HERBIE1

Sorry guys, but they have the funding and the resources to put out propaganda like this; we do not. I wouldn't be too concerned yet- there are still too many variations on prehospital care for them to claim that Fire based EMS is the only way to go. Money is the number one concern- especially in smaller communities- and converting FSR to a cross trained system is still cost prohibitive for many places. 3rd service providers work well in some areas, while they have failed miserably in others. Lots of reasons- politics, patient and population demographics, size and lay out of the city- we all know the variables. In some places, I know that their fire based EMS system is progressive and top notch. In many others, it is sorely lacking. Point being, like it or not, the more tools(certifications/qualifications/education you have as a provider, the better off you- and the citizens- will be. You become far more valuable to the people you provide service to, and more of an asset to your employer and municipality. These days, everyone is being required to do more with less- from public safety to running your local bakery. In a perfect world, EMS would be pure EMS, and fire would put out fires. It doesn't work that way anymore.

Unless you are talking about medical arrests, I disagree. Screwing around with a soon to be or already down traumatic arrest is futile. Address the basics, correct what you can immediately, and do the rest enroute. Trauma patients need an OR, not prehospital care. Obviously it also depends on transport times, but in general, there is no reason to delay transport on a trauma patient. Stay and play is for medical calls. Good point about organ donations- if you can keep someone viable for that, it is well worth any effort you make.

Obviously nursing home staff must abide by their own rules and regulations. Many times, the majority of care is provided by CNA's and LPN's- NOT registered nurses. As such, many do not have the knowledge to make any decisions on their own. Yes, the doctor is the one who has the ultimate say so, but it is up to administrators to work with their staff and docs to come up with policies that work for everyone. The health care system is broken in so many ways it's difficult to know where to start. Private docs use ER's as their own personal labs and to screen their patients. They send people for routine tests vs to an outpatient clinic because they get the results immediately. It used to be many docs would see a patient in their office and if they require admission, set up a bed and the person would undergo the needed workups while an inpatient. Now, they want to limit hospital admissions so the sooner they get someone discharged, the better. Go to the ER, get a stat EKG, a couple Xrays, a CT, and bloodwork and the patient does not need an extended stay. ER's OR's, and ICU's get priority on all tests and procedures while inpatients must wait- they are considered "routine" labs. Same with nursing homes- bloodwork drawn at a nursing home may take several days to get back and any treatment needed gets delayed. Much easier to send the patient to an ER, get the requisite tests and begin treatment right away. I agree, you can't blame the nursing home staff for following protocols, but you can and should blame them for incompetence.

In the case of a homicide, for example, if we confirm triple 0, the police can declare a crime scene and it becomes a medical examiner's case. We simply document our findings and call it in. Other than applying the EKG leads, no other treatment is rendered so as to preserve the crime scene evidence. For other trauma, the patient must meet the obvious DOA criteria - massive head injuries, copious grey matter, decapitation- (obviously), a suicide jumper from height with associated massive injuries, etc. Anything else- they get transported. I do know in some systems, if a person is a traumatic arrest and asystolic, they are NOT transported. The survival rate of such patients is essentially zero, so wisely, many systems opt to save the cost of a transport and protracted resuscitation attempt at the hospital. In the case of traumas, I have never terminated a resuscitation once started since if they are viable enough to work them, then what they need is a surgeon, not a paramedic anyway. We also have no such protocol to terminate a trauma resuscitation and don't suspect we ever will.

