fakingpatience

I actually have looked through a patients wallet for information about them before. In this case a middle age guy was found wondering a building where he lived, with his wallet on him. The man was unable to answer any questions, but had nothing physically wrong that we could find with him. During transport to the ED, I looked through his wallet which the pd had given me to try and find any more information about him (some people keep a list of medications in their wallet). In this case, I had nothing else pertinent to do for patient care, so I didn't feel bad spending the time to try and find some more information about him.

Ok, so sounds like I am going to ask fire to take spinal precautions on all patients when extricating them. I'd let them decide who it is safest to extricate first, while telling them I would like the driver of the truck ASAP.

Gonna need both other BLS units, and the ALS back up. So far I see no reason why we have a time out listed for the burn center, none should need to go there above the level 1 trauma center, which is probably where we are gonna be headed.

For the woman in the truck: even if she smells of ETOH, I can't assume her inability to respond properly is due to the ETOH, since she likely has a head injury also. I'd also be concerned about a chest injury on her from the bent steering wheel.

A 400 pound guy with no medications? Something doesn't seem right there...

When you ask him more specifically what "cruddy" feels like, what does he say his symptoms are? Vitals, especially a BGL. If he isn't already on diabetes medication, my suspicion would be that it is just not diagnosed yet. Hyperglycemia could lead to the dry skin and "cruddy" feeling, and symptoms are slower to present.

Next question... can he walk? No need to carry someone who is just feeling a little ill, if all their vitals are good, and no reason to think cardiac/ respiratory/ anything that would get exacerbated w/ exertion.

I guess dealing with the family/friends of the patient is in most cases more stressful than dealing with the dead person itself, especially when it comes to children.

I agree. Working a code, or going to a DOA really doesn't bother me. But seeing and hearing the family grieve when they hear their loved one is dead gets to me worse than anything else. Talking about the incident with my partners helps me, and having partners who can still make jokes and make light of things (not in front of the family of course, and still being respectful), liking singing "start your day with a DOA..." helps. Usually I depersonalize the incident completely, which is why it is harder for me to see the family, or if there is something in the newspaper about the person who died, I usually try to avoid seeing it.

Is the garage safe to enter? The roof looks a little iffy in the pictures to me. For now, I stand back and let the fire guys do their extrications, and try and talk with the people in the car.

The people in the red car are able to speak well you say, do they complain of any injuries? How did the accident happen according to them?

The woman in the blue car, what kind of responses is she giving?

How far away is the ALS unit? Is there another BLS unit available? Based on injuries, we would probably be fine with 2 units, but if one of the people in the red car are hurt worse, then we might need a third unit. I don't think I'd call for a helicopter, unless we needed another ALS unit and non were available.

Once the people are extricated, what is my first impression of all 3?

Thanks for all these scenarios everyone, they are fun!

The posturing is a very bad sign, we have a spinal cord compromise. While he's breathing on his own lends me to believe it may be we are not dealing with a severed cord but one that may be in compression somewhere.

Don't mean to derail the train of thought on this tread, but I have a quick question. Posturing is a sign of head trauma, not necessarily related to spinal compromise, right?

Honestly, I wouldn't worry about getting another 14G in, don't think I would have even tried with the first one. A 16 should be all the hospital needs to give bloods I believe, and everything we want to give would be fine with an 18.

Does the pt still have a gag reflex?

Oh, and what does IVC stand for?

If we can't establish an airway in the field, I would pick the quickest option to get him to the closest place that can RSI or establish another airway (cric if necessary due to facial trauma). Probably would end up going to the ER, and having the helicopter there ready to transport this kid to a trauma center once he has an airway.

(sorry this is so jumbled)

EMS care in NYS can be the blueprint for this change and it will spread 50 states. The EMT program will be an intense 8-9 month long & college equivalent of 6-8 credits. The EMT-P will incorporate CCEMTP training, only available as an A.S. and B.S. degree program in Emergency Medical Paramedicine.

Not meaning to nit pick here, BUT where I took the EMT-B course, it was already 10 collage credits (not in NY). NY should first focus on catching up with the rest of the nation, and accepting national, rather then trying to restructure the entire program. The national standard for EMT-B is already about 1/3 longer then the NY standard.

After making sure he is breathing, or having someone assist him w/ respirations (including NPA/ OPA) if he is not, Vitals, including GCS. Is he posturing? Ask bystanders if he moved at all after crash, did he appear unconscious immediately, or was he initially conscious and lose consciousness slowly. What caused the crash? How did he fall, what did he hit first?

What do his pupils look like? Are they responsive, are they equal, or is one blown?

Full trauma assessment

thanks, quick question, how long are cpr liceneces good for? I got one about 2 years ago so i need to renew i would think.

