HERBIE1

I think you need to provide more information. What is the number of employees and their level of certification? What are the manning requirements- ie-1 EMTP/1EMTB? Are there contractual issues that mandate work schedules, vacations, time off, comp time, etc. I don't know if a pat formula would be the best idea- maybe I'm wrong.

Based on the abstract, I am inferring that because the patient received the steroids sooner, they did not decompensate as much as if the treatment was administered in the ER, they stabilized quicker, and their rates of admission were less. Intuitively, this makes sense-more aggressive treatment would mean a better outcome for the patient. Although the study excluded COPD'ers and smokers, in my system we have more than enough patients who merely have asthma with no other complicating diseases so I would like to see this implemented here.

To me, this seems like the current trend- more prehospital care vs waiting until the patient arrives in the ER. Because of the inherent intertia of providing most ER care, for example, we can provide analegesics to a patient sooner- vs getting triaged, registered, seen by a nurse, seen by an MD, awaiting orders and administering the pain medication.

On a slight tangent, a few years ago we began using a combination of atrovent and albuterol in COPD patients, knowing that unless we have an extended transport time, the benefits of the atrovent will generally be seen after the patient arrives at the emergency room.

Thus, my question is- is the wave of the future providing treatment that is more beneficial to the patient in the long term vs simply emergency mitigation and stabilization? If so, that means that our scope of practice will rapidly expand whether we like it or not. I have no problem with that, as our roles have been evolving at an exponential rate over recent years anyway.

LMAO

Talk about full circle. Funeral homes are where many ambulance services got their start.

in our protocol, we have specifically 50mg of benadryl IV for Dystonic reactions. It's stated in the general medical protocol. We don't have to request orders from medical control but I call anyway because I want a 2nd opinion even if it's over the phone for the benadryl.

If the shoe fits dystonia, then put the shoe on I always say.

We have no specific guidelines but have given the Benadryl many times in such cases. I simply describe the symptoms and ask for the Benadryl. Works every time.

Luckily, the worst that can happen if it does not work is a sleepy patient.

If the patient has a normal level of alertness, a normal neuro exam, no signs of intoxication, no pain on palpation of the spine, no painful distracting injuries, and no pain with 45 degree lateral movement, flexion, or extension of the head, then no spinal injury exists. This is well supported in the evidence based literature.

The spine is a bag of bones, and it hurts when it gets fractured. I don't put every patient with a MOI in bilateral traction splints, and I don't put every patient with a MOI on a LSB.

Be a professional. Learn your job. Do it well.

Or, find something else to do.

Tom

Either you work in a progressive system that allows you to make that determination, or you are playing with fire. I'm thinking the former. The skills needed to clinically clear a C-spine aren't difficult to learn, but then again, we work under someone else's license so if we make a mistake, they will need to answer for it as well as the provider.

I've been a member here for years, lurked occasionally, but never posted until recently. I am impressed by the breadth of talent, the far flung locations people hail from, and the range of education, ages, and provider levels. We have everything from volunteers to MD's here and everyone brings something different and valuable to the table.

I like the idea of getting unique perspectives on problems many of us face. I think too often we get wrapped up in our own little worlds and fail to see the commonalities of what we do. Are there differences in how we operate, how we provide care, and the trials we face- absolutely, but it seems most here are generally fixed on helping each other and the people we respond to for care.

Here's a hearty golf clap for the site admins and all those who make this place happen.

im asking because im turning 17 in 20 days

Again-if you are a student, ask your instructor or preceptor. If not, check with your state regulatory agency- Department of Public Health?

As anyone who works in a ghetto can attest, there are similar examples of stellar parenting everywhere you look. 2AM in the ghetto looks like high noon in downtown Manhattan- toddlers just hanging out while their parents party their arses off.

We call it GST(Ghetto Standard Time)- Ghost towns until at least noon.

can it be possible? im asking because im 16 and im a EMT-B student but i heard that you can somehow take the state exam at the age of 17 is this true? btw i live in florida

At your next class, ask your instructor.

