, if he has a hx of angina and a sys. BP > 120 (and his own nitro with the 6 rights) an NTG, note to the nearest (hopefully a STEMI center, but then I can't do an EKG as a BLS here) and hope for the best.... If the new heart already has ONE MI, why can't it have another? Then again if everything around it indicates epigastric pain.... my tx still doesn't change. And I'm sure as hell ruling out MI. ~MBC

*feels all welcome and loved*

Back when I worked transport, "Asleepius" used to be me in the back... The company I used to work for used to be really nothing more than a medicaid taxi. I guess the distinction always felt like a line between, when am I truly providing patient care, versus when am I simply another mode of transport when no other option is viable? I would never, ever have taken a tip from a patient or a family member of a patient who was not stable, since I considered that to be working as a medical professional (an EMT). When it was the good ol' dialysis shuffle, though, the ambulette drivers not only got better pay than I did, they got better benefits and did less work. So tips weren't such a sin on the transport jobs, in my opinion. But now that I'm 911? Forget about it. I would tell the person to make a donation to a worthwhile charity in the name of my service and my unit, and write a nice letter to my boss saying how good of a job I did. I'd rather see it buy that than a giant caramel iced latte. Well...... maybe..... *whimpers, looks for her neighborhood dunkin donuts* Side note: "Why is it that it's a penny for your thoughts, but you have to put your two cents in? Someone's making a penny and it isn't me." -- Stephen Wright

*doffs her cap* I thank you for the compliment, Ruff. I try to be productive, thoughtful and constructive in my posts. Just my two bits (prices went up due to inflation and the rising cost of brain food).

Y'know, reading that blog made me think of two things. First of all, it makes me feel ashamed of the fact that I can be cold, clinical on a scene when I have to be. I know it's a survival mechanism, but sometimes having that mechanism in place wrenches at me later. Perfect example. I worked up a 5 year old cardiac arrest a couple weeks ago. My first peds arrest (relatively new tech; 1 yr txp, only a few months in 911). And the worst feeling I walked away from the call with was, "Aww s--- I got peds puke on my arm." I had four different people (a dispatcher, a supervisor and my station supervisor) ask me if I needed to talk to a counselor. I told them no, I just need to wash my arm and get something to eat, and I had a mash bowl right after. Later, though, it bothered me that "I'm hungry" and "Eww." were my primary thoughts. The other thing that Spenac brought up (In most cities you can just dump it on the ER, to paraphrase) really, really makes me want to get that medic certification. I've asked some of the medics that I work with, how do you deal with not having anyone else to call when a job goes bad? One of them, one of the guys I really like and look up to, said, "I deal with it by knowing my protocols and knowing that I do my skills correctly." In other words, he knows he's just human, but he does what he can and what he's allowed to do. I don't like feeling like making it the medics' problem or the ER's problem. I want to take that kind of responsibility, so that I KNOW that my patient is getting the best care I or anyone in my service can provide. Thanks for posting that link. It's touching.

Lobster sticks to madness!

According to Merriam-Webster's Medical Dictionary, Infectious is defined as: 1 : capable of causing infection <a carrier remains infectious without exhibiting signs of disease> <viruses and other infectious agents> 2 : communicable by invasion of the body of a susceptible organism <all contagious diseases are also infectious, but it does not follow that all infectious diseases are contagious —W. A. Hagan> —compare CONTAGIOUS 1 —in·fec·tious·ly adverb —in·fec·tious·ness noun Contagious is defined as: 1 : communicable by contact <tuberculosis in the contagious stage> —compare INFECTIOUS 2 2 : bearing contagion <many persons … are contagious long before they are aware of the presence of their disease —Journal of the American Medical Association> 3 : used for contagious diseases <a contagious ward> —con·ta·gious·ly adverb —con·ta·gious·ness noun Hopefully no one will criticize me for not having any posts on this BB in the past. I've spent a good while today reading every post in this thread, carefully considering its viewpoints, and have come up with the following as my personal musings on the topic. -How many documented cases have there been of healthcare workers exposing their patients to blood-borne pathogens? I've searched; perhaps my google-fu is lacking, but I haven't found any hard data on this. Even if there were, say, 10,000 documented cases of this (which I personally doubt), how many patient contacts have been made? Between the EMTs, the paramedics, the RNs, the CNAs, the MDs, dentists, surgeons, PAs, and any other acronyms you can name making contact with any given patient, the risk of any given healthcare provider exposing a patient to the HCWs blood is infinitesimal. -Even if this WERE to occur, which (as Dwayne so elegantly pointed out) is highly unlikely, what would prevent the patient from following the same exact procedures that all of us do when exposed blood-to-blood with ANY patient, positive for whatever H-V disease or not? Ask (or get a court order) for the HCW's blood to be drawn and tested, take baseline bloodwork for the patient, and offer the patient ARV medications once the risks have been fully explained to them? Early ARV treatment of persons known to come into contact (even blood-to-blood) with HIV has been proven to drastically reduce rates of seroconversion. Who considers this to be any less of an option for our patients than it is for ourselves? "I would suppose a better question to ask is how do you determine when a HCW is too high of an infection risk?" THIS is the real question, and I'm afraid I forget who raised it (Sorry!) My theory is, anyone who is contagious with an airborne disease should be restricted from patient care until they are no longer contagious (this includes those who are TB+, the flu, the common cold, or anything else), but anything that requires extraordinary measures (i.e. blood contact) should not be restricted at all. The point that an infectious (NOT contagious) person with any kind of chronic ailment should be restricted should be the point at which they are no longer able to perform patient care (due to disease process, medication side effects, whatever). It seems that some are worried about one of us being the next Typhoid Mary of EMS. Personally, I agree with whoever it was (Sorry I can't give credit; it's a loooong thread) who said they would rather be treated by someone with an infectious disease. Personally, I find people who have gone through hardships and come out of it still wanting to help people make the best EMTs and medics.... or at least until we burn out on being nice and finally give up and be pricks like everyone else Just thought-food. These are my opinions. If you don't like them, I have others.