Most are good for 2 years. Check and see if it is required for your class though. In my class, CPR for the professional rescuer was obtained in class, we did not need to come in with CPR (that I can remember).

Does the dispatch information give any indication of immediate past, or active violence in progress? That is one deciding factor.

Some jurisdictions have preprogrammed information in the computer assisted dispatch system, where a premise history will pop up. We had one location where EMS was on orders to not go in the building until the NYPD precinct cops were on the scene, and NYPD Emergency Services at minimum notified, or responding. The premise history was entered after a frequent flier patient went after a crew with a knife in one hand, and a ball peen hammer in the other. EMS and the cops didn't care that the patient was at least 70, with a diagnosed cardiac condition, which the patient always vehemently denied (I had him once). The crew's safety came first.

(For those old timers here from NYC HHC EMS with the knowledge, I'm talking about "Merlin")

I used to work in a place that had a computer system like that. Certain addresses could be flagged by dispatch for having violent offenses in the past, and whenever that address popped up, we always had PD go in first to clear a scene, regardless of what the call was for. As much as it sucks, there are people who will attack us simply because we are dressed in uniform. A call for a child w/ difficulty breathing could lead us into a very volatile scene, and IMO, if we know that location has a hx of violence, then it is our right and responsibility to wait for PD to get there first. As much as I want to help others, mine and my partners safety comes first.

I miss having the computer system where you could see a record of recent calls to the address, and see if it was a flagged address. We don't get any computer info here, it is all what the dispatchers choose to give us over the radio, and sometimes they forget/ don't think info is important enough to say. A couple weeks ago, I called on location to a call, and was told "the scene is now safe to enter" I was NOT HAPPY with dispatch, since we had never been told the scene wasn't safe...

I also took a while to be confident with my skills as an EMT. In my town, the agency I volunteered with had me as the third person on the ambulance. So I was never alone with the patient, I had a paid staff in the back with me. At first, I observed and took vitals and anything else the person directed me to do. As time went on, I started taking more of a leadership role on calls, to where eventually the other person in the back wouldn't do anything unless I specifically asked them to (or I was missing something vital!). For me this was the perfect way to be eased into the EMS field. I now work full time as an EMT, and am confident in my patient care skills, but still trying to learn more to better myself as a provider.

There are many people who are proponents of just "throwing you in there", sink or swim style of making you more confident in yourself. There is a time and a place for that, but I think that for myself, and others, if I had been thrown out there in the beginning, I would not be as confident in my skills.

Unfortunately, in my experience, most private agencies (or actually, any paid agencies) won't do a lot to boost your confidence. You are either ready to work or not. I recommend finding a place to volunteer where you can get your feet wet and build up your confidence in your EMS skills.

Anyone know of any good WOMENS boots? I have a pair of magnum that I love, but they don't hold up well at all, and I need a new pair before it starts to get really wet outside. I have heard that a lot of the companies have actually stopped making women's boots. My local store is no help, they think the only difference is that the womens boots are smaller sizes. I have a really narrow heel, and there is way to much room in the heel in most mens boots for me.

Congrats! If it makes you feel any better, I volunteered for about 9 months, and moved across the country before I could find a paid EMT job...

Don't get to bored during orientation

Studied it in the texts, and been in the field 38 years, and until this video was published here, never seen one!

Guess some folks have all the luck.

I technically had a patient with a flail chest, I think. Thats the thing that sucks about being the basic on an ALS ambulance. Our guy had major crush injuries and needed to be at the trauma center, so as soon as he was extricated, we loaded him into the ambulance, and I drove to the trauma center. I asked my partner about it after the call, but its still not the same as being back there with the patient. Can't wait till I'm the medic in the back (2 more years...)

Anyway, the pt ended up having 6+broken ribs, and a small pneumo (my partner and the other medic in the back didn't realize he had a pneumo), but wouldn't even tolerate a pillow splint for his ribs.

What is flail chest?

What caused it?

What are your primary short term concerns?

Longer term concerns?

Load and go/stay and play? Why?

Treatment?

Please folks, if you know all of the above answers, please don't ruin it for those that can learn by asking and exploring. We already know you're smart. To the rest that are familiar with this, please feel free to jump into this thread in a mentor-ish way and help it move along if you would.

I have no info on this patient so we're going to deal with him in gross terms only, OK?

Dwayne

Ok, I guess I will take a stab at the questions

What is flail chest?

If I am remembering my textbook answer correctly (no I am not looking!) when two or more (or is it 3 or more) ribs are broken in two or more places

What caused it?

As others have said, major trauma to the chest

What are your primary short term concerns?