I don't think you need an EKG to "prove" death. It is an MCI, multiple patients, the last thing I'm thinking about dragging around the highway is the LP-12. Its pretty simple. If he isn't breathing, even after you open his airway, he is dead. If you get more resources on scene, sending someone to double check probably isn't a bad idea, I really don't see where EKG evidence has any role in a multi patient trauma senario. Its likely that the patient in question WAS breathing, it just went unoticed. I suppose a monitor might have revealed a rhythm that might have prompted the provider to take a closer look, but honestly, this is a training/education issue, not something that should require a piece of technology to decide, IMHO.

Unless it's an obvious DOA-decomposition, decapitation, lividity/rigor, etc, our protocol says you must use a monitor to confirm DOA. As for multiple victims in a trauma situation, then obviously impending death is treated as a black. Clearly, if you are the only crew on scene, and the next available units are nowhere close, then 2 critical patients could overwhelm your resources. Point is, everyone's situation is different, and your actions depend on your specific resources. I am in a high volume urban area with plenty of resources available in all but the largest incidents, and I have never left a "nearly dead" patient(ie agonal resps) without attempting treatment. Futile most of the time- yes, but that is our protocol. If they show signs of life, they are worked.

Obviously, in a trauma scenario, a cardiac rythm is not the first thing you worry about, but if you want to confirm DOA, that is the only way to prevent pronouncing someone who is not yet deceased.

Do I hook up every traumatic arrest? Only if I am working them up and transporting.

Not yet but we do a good number of mobile ECMO patients being transported by at least 5 facilities in the U.S.

Also, don't forget that VADs may be seen in children as much if not more than adults especially if there is a large children's hospital that has a cardiac program near you.

Many patients that have congenital heart anomalies are now adults and their meds, history, BPs, SpO2, and ECGs may look a little different than what you would expect to see from the "norms" in a Paramedic text.

I can understand all the portable devices, but I am still amazed at the complicated devices- like the VAD- that are used at home now.

Good point about the presentation of a seemingly "normal" patient. Thanks to modern medicine, kids routinely survive conditions that would have been fatal just a few years ago. A child could easily present with a bundle branch block or other abnormality usually seen in older folks.

To the point of not adequately assessing someone...

I've almost been fooled by patients who I thought were dead- especially those at crime scenes. We had a drug deal/ robbery gone bad where victim #1 was on his hands and knees, bound- hands and feet- and had his neck sliced from ear to ear, getting each carotid in the process. Messy.

We confirmed he was DOA, (pulse, auscultation, and EKG) and then found another victim- a female with the same injury, only she was sitting up, propped against a door. She also had that ghastly shade of pale/grey that means she probably lost most of her blood volume. As I approached to check her carotid, she opened her eyes, picked up her head, and attempted to speak. We had a nice anatomy lesson as we could see all the internal structures of her anterior neck. I nearly had an MI myself and think I wet myself a little. After working her, the best we could get was a 60 systolic BP after nearly 3 liters of LR(before we were using .9% saline). She made it to surgery but I read in the paper that she died in the OR.

Point is, it takes no time to confirm the DOA with a monitor. I also find that in all but the most obvious cases of severe decomposition, placing the leads on someone and showing the family Asystole, I think it demystifies and confirms your claim that there is nothing you can do for the person, and helps the family start their grieving process. Most people know that "flatline" is NOT a good thing. Also, it keeps "mistakes" like missing a bradycardic rate- from occurring.

This study was done in 2008 by the Mayo clinic and published this year:

http://www.pubmedcentral.nih.gov/articlere...i?artid=2672978

This is the conclusion of this study:

This spinal immobilization guideline demonstrates efficacy in identifying those at risk for spinal fractures. The guideline accurately identified all cervical fractures found in this study. The use of an age-extreme criterion may enhance this already effective guideline. Further analysis of compliance failures may add to the guideline's ability to predict fractures.More than 20% (9/42) of patients who had spinal fractures found in this study had indications for immobilization, but it was not performed by ambulance staff. Continual training and regular case review with quality assurance programs should frequently evaluate spinal clearance guidelines. Quality assurance, patient follow-up, and audit systems may improve compliance. It is imperative that ambulance systems monitor and continually review this guideline and train for its application.

