Bieber

Wow, I'm surprised at how many replies I've already gotten--and I just woke up! Thanks everyone for the prompt responses. I know, I am very ambitious. Patience has never been one of my defining characteristics, and when I see something I'd like to change, it's hard not to just dive right in both feet forward. I understand that anytime you try to upset the status quo you risk upsetting the wrong people, and that I'm going to have to tread very carefully. I'll try to address each of your posts individually. Carl Ashman C-Spine clearance would definitely be on the top of my list, and you're right I may have to condense my list a little bit. I don't expect all of them to get approved even if I am so fortunate to have some of them accepted. MOI for Trauma Triage I don't disagree that the MOI can be one indicator of the severity of injuries, but currently it's our only criteria by which we triage trauma patients by standing orders and leaves a lot to be desired. EKG/IV Application Currently, if it's one then it must be the other. And if it's either they must be code yellow. To be honest, I can think of a lot of excuses to do an EKG on somebody without necessarily thinking they need an IV as well; and vice versa. I would also like to move our practice to be more in line with that of the local hospitals; and I know that not every patient who gets an IV at the hospital gets put on the EKG as well. Narcotic Patient Monitoring This one I don't have so much of a problem with as many of the others, it's more about moving our practice in line with the hospitals. SpO2 monitoring SHOULD remain mandatory with all patients receiving narcs, but I know most of the hospitals around here don't automatically put them on the EKG as well. It's more about narrowing the difference between "EMS medicine" and "hospital medicine". (Don't take this the wrong way, I'm not trying to turn us INTO the hospital, only trying to make our practices more in line.) Code Blues I can't see us getting automated compression devices here due to their cost and the fact that we always have plenty of hands on scene to do CPR, to be honest. I hadn't heard about anybody doing PCI in the fully arrested patient, though, and I know they're not doing it around here. Could you share a link with me? In general, however, there's really nothing more the hospital can or will do other than the same stuff we're going to do on scene. Until there's a concrete benefit to transporting code blues to the hospital, which currently there isn't--at least around here--I don't think we ought to be transporting dead people. Cardioversion I agree! Pain Management Mhm. We certainly shouldn't be giving pain management to hemodynamically unstable patients, but with stable multisystem trauma patients? They deserve to have their pain controlled well. NSAIDs I agree. And while I'm more than happy to do what I can to take care of my patient's pain, I also realize that fentanyl may not be appropriate for every patient and I'd like to have some other options. We do have Toradol, but we give that almost solely for kidney stones. O2 Therapy Indeed. We're only required to keep sats at >97%, but all chest pains require at least 2 LPM by NC and I think that we can do without that. Febrile Patients This one I need to do a bit more homework on, but I think it would be good to have some options, especially for febrile pediatric patients. Treat and release options This one isn't going to happen. I know that it won't. But I want to introduce the concept, get it into their heads and make them start thinking about it, and realizing that it's happening in other parts of the world and that for EMS to become sustainable in this changing healthcare environment, we're going to need to really start reexamining our educational standards and our medical schedule of billing. Thanks so much for your advice, and for sharing that presentation, Carl! BEorP Yeah, especially considering we're going to be having a major protocol revision sometime towards the end of this year, it's really hard to say whether or not these issues have already been addressed or if my medical director is already planning to change some of these things. I know that the medical director certainly talks with other physicians in our community, and I'm not sure exactly where those doctors are coming from but I have a premonition that they're not greatly enthused by the idea of changing too much of the status quo for EMS. NYCEMS9115 Thanks for your advice! We're nowhere near the size of FDNY or even the old NYC*EMS, but we're still running more than a dozen trucks so I have at least of a glimmer of an idea of how tough it must have been for you to make any major changes within your organization. Doczilla Thanks, Doc. I've read the protocols of a few services that implement some of these changes I would like to see us have (Wake County EMS, for one), however sharing them with my medical director might be a good idea as well. You're right about meeting the medical director one on one, which is exactly what I was planning to do. I've always found that presenting alternative opinions on a one on one basis to always be better than trying to tackle the entire administration all at once. Thanks for your advice. (Would have used quotes on all this, but they were giving me trouble.)