A broken rib puncturing the lung, causing a pneumothorax (I am not really clear as to the differences between a regular pnumo and a tension pnumo, but I know both are bad). Or hemothorax, or hemopneumothorax... either way, not good. How possible is it for the fractured ribs to actually damage the heart? I would assume if it is in the right place, on a relatively skinny person it could, which would be bad bad bad.

So pretty much my main short term concerns are breathing problems

Longer term concerns?

Um, complications from above?

Load and go/stay and play? Why?

Treatment?

I am pretty sure regardless of BLS or ALS, I would load and go. BLS there isn't a whole hell of a lot I can do for them except use the BVM if their breathing gets really bad (if I am remembering correctly, the BVM uses positive pressure ventilations, which would negate the flail chest because it would not be negative pressure on inhalation, so the entire chest would expand w/ every breath). We don't have x-ray/ MRI vision in the field, so although we can guess, we can't know for sure what all damage is done beneath the skin on this guy. Whatever caused the force strong enough to break multiple ribs is going to put me on high alert for other injuries (not that I am triaging based on MOI, just higher index of suspicion). If he does have a punctured lung, he needs a chest tube, and while ALS providers could do a chest decompression in the field, I am pretty sure that is only a temporary fix. Either way, this guy probably needs surgical interventions (is a chest tube officially a surgery, since it is often done in the ER?)

Wow, I've never actually seen the paradoxical movement before! Is it usually that pronounced?

* You've ever left your ambulance door unlocked at a hospital and come out to some horrible joke having been played on you (someone turning your sirens on, someone using a spine board strap to tie your inside door handles together, etc.).

Someone did that to me last week! I went back to the ambulance exhausted after dropping my pt off at the ER, and turn it on, only to hear the loudest, most annoying siren we have blaring. I almost jumped out of the ambulance...That woke me up for the next 10 mins or so!

What do you mean telling someone? Do you mean telling other health care professionals/ law enforcement? Or do you mean talking about something a pt told you to someone not in a professional setting? If it is the former, I think you are well with in your rights to tell the professional what they told you (ie, if someone admits to assaulting another person...). I do not think it is legal to tell the info to someone else. Simply by telling them the non-medical information, you are inadvertently divulging medical information, specifically that that person was transported by you, which I believe is protected information.

Remember, when you are starting an IV, even if you are nervous as hell, don't let it show to your pt. You need to show them you are confident and competent, and if you look nervous, then they will become nervous, and harder to stick (more likely to flinch, pull away, refuse to let you stick them). One of my first "real" sticks, I looked to the medic on scene to make sure she agreed with my vein choice. The pt noticed and started saying "don't let her touch me with that needle" I ended up getting the line, but afterwards my medic gave me a long talking to about not looking confident in front of the pt. You need to put your pt at ease, and they won't be unless they think you know what you are doing.

My FD runs a fully staffed BLS Non-Transporting Heavy Rescue Truck. It includes all the equipment that a BLS ambulance has, with the exception of a cot. We have all the backboards including a pediatric one, scoop strecher, vacuum splints, KED boards, LifePak 12 (with 12-Lead ECG, NIPB, SpO2 and AED defult mode with ALS manual mode with pacer), jump bag, trauma kit, pediatric kit and all the other equipment that the state requires a BLS rig to have.

We have one engine that we run as a BLS rig and it is much simpler. Jump bag that has airway kit, OB kit, suction, c-collars, meds and other misc equipment. We even have a LifePak 12 that only has SpO2, four lead ECG (no 12-lead), defaults to AED but can be changed over when ALS arrives to be maual defib and pacer. We have no backboards or splints on this rig. We have this since it is second out to MVC's and first out for fire's and haz-mat.

The reason we have the Rescue Truck is because we respond on 100% of 911 calls that our ambulance has. Hope this helps.

Wow, I am jealous, it sounds like your unit is better stocked than my paid ALS ambulance! I wish we had vacuum splints and a scoop!

Actually, I am not with AMR. I decided to go with the smaller agency in my area in hopes they would treat the employees better. From what I have heard from most people, private sucks, no matter where you go. My smaller agency doesn't seem to treat employees better than the big agency here, people just say "at (big agency) you can hide in the crowd, here they can see and punish everything you do wrong." Now I don't think there is anything wrong to being held to standards, in fact, I think my agency should hold us to even higher standards, it is how they run the business side of treating their employees that is wrong.

Let me take a stab at this from my BLS education (aka, I don't know much about the drugs)

.