This is another study, published in the Journal of Trauma, Injury, Infection, and Critical Care in 2005...

I have the full study, but no longer have online access to the complete article. Sorry, but my scanner is down or I would scan this article for you guys This is a citation for the study and abstract:

BACKGROUND: To evaluate the practices and outcomes associated with a statewide, emergency medical services (EMS) protocol for trauma patient spine assessment and selective patient immobilization. METHODS: An EMS spine assessment protocol was instituted on July 1, 2002 for all EMS providers in the state of Maine. Spine immobilization decisions were prospectively collected with EMS encounter data. Prehospital patient data were linked to a statewide hospital database that included all patients treated for spine fracture during the 12-month period following the spine assessment protocol implementation. Incidence of spine fractures among EMS-assessed trauma patients and the correlation between EMS spine immobilization decisions and the presence of spine fractures-stable and unstable-were the primary investigational outcomes. RESULTS: There were 207,545 EMS encounters during the study period, including 31,885 transports to an emergency department for acute trauma-related illness. For this cohort, there were 12,988 (41%) patients transported with EMS spine immobilization. Linkage of EMS and hospital data revealed 154 acute spine fracture patients; 20 (13.0%) transported without EMS-reported spine immobilization interventions. This nonimmobilized group included 19 stable spine fractures and one unstable thoracic spine injury. The protocol sensitivity for immobilization of any acute spine fracture was 87.0% (95% confidence interval [CI], 81.7-92.3) with a negative predictive value of 99.9% (95% CI, 99.8-100). CONCLUSIONS: The use of this statewide EMS spine assessment protocol resulted in one nonimmobilized, unstable spine fracture patient in approximately 32,000 trauma encounters. Presence of the protocol affected a decision not to immobilize greater than half of all EMS-assessed trauma patients. Burton JH, Dunn MG, Harmon NR, Hermanson TA, and Bradshaw JR The Journal of trauma 61(1):161-7, 2006 Jul - Who cited this? | PubMed ID: 16832265 | Fulltext

This is the final paragraph of the discussion, from the full study:

In summary, the use of prehospital EMS spine assessment protocol affected a decision not to immobilize greater than half of all trauma patients in this predominantly rural state. The presence and accuracy of this EMS protocol did not appear to place trauma patients at substantial risk of adverse neurological outcome as a direct consequence of the selective patient spine immobilization decision.

Thus, it seems the selective use of full C-spine precautions is a safe and valid idea -as long as proper protocols and training are provided.

To me, and to any provider that's been doing this for awhile, I think we know when there is a potential for a serious spinal injury based on MOI, exam, or PMH. I can count exactly ONE patient in 30 years who had a C-spine injury that I did not suspect based on his exam or MOI. It was a 60ish man who tripped and fell, sustaining a small head lac. He was ambulatory, with no other complaints or injuries. He simply wanted a bandaid and to go home. For some reason, I chose to fully immobilize this guy(listen to that inner voice, folks)-much to the amazement of my partner and a nurse bystander- and delivered him to the closest ER (BLS)- which happened to be a Level 1 Trauma center. Later that day, the attending trauma surgeon(who I know very well) pulled me over to an Xray viewing box to see something. Of course, being paranoid, I wondered what we had done wrong. LOL

She showed me a nasty looking dislocation/fx of C2-C3 I think- and said it was from my little old man. After I picked up my jaw from the floor, I asked how he was doing. No deficits, he would probably get a halo and would be fine. She gave us an "atta boy" and asked why we had initially immobilized him, based on his MOI and exam. I said I honestly did not know, but am certainly glad we did.

Bottom line- I think we can all agree that a complaint of neck pain after being rear ended at 5MPH should not mandate a full immobilization, and we are finally seeing data to back that up. Experience, education and training(along with a solid protocol) and applying that to patient care is what this business is all about.

We were just notified of someone in our area who has a VAD, and that they should have trained personnel with them at all times who are aware of it's function. It's a private residence, and it seems they are in pretty fragile health, so we may need to deal with them. We received brief instructions as to where we should defib PRN, the fact that we will feel no peripheral pulses with the device, etc, but a few of us are requesting more info on this.