This is SOP for most nursing homes. How many times have you been called for a cardiac arrest and the staff insists the patient "just stopped breathing" when it fact they have rigor and dependent lividity. I recall one time when the staff was doing CPR to beat the band as we arrived. Sadly, this poor lady was so stiff her entire body rocked like a see-saw with each compression. The person had been down so long you could move their entire body by a finger. They will give you a set of vitals that aren't even close to being accurate. The problem is, unless it is an ultra fancy facility, the folks who work there generally aren't the cream of the crop in the health care field. Obviously things change if this is a contract account and you are their private provider. You would need to tread lightly and let your management handle your beefs. Bosses don't take kindly to an employee losing an account because they bitched at the NH staff. In the case of 911, we always have to respond- even if the case turns out to be total BS or a chronic problem. Is is abuse of the system- of course, but when staff at these places turns over almost daily, "education" is almost always a waste of time. Years ago when I was in management on the privates, part of my job was providing CPR training for all our nursing home accounts- that was quite an adventure. While I was there, I also took the opportunity to explain about proper use of EMS resources- ie use a medicar when possible, request the proper type of unit, the importance of accurate info, etc. Trust me, with some of these places, much of the staff couldn't spell CPR, much less perform it effectively. I was more than happy to work extra with anyone who wanted help but few took me up on that and I certainly was not overly strict with my expectations. As a result, I failed a few of these people and the administration complained to the owners of my company. I was essentially told to pass these folks no matter what because their CPR card was a job requirement. I refused, they got someone else to provide the training and suddenly everyone passed. Soon after I resigned my position in management for these- and other reasons. Point is, realistically, there is probably not much you can do about this abuse issue.

Along the lines of the equipment failure thread, I was thinking... What pieces of equipment have you forgotten either on scene, or at an ER? Stretcher- a couple times left at an ER. (Had a cardiac arrest as the next call, needed to break out the mass casualty litter for transport for one, called for backup on another) There is nothing like the feeling when you open those back doors and see a very large empty space where your stretcher is supposed to be. First response bag- several times. (Luckily we have multiple meds backups but no extra larygoscopes. In one case, it wasn't forgotten, but stolen when our backs were turned. IN another, a bystander driving by, in an alley, who was far too close to us, gawking, rolled over the bag with his car, destroying the entire contents of the bag) Stair chair- many times Those were the biggies..

Congrats on your first tube! If you are in a low volume area or somewhere where you don't get the acuity you need, opportunities for intubations may be few and far between. It's like any skill- practice makes perfect. Just like anything in EMS- no 2 cases are the same. Funky anatomy, emesis, blood, teeth, short/fat necks, swelling, spasms, wrong sized tube, foreign bodies- you never know what to expect, so expect the worst and be happy if it's not complicated. If you are lucky enough to have RSI protocol- we don't-it sure makes things easier. You also need to forget the ego thing and know your limitations- even ER docs need to call an anesthesiologist sometimes, but we don't have that luxury. A doc would also much rather hear you opted to simply give good ventilations with an amb bag and an oral airway vs screwing around with a tough tube. Of all the true saves(survived to discharge with few or no deficts) from full arrests I can recall, many were achieved without ever intubating the patient. As long as this person is being adequately ventilated and the airway is protected, the manner which you achieve the results is irrelevant. Many times, I've had a bad trauma, or a complicated medical arrest, you are so busy doing other things- radio report, medications, analysis of a rythm, decompression- that the intubation waits, as long as the person is being properly oxygenated. Obviously, the amount of help you have is also key here. As for trauma, like was mentioned above- throw and go- and do whatever you can enroute to the trauma center, the clock is ticking. These patients need a surgeon if they are to have any chance at survival. As you will see, there is no set "right way". Each situation is different- scene safety, lighting, puddles of water, mud, cockroaches and rats running around- obviously the back of the rig is the preferred location. Experience- and until you have that- a seasoned partner- will tell you what's your best option. Again- congrats- you never forget your "first time". LOL

Take home message: You will have to go beyond your EMT book to adequately understand "hyperventilation". Exactly true. When asking questions like this, you need to consider the target audience. Like many times, someone who may have a more in depth knowledge of a subject could read into a question and challenge many answers. Just as if you have someone with CO poisoning, if you simply look at their pulse oximetry values, they may say the patient is saturating at 100% when they are actually severely hypoxemic. In other words, like many things in medicine, very few things are black and white. Point being, instructors need to vett their questions thoroughly to avoid potentially ambiguous answers.