Once you start ventilating the pt, have someone find someone who knows the pt, get a history, as someone else said, make sure no DNR, ask about other meds... Any other s/s of a problem, diaphoretic, wheezing prior to losing respiration, hives, trauma...? Any medical bracelet? Have someone check pt's carry on for meds they are carrying. Start an 18 G in one arm, and a 20 in the other if you can hook up two IVs/ have access to a saline lock.

Reassess vitals. Pulse? Strong, weak, regular, or not... where can you palp it (to get a general idea of the BP). Get the AED hooked up to the pt, so you don't need to worry about it later.

Find more people who can do CPR... once this guy goes down for the count, you could be doing it for a while. However, I don't think I would ask specifically over the intercom for someone who knows CPR. On a plane, you need to consider the potential for an MCI if you cause panic. I would probably try and bring the pt into the back flight attendant area (if feasible, and doesn't compromise care), just so that it is not in front of the entire plane.

And I am confused, you said the plane had many other non-als code drugs... aren't all the code drugs ALS?

So here is my update about a month into my new EMT job. Things are very different in this new town I am living in than where I was before. EMS is ridiculously political down here, it is all based on the money, and making sure not to upset the volunteer fire fighters. We run calls in two towns. In one town we run with volunteer fire fighters. Now for that town, we have to go hot to EVERY call, regardless of the nature, unless it is an "ambulance only," and the fire departments never down grade us. For the most part, there is not a great working relationship with the vollies for example, if we get to the call at the same time as them, they will rush in to get pt contact first, instead of helping us grab all our stuff, and holding doors and such, since we will be the ones continuing pt care.

The other town we run with is even weirder. They have paramedics w/ their fire department who are not fire fighters, and only go to EMS calls. We always go cold to those calls, regardless of the call coding. Once we are there (and we are an ALS ambulance, w/ a medic and basic), the fire medics can decide if they think the pt is ALS, in which case the fire medic jumps in the back of our truck w/ all their stuff, and techs the call, our basic sits in the back not saying a word or touching anything, and our medic becomes a driver. Talk about a redundant system/ waste of resources. If they decide the call is BLS, our basic techs it, and again, our medic drives. Pretty much, we are nothing but a taxi service in that town.

Now, as far as my agency goes, we have a good mix of people who like the job, and people who hate it, but almost no one I've talked to wants EMS to be their career. They are all in EMS as a stepping stone job, until they finish nursing school, move somewhere else, get into PA school... Part of this I think is because the company doesn't treat the employees well. The pay is crap, and they can force you to come in and work on your days off, which really doesn't work for people w/ families/ lives outside of EMS. Also, the equipment is really old, which just makes it harder to do our jobs. I got really lucky with my partners, and I got people who like their jobs.

I know most of this post makes it sound like I hate my job, but I really don't. I still can't believe I am working full time in EMS, and getting paid for it! Overall, I am pretty sure this company isn't going to be a long term career place for me, I just need to decide if I can stay here 2 more years, so I can get medic school done (they don't support you going through medic school, but lots of people are able to do it while working full time here), or if I want to move sooner than that.

OK, I am going to throw a female opinion in here. I would not under any (or at least any I can think of now) circumstances allow any provider who did not absolutely 100% necessarily need to to examine ANY of my privates. Even if the pt is in severe pain, there is nothing we can do by examining her that we can't do without the detailed exam. If she is bleeding, it will show through clothes and onto the sheets if it is heavy. Ask the pt if anything is stuck/ impaled, and if they say no, just trust what they say! Yes, some pt's will lie to you, but as someone else mentioned, pts lie and there is nothing we can do about it. Get a detailed history of the pt, when the pain started, type of pain, last menstrual cycle...

Oh, and uglyEMT, " I do believe if the patient called us for pain in their genitalia then it would have to be pretty bad and I dont foresee them holding back information" You would be surprised some of the calls I have taken... let me just say that yes, I have taken a vaginal pain call where the pt was not in severe distress, just 3 am and mild discomfort...

Again, as others have said, I think it is situational. If a woman is pregnant, and birth is imminent, than by all means, expose and do what you need to. Unless the call is very critical (and I mean, severe bleeding, pt unconscious... ) I would not expose.

Sorry if this is disjoined, I went on a call in the middle of typing it...

Welcome to EMTcity! When you say you are getting ready to take the EMT class, do you mean you are taking prerecs now, or just personally preparing for the class? One thing that you could do now, if you deal at all w/ your clients' medications, is to start learning them. They will not be medication you are able to give as an EMT, but so often we have pts who can hand us a medication list, but don't know what any of the medicine they take are for. Also, study the diseases your clients have, they will be ones you will run into in the field, and more knowledge can never hurt!

As far as stories, have you read any of the EMS blogs out there? There are many that are great in terms of stories and thought provoking posts. Let me know if you want any links to some of them.