I don't know how common these devices will become- at least in the prehospital setting- but I am truly amazed at the technology/equipment that used to be reserved for ICU's is being used at home. Internal defibrillators, PIC lines, home dialysis machines- just a few years ago we would have never seen these things in the field.

What's next- a home heart/lung bypass machine?

Would you work this code???

Yes [ 27 ] [75.00%]

No [ 9 ] [25.00%]

Best look again ...

When you say respondents, those that agree with the "Work the Code" through vote vs the others that attempt to rationalize while they would not and a further point VFib and PEA were introduced after the initial post .. its a EMTCITY rule if a thread is posted then it will go of topic .

cheers

Oops- damn typo. My bad...

I realize that most threads get derailed- and the longer they progress, the more off track they get. My point was that yes, after some qualifiers, that despite all the rhetoric to the contrary, most people WOULD work that patient.

How many EMS services require annual physical checks-ups for their staff? All of Saskatchewan does.

We are starting a wellness initiative here- but it is only voluntary. Blood work, "heart scans", physicals, etc. It's a good thing- a good number of people have been found to have significant heart disease, HTN, or other illnesses and if it wasn't for these check ups, they might not have lived to collect their pensions.

Ours does too Kat. Physicals, cholesterol check, BGL checked, ECG, BP etc. My employer will work with us through the hospital to correct any problems or potential problems. That being said, I have yet to see anyone be dismissed over this. However, there is a time frame in place to reach a certain weight, cholesterol level etc. I'm not exactly sure what it is, but I do know it is enough time to reach one's goal.

I'm 48 y/o and can do this job as well as or better than some of the younger medics. The difference is, I'm not all full of piss and vinegar. I take the time to assess the situation and treat accordingly. I'm positive some of our younger staff get wood when the tones go off! I'd rather have a partner who has some life experiences than someone who thinks they do.

I agree with you, and I'm the same age as you are.

I like the energy of new guys and sometimes it helped me when I would be dragging, but that energy does need to be focused and channeled. That's the job of a veteran partner.

Now, I have a veteran partner, but we are of the same mind- we don't get riled up, BS is BS, but if you are sick, we do everything humanly possible to help you.

What I find humorous is that despite all the rancor and vitriol, according to the poll in this thread, 75% of respondents would NOT work this arrest. Methinks some folks argue just for the sake of arguing...

Please lets not resort to name calling.

Kat has some very good points there see its not only the OLD that die its the young too. So were they too OLD for EMS? IF 23 is old then heck I must be preJesus or something. Like I said before as long as they can do the job I have no problem with it. But we are beating a dead horse once again.

I stand by my earlier posts, and although most of those obits don't mention a cause of death, it merely supports my argument. This is a very demanding profession that takes a physical and psychological toll on people. Lifestyle choices, repetitive motion injuries, stress, odd hours, sleep deprivation, adrenaline ebbs and surges- it all takes a toll. As for younger people who suddenly pass away, we all know when your number is up- that's it- BUT in my department, I know of many people in their 40's who have had angioplasties, stents, and even a few with full blown bypass surgeries. That is NOT normal for this age group.

I am willing to bet that once some comprehensive, multigenerational studies are done(we need enough data for a valid study and we're still pretty young), it will be shown that the life spans of EMS providers are significantly shorter than that of the general population.

There's also a difference between being able to do something and whether or not someone should.

However, because of some Paramedics lacking the ability to intubate or not knowing when to stop trying and use an alternative airway or just bag, we are seeing many more swollen and bloodied airways that require the big tools to come out of the closet such as the fiber optic scopes to assist with intubation in the ED. We have definitiely seen a great increase in traumatized airways over the past 5 years. Combi-Tubes have also been part of the problem as some are just not mindful of what they are doing when the ram a tube that large into the throat and inflate cuffs that can do some serious damage if in the wrong place. There is now several pieces of literature being published on this new traumatic trend. Thus, some EDs have beefed up their intubation tools. Many of these patients may require traching if the throat does not heal in 7 - 10 days or if the ETT will further irritate a throat and cords already damaged.