Hi everyone. How are you all doing? I'm well, getting over this bronchitis, working on my schoolwork, and hopefully upgrading to full time employment here soon. As you all know, I'm not perfectly content with my system's protocols. Thankfully, we've recently gotten a new medical director, one who has previously worked in EMS and one who, from what I've noticed, means to improve the system. However our protocols have to be approved by our very conservative medical society, so I know that we're not going to be changing too drastically. Nonetheless, I remain undiscouraged and in fact challenged by this. We're a very large system here, and I've never even met our new medical director, let alone all of our employees, and only our EMS director twice. Because of this, it seems like any interaction with them will be very formal, and even if it weren't, I like to be thorough. So I am beginning work on a presentation to try and explain to them what changes I personally think we should implement, and why. Besides having a conservative medical society, many of our paramedics and administrators seem rather conservative as well, and I know that to implement many of these changes (or to even have a chance at getting my voice heard), I will need to come well armed and well prepared, which is why I want to prepare and present to my medical director a very formal, well thought out and well researched presentation. Unfortunately, even if I succeed in giving the kind of presentation I would like to, I know that I may be denied or even stigmatized for having the audacity, as not only a new paramedic but also possibly as a new full timer or even still just part time at the time of this presentation. All the same, I know the kinds of things I would like to see in my system and I want to give it my best shot. I've listed below some of the changes I would like to implement, what I am asking from you is your advice on such presentations. If any of you have created such presentations yourselves in the past, I'd love to hear your feedback on how you produced and presented them. Right now my idea is to present each idea, explain why it is superior to the current system, and include studies and references that support it. For the record, I haven't yet gotten into the dirty work of looking up research articles to specifically cite, however on all the applicable issues I have previously read research studies that dealt with them. Current Ideas: Field C-Spine clearance (thinking NEXUS, but I need to do my homework). Eliminating/downgrading the importance of MOI in Trauma Triage. Eliminating some of the restrictions on EKG/IV application. Reconsidering mandatory application of EKGs on patients to whom narcotics are administered. Adding IV locks to our equipment. Eliminating transport of code blue patients. Changing cardioversion to standing orders. Increasing pain management options/dosages, including to multisystem trauma patients. Adding NSAIDs for mild to moderate pain for whom narcotics may be inappropriate. Replacing mandatory oxygen therapy with clinically appropriate O2 therapy. A standing pain/nausea protocol. Increasing/adding dosage/drugs by standing order to the pediatric protocols. Adding a protocol for febrile patients. I'd also like to discuss treat and release options and primary care alternatives (referrals, etc). Finally, and this is something I've been playing around with in my head, I'd really like to write a textbook/field provider's guide that includes all of those things that we SHOULD have learned in paramedic school. I want it to be a book that covers the full breadth of medicine much more than what we currently learn. I understand that it's arrogant to think that I could write such a text, but with no one else trying to create a book that covers ALL aspects of medicine specifically aimed at paramedics, I feel like this is something I can't wait for a smarter man than I to do. So, come on. Tear my ideas apart or build them up, either way you'll be helping me.

Sure, feel free to send me a PM.

You're ridiculous. If the solution to the patient's problem is to pump them up with sugar, and if pumping them up with sugar will (see, Wonder Drug Advertising) take them from obtunded to alert in a matter of moments, then how do you think they're gonna feel when they wake up with an amp of sugar in their bone? Think it might be a little painful? Think a little prophylactic lidocaine while they're unconscious so when they return to consciousness shortly thereafter might not be not only reasonable, but good patient care? "Nah, Bieber, shut up you silly newbie. That's just crazy talk. Go back to driving the ambulance."