I'm not sure why they are so vague on the concept of a "minor" in their system. I've had minors sign refusals with the direction and approval of the base station. (A/oxs3, understand risks, consequences, no drugs, alcohol, head injury, etc.) It's rare but it does happen. It does not say whether or not he contacted medical control. As for us- 17 is still a minor. In this case, I would suggest this patient might have been dealing with rhabdomyolosis. Very serious issue that can cause renal and liver failure, shock and death. Probably impossible to distinguish between this and simple heat exhaustion in the early stages. If this happened to an adult and not a minor, we wouldn't be having this discussion- they can legally refuse.

That's the way I'm leaning. Picnic in the park, spring day, probably recently treated by pesticides/fertilizers, etc. I'd also begin to worry about possible decon here-did they accumulate the poison by touch, contact or ingestion, etc. Watch for S/S of possible organo-phosphate poisoning.

That would be a neat trick, considering my oldest will be 22 this year.

All well and goof, but... I still don't think the owners of Google or the vast majority of their employees- are applying for food stamps any time soon.

Welcome from another rookie- at least in this forum. Wow- haven't referred to myself like that in over 25 years. Getting old...

I will echo the comment that this is NOT a job related problem, it's a relationship issue. If someone has issues about working with the opposite sex, they probably also go ballistic every time their spouse isn't within 5 feet of them or every time they leave the house. Trust.

There needs to be an assigned safety officer responsible for ensuring compliance with rules and regs. PPE used, proper equipment brought to patient, proper safety precautions practiced. There also needs to be a discplinary procedure in place for people who refuse to abide by the rules with appropriate consequences. People who enforce rules are not the most popular members, but they serve a vital role- keeping us safe and ensuring we go home to our families every day.

Careful there. Where will something like that stop? Do we also need to take all pregnant teens to a family planning center? How about taking truants back to school? I guess it depends on your area but there are usually more than enough social service agencies, and most ER's also provide alcoholics and/or drug addicts with referrals upon their discharge. We also need to distinguish between rehab and detox- not necessarily the same thing. I agree that in most cases, all an alcoholic needs is to sober up and maybe get a meal, not take up space in an EMERGENCY room. Again- this is a liability issue. No system would want the responsibility for taking an alcoholic to a rehab/detox center if they found out later about an underlying, unaddressed, and serious medical problem that needed treatment. The drunk tank idea- a medically supervised facility- could work if there was an agreement with the provider. It would certainly take some of the stress off the ER's.

I think that taking the National registry is a personal choice. For some it could be beneficial to their career, for others it will make no difference. Maybe it's a personal challenge, or simply for personal development.

First, good luck with Mom- it's tough. Been through it myself. I'm an urban medic but Ill throw my nickel's worth in anyway. Well, it sounds like you have 2 problems. First, there is a professional issue, where you would like to keep up the volume of ALS calls to keep your skills sharp, but in a less populated/more rural area, that will be a problem. Second, you need to be closer to mom for obvious reasons. If you are confident in your skills, I wouldn't worry about the longer back up time. You simply do the best you can.If you can afford the pay cut, then you do what's best for your mom- that's the bottom line. Family first.

Tom- I would also consider what your future goals are in this field, how old are you, do you have a family to support, etc. Do you aspire to a higher position- management, teaching, training, etc, or will you be happy as a field provider? It would never hurt to challenge yourself and go for the NR, but you need to have a plan. What can being nationally registered do for you? If you want to move on/up, maybe a better use of your time and money would be a public safety/ management/leadership degree? Most of us don't have unlimited time and/or resources, so you need to prioritize your goals and decide what you need to do to achieve them. Either way, good luck.