So it is no picnic for those of us in the ED when these botched airways come in. It definitely is not much fun for the patient who may have to adjust to a trach tube for awhile or learn a different way of communicating. The lack of education and proper training of prehospital personnel has a profound affect on the healing process if there are complications of a traumatized airway and aspiration as well as the initial complaint.

Good points. There is no shame in admitting you can't get a tube. Even ER docs occasionally ask for help from an anesthesiologist for a tough tube. Everyone has a bad day-and just like an IV- you can always ask your partner to try if you really need that tube.

If I was having a bad IV day- blowing IV's that seemed easy- I'd call them "tape tearing days"- when all you are good for is tearing tape to secure the IV for your partner. It happens- we're all human.

Proper bagging can be just as effective in oxygenating a person. Don't destroy the person's airway and make it tougher on the ER staff.

The patient is dead. I would not have worked the code but I would not fault someone who did unless they let another patient die while using resources on him.

I also am making that decision with 18 years experience.

It's all about your local protocols. If you don't work someone, you had better be darn sure they meet your standards for a DOA and you document your arse off. In my system, agonal breathing is still technically alive- even with some grey matter protruding. Wrong- maybe, but I don't write the policies.

Obviously agonal respirations are not a good sign and generally not compatible with life, but you also need to know their cause. Is this personal terminally ill with cancer, or do they have a potentially "fixable" problem? Is it an airway issue we can treat, or is it because their brain is herniating? It's not up to us to make calls like that unless, as you say, it's a multivictim triage situation. If you are presented with several critical patients and not enough resources, and one is agonally breathing, yes, that person is a black.

Definitly not for a life threatening injury or illness, don't recall what it was but the guy was pissed.

Nothing like the blood and vomit to darken the way. What I hate is there are now Paramedic programs that are not even requiring intubation of anything but a dummy. At least OR patients are alive even if clean so it is more like what we deal with in the field.

It's funny, when the airway/pharynx is clear- no emesis, no funky anatomy, no dinner, blood, or teeth- it almost seems wrong, doesn't it? LOL

An intubation dummy is fine to demonstrate the steps in a simulation or a skills assessment- proper positioning of patient's head, cricoid pressure, oxygenate, bag, etc, but to not be able to intubate a real patient- to me, that's asking for trouble. It's too important of a skill not to be as prepared as possible.

Yup maybe we should start doing that in the field. Sorry buddy I can't protect your airway because you ate today.

When doing intubation's at the hospital they actually canceled a surgery because the person chewed a little tobacco that morning, said the juices could have entered his belly and be a possible aspiration threat prior to intubation. They should be with me in the field where we remove the tobacco from the patient just so we can try and see the landmarks to intubate. Doctors are so spoiled.

Cancelled a surgery because of tobacco juice?? Obviously that was an elective surgery, but still...

I'll never forget my first intubation, right out of school. I kept thinking- hey, this doesn't look anything like those patients in the OR!

HERBIE1

You some make excellent points ( theoretically) is this truly a young persons profession or a just a requirement of fitness, oh and count me in when trucks start using 3 persons as a standard crew with powered cots.

Sweet!

BUT realistically there are just so many educational or administrative jobs out in the real world and who is to assume that because one is an proven knowledgeable experience field medic that they would automatically be a good instructor ?

Point further in educating adults/ Paramedics (since you raise the question) one should not require education regarding teaching the theory level alone ie A+P, Cardiology, Respiratory doing lesson planning +++ , heck it takes 4 years and a BA to teach grade one where I live, why do the rules of education change for Paramedics?

Education of Paramedic by other Paramedics I believe is folly on many levels, we must include all health care professionals trained as educators as this could give us a stronger professional back ... so to speak.

Honestly in my Clinical s alone OBS/GYN RNs were the experts that trained me for Maternity (thank god, they would deliver more in a week than most Paramedics see in there entire career) spending 2 days in DI with a Radiologist (well that did not hurt either, even though she had never even sat in a gut wagon) attending lectures in infectious disease control by MDs on MRSA, well I think you may see where I am going with this point.

cheers

Agreed on the education issue. I wasn't necessarily referring to teaching an EMT or paramedic class, but also in-service/inhouse training, or orientation for new hires. Yes, not everyone can teach, and people SHOULD have teaching credentials- although some are natural teachers.