John, tell me about your paramedic school. What were you taught from day one of paramedic school? Were you taught that the goal of paramedics was to follow their protocols faithfully, unquestioningly, and without ever thinking outside of the box? Was that the moral at the end of the story? Or were you told that paramedics exist to provide competent, safe, and appropriate medical care to patients? I challenge you to find in any paramedic textbook any quote that says that our mission is to follow our protocols. You won't. That's because that's not the mission of EMS. The mission of EMS is to provide emergency medical care to patients and to help them in their time of desperation. You may not agree with Dwayne, and that's okay. But why did you get into this profession? Were you bursting at the seams when you got your acceptance letter, so full of exuberance and jubilation, at the idea of being able to follow your protocols to the letter? Or were you excited to be able to provide medical care to people when they were at their worst; ecstatic to be able to HELP people? We didn't get into this job to follow protocols, we got into it to help people. That is our primary goal, that is our mission. Protocols exist to facilitate that mission, but at the end of the day, you have somebody's life in your hands and you better learn to respect the fact that it is up to YOU to protect that at any cost. Are you going to have the same courage Dwayne has shown when that day comes? EDIT: (Addition) I'll say this. Someday I am going to be dying. I am going to be sick or injured and I am going to know all too well the kind of men and women who will be taking care of me. And there, in the back of my mind, I am going to be crying out desperately for someone to save me. I am going to be begging for someone to do whatever it takes to keep me alive--not to do whatever it takes to follow their protocols. And I hope that the person who cares for me in my time of need is as selfless as Dwayne and as willing to give up everything for my life, because while it's easy for us to take a step back and not really see the value, the preciousness, and the gravity of our patient's lives through their eyes, we need only become as helpless as they to realize just how desperately we all want to live and be saved by that one person who is willing to do whatever it takes for us. Dwayne has proven himself as that man. I haven't, not yet. And I'm willing to bet many of us here haven't yet proven that yet, yeah, even you. So Dwayne, by all means, drill into my bones. Act outside of your protocols if you feel you must. Do whatever it takes. Because when my time comes I am going to ask you to do one thing and one thing only, the same thing every one of our patients ask us, the same thing we will all eventually ask of someone else in the hopes that they will have your same courage and conviction: Save me.

Only two more days of antibiotics after today, and I'm feeling much better. I stopped taking the prednisone two days early due to it giving me wicked bad muscle cramps, but the doc says that's all right. On another note, I'm interviewing for a full time position on the 12th. Not sure how many available spots there are or how many other part timers I'll be competing with, but I'm keeping my fingers crossed.

Yeah, seriously, share that link with the rest of us! I'll be more than happy to pass it along. EDIT: Oh. Wait. April Fool's day.

Around here I only ever hear people reporting the total number. Though maybe I'll start giving each number separately.

We have to put in the GCS of every patient, but there's a little "check the box" area in our ePCRs that automatically calculates it. We also have to give a GCS for all trauma alert patients. I'm getting somewhat better at remembering it, but like Dwayne said, unless you give each of the values all it really tells you is that "this guy is fully awake, fully obtunded, or somewhere between the two". I'm from Kansas.

I'll let you know tomorrow. I haven't worked since I've been on the meds, but I'll be working a shift tomorrow. Today my dose dropped down to one pill of prednisone a day. Hopefully it won't be an issue, but we'll see. I'm going to be at the same station one of our two medic captains stays at, so if there's any major issues he'll be conveniently close by for me to discuss leaving early or whatever accommodations I need. The NP didn't seem to think I'd be unable to work, though.

From http://www.hhs.gov/o...mary/index.html

Oh, Keflex apparently causes headaches. Ouch.

To the first one, well it seemed like it was starting an argument for the sake of starting an argument rather than as a justified response to what someone had actually said. To the second, you're right that men and women aren't equal in a literal sense, however in the sense that I think everyone here would agree that nobody should be disqualified from a job based solely on whether or not their parts dangle as opposed to their actual ability to do the job. Are there certain things that men will never be able to do and vice versa? Without a doubt. But for the most part, a person's ability to do a job is based on their drive, commitment, knowledge, and adaptability far more frequently than it is on whether they pee standing up or sitting down.

I've never been much of a fan of the idea that pain relief is bad for abdominal pain patients. Honestly, the physical exam can only tell you so much, and like you said, who's gonna start opening up someone's abdomen without a CT and labs? We can't give pain relief for head injuries or polytrauma, unfortunately. Maybe someday...!

Thanks for all the kind words, everyone! I'm not a big fan of taking meds unless I absolutely have to, but after a month without relief I figured I might as well go to the docs and let them pump me full of antibiotics and steroids and who knows what else. Ten days of Keflex, nine days of prednisone, I'm probably not going to take the codeine since the cough hasn't really been keeping me up at night; I'm gonna take some Mucinex though. Been trying to drink a lot of fluids. Wendy, I woke up last night and noticed my heart rate was kind of high and I had some trouble getting back to sleep and I felt pretty fatigued all day yesterday. Other than that, my only other complaint is a headache that I've been nursing all day today. Tomorrow I drop the dosage in prednisone from two pills to one, and I stay with one pill for three days and then a half a pill for four days and then I'm done. By the way, Keflex smells horrible and leaves your breath the same. Just sayin'. Ruff, sorry to hear about your wife, your kids, and yourself! Hope you get to feeling better soon. I definitely prefer to be on the provider side of illness.