You are right about specialty centers. These days, in order to get the best outcome for your patient, clearly the best option is to take them where they will receive the most appropriate care. The only exception we have is for burn patients. We have a couple burn centers, but a serious burn is not a reason to head to a burn center- especially if there are airway issues. Let the nearest comprehensive ER take them, stabilize the airway- secure the airway with a trach, fasciotomy, central lines for fluid etc, and let them transfer the patient later. Want to scare the crap out of an ER- take them an OB patient- especially high risk if they have no peds or OB facilities. Their lawyers only see potential lawsuits and want no part of them. Like you said, many times these specialty centers get more than they bargained for. When the trauma system was first established, rules regarding what constituted a trauma patient were pretty liberal. As a result, they were flooded because nearly any injury qualified as a "trauma". The system was tweaked and essentially triaged the trauma patients based on mechanism of injury, stability, airway issues, etc but in today's world, there is plenty severe trauma to go around. Then again, just like us, in order to become top notch, they need the practice. LOL

I honestly don't know our UHU stats, but if you are new and want to learn the job, you want volume. No other way around it. In a busy urban system, you can see more in a week than some folks see in an entire career. Obviously, after a certain amount of time in the business, your brain and body tell you it's time to slow down a bit. Ideally you want a situation where you can transfer to a slower spot after you put some time on the job so you can save some sanity and body function. I would also look into the other factors- I know the Phily system has some serious issues you may want to consider. Working conditions, assistance, training, equipment, system policies/procedures, working relationship with other groups and the city, benefits, pension/401K issues, job security. Lots of things to consider- Good luck.

Difficult? Maybe, but the bottom line is you have to look at yourself in the mirror every day. I've been in that situation several times- not with millions, but certainly tens of thousands of dollars. All involved gangs and drug deals gone bad. One, the victim had pockets full of cash which we discovered in the back of the rig, when no witnesses were around besides my partner. These days, the paranoid cynic that I am- I assumed it had to be a set up- too easy to take the money without anyone knowing. We joked about a nice vacation, a new car, etc(which alone would arouse suspicion) but we turned it in at the ER and even documented that fact. I had many more instances when I worked at a trauma center, but then again, there were also about 10 people in the trauma suite with me. The thing is, generally the locals(and in the old days, sometimes the cops) will take anything of value long before we show up- guns, money, jewelry, etc so it's not that common to encounter this situation. The guilt I would have later would tear me up, though. Not worth it.

Obviously any company or municipality rules should dictate your actions. Many do have ethics policies- we have mandatory annual ethics training- but a better barometer should be your own personal morals and ethics. If a situation/gift feels weird or awkward, it's probably wrong. Think about that inner voice we use all the time. It's the one that tells us that a seemingly stable patient might be ready to crash, or a seemingly cooperative, calm psych patient is ready to snap. Trust that inner voice- it will get you out of more tough spots than all the training in the world.

Obviously many of the calls that fire, police and EMS respond to do not turn out to be what we would call "emergencies". Problem is, what happens when one of those calls really turns out to be true emergency? Things like priority dispatching are supposed to sort out the nonemergency from the real thing and assign the proper resources to mitigate the problem, but what happens when one slips through the cracks? Who will be left holding the bag? It's NOT the crew responding, but the municipality or company who will be responsible for those responses. This is a huge liability that could easily result in a multimillion dollar judgment, and it makes no sense from a fiscal/management perspective to take that chance. Problem is, because of budget/ personnel/resource limitations, things like priority dispatching are merely a calculated risk and necessary evil. In a perfect world, we would have all the resources we need, people would not give false information when requesting help, budget restrictions would not exist, and pay would be equitable for all for the type of service we deliver.

Of course every system has their own problems. The problem is, because the systems that provide prehospital care varies so much that many of the problems are NOT universal. In some areas, pay is the primary stressor, others deal with a lack of resources and/or funding. and others may have all of these issues and more. Point is, it would be nice to say that every person that provides prehospital care would be fairly compensated for their talents, but that is NOT the case. Fire based EMS vs 3rd service vs municipal contract provider- the quality of care provided is up to the practitioner. I think most people in this business DO appreciate what a great profession this is or they would never endure the various hardships that come with the job. Of course, we always strive to make things better.