I also agree that there are a limited number of administrative spots too, but there are also other options- field supervisors, PR people for community outreach- we're a creative group, we can figure out something to use the talents of the "experienced" folks. A good, experienced preceptor impacts one student at a time. If you can use that person to impart knowledge to whole groups of people, isn't that a better use of such a valauble resource?

As for our initial training- well we know this is an age old problem. My paramedic program was taught by 2 RN's who had never worked prehospital, but at the time, there were NO paramedics teaching paramedics around here. Like you said- ideally we should learn from the experts in a particular area- would you want to be taught how to intubate by a podiatrist?

Just to make it more difficult for you I'll throw in my 2 cents. If you want to go to medical school, do not worry about becoming a paramedic. Focus on your premed studies and get the best grades you can. Study hard for your MCATs. Get experience as an EMT while you are an undergrad (it probably won't help your application but it does give you something to talk about during your interviews and also gets you accustomed to dealing with pts and emergencies) and get involved in research. It will take longer than the other routes but you will have a mansion in Beverly Hills, several Lamborghinis, a yacht in the south Pacific and all the super models you can handle (sure beats California EMS).

Interesting comment about going to med school, doc. My wife is in administration at a local University and part of her job is advising preprofessionals looking at med school, pharm school, and dental school. She asked me some time ago about people who thought becoming an EMT or paramedic would help them to get into medical school. I told her the same thing you said- if your heart is already set on med school, go for it and forget EMS. The only caveat I made was to advise the youngest ones(still in high school) who were not sure about their career path to consider prehospital care to get their feet wet in the business. I suggested taking an EMT course as an elective(if offered) while you take the usual premed classes.

I have a buddy who went the undergrad EMT route, and he used to ride along with me all the time. He loved prehospital medicine and EMS. He was always premed and knew he wanted his MD, only worked as an ER tech while in med school(never on the street) and he's now a surgeon, a partner in a physician group, making BIG bucks with 2 homes, a plane, and all the toys he can handle. That route worked well for him. He initially wanted to be a trauma surgeon but decided he wanted a "normal" life.

He still tells a great story about when I taught him how to intubate. He says he now much prefers to have someone else intubate- when they are paralyzed, dry, and an empty belly. LOL

My point is that this is a young person's profession. If you are seeing any significant call volume, it takes a toll. Yes, one man stretchers are a God-send, but there is still a very large portion of the job that IS physically demanding. Obviously, there are exceptions to every rule and some 20 somethings can't perform physically, but let's look at the odds. An average 25 year old vs an average 70 year old- who will be in better shape?

Could a 70 year old do basic transfers, in a controlled setting- I see no reason why not. Problem is, unless you are able to decide which calls a crew responds to(interesting wrinkle, I must say) you normally don't get to choose your situations or types of patients.

It's not just about the person, it's about the patient and the person's partner. I've worked with many women(and yes, a couple men) who simply could not lift, and have hurt myself compensating for their lack of strength. It's nobody's fault, women simply don't have the upper body strength and that is what a significant portion of our job demands.

I said it before- when someone reaches the age of 60 or 70, if they are still interested in EMS, I think their talents and experience would be more valuable as an instructor, a trainer, or mentor vs a field provider. Give back to the profession and utilize the experience they have to instruct new hires. I don't know about other places, but too many of our upper level administrators have had limited or no street experience. How can you effectively formulate and dictate policy when you are so far removed from the field?

Let the people who have put in their time TEACH, give back to the profession, and mentor the next generation. We NEED good people to carry the torch and lead us forward from here. They can provide valuable insight, knowledge, and skills to those who are just starting out. I'm all for education, but what good is someone with a bunch of letters after their name if they have no practical experience to base their teaching on?

You need both.

Depends on the software, I think. I use the narrative section to fill in details that aren't covered by the available options on the software pull down menus, and include any other pertinent scene info. No need to repeat things that are already included in the standard options- just fill in the missing data.

Ask to see the reports of others and you eventually will develop your own style, based on an amalgam of everyone else.