Something I noticed about fentanyl last week. It works great, but damn if it doesn't have a short half-life. My partner used it for a peds patient with a possible broken tib-fib, and while it worked great for the kid for about fifteen minutes, after that the pain was coming right back. I knew morphine lasted longer than fent, but I was surprised at just how quickly the fentanyl's reaction diminished.

Correction to the end of my last post, it should read, "and fallibility doesn't make someone inherently evil". I blame my bronchitis.

Okay, I don't disagree that there are some wrongs being committed by this guy, but you're twisting the issue into something else. The title of this thread wasn't to imply that women's freedom could only be granted by man, only to imply that the manager of an EMS service (who does, in fact, have the power to permit or deny certain things within his service) was not allowing two women to work together. And while that guy may be something of a male chauvinist or even downright sexist, the fundamental question of the equality of women and men was not questioned by anyone but you. Furthermore, this particular manager may not inherently be sexist so much as misinformed, misguided, or acting based on any other multitude of inherently harmless beliefs that resulted in not so harmless behaviors. Trying to ascribe any sort of mentality to this guy based on what we know would be a folly. So please, don't turn this into a philosophical debate about the equality of the sexes. I don't know anyone here who wouldn't agree that men and women are equal. And we don't know what this guy's personal views are, only his actions and his reported reasoning. Is it wrong? Yeah. Does that make him a sexist or a misguided soul? Who knows. His actions are sexist, he may not be. People are not infallible, and infallibility doesn't make someone inherently evil.

That's -2.

Are you trying to imply that those who serve in the armed forces are the only ones who serve their country and as such are the only ones who have truly earned the right to wear the flag?

So I went to the doctor's today after battling a cough for about a month. The NP had a listen to my lungs and checked out my nose and throat and said I got bronchitis and pharyngitis. Put me on Keflex, prednisone, and promethazine with codeine plus I got a shot of prednisone in the ass right there. They said I'd be good to go back to work on Thursday, but that I should try to rest up till then. So, that's what I got happening on the personal side. I think this is actually the sickest I've ever been (though I think that steroid shot is already helping), which I count myself fortunate for. My brother got pretty much the same treatment plus an albuterol inhaler when he came down with pneumonia about a month ago.

I think that would classify as discrimination. Surely their employer mandates all employees to be able to lift at least 150 lbs, so the two of them together should be able to handle most any patient and in the times they can't, they should be able to call for lift assistance from other departments. I would bring it up with the boss. EDIT: Addition. Also, as far as dangerous hoods are concerned, they signed up for the job. And if they feel unsafe, then it's time to stand off and call PD to clear the scene before they move in. Same as at any other EMS service.

To be honest, I haven't used any of those formulas since leaving paramedic school. The only drips we have are lidocaine and dopamine, and I use the clock methods for both of those. It's probably something I need to review. Good luck in paramedic school.

We give narcan undiluted IVSP just enough to reverse the effects of the overdose (respiratory depression). I'm not sure why you would need to dilute the narcan unless you're giving the full dose all at once; if that's the case, why not just give it slowly in the smallest effective increment? As far as IV versus IO in this instance, I would hold off on the IO if I could get an IV or give the narcan IM. Sure, IO's aren't the scary beast we sometimes think they are, but I'm not sure why you would need to do one in an overdose when there are so many other options available. IM, IN, can't you give it PR too? Nothing wrong with an EJ either, though I'm not going to go that route unless I can't find another IV site and not if it's just a "protocol" line. Like the IO, it's not as scary as we think it is, but it's still overkill if you're just starting the line due to protocol and not because you actually expect the patient is going to need it.

Around here, police only show up to MVA's and scenes with violent patients/bystanders, and code blacks (obvious deaths). If the calling party were to say that the mechanism of injury was the result of someone being pushed, they'd show up, otherwise it'd just be another one of many, many falls.