Bieber

Wow, great post! I remember reading about it very briefly during EMT and paramedic school, but not anywhere in as much detail as what you've just provided. Thanks for sharing!

As far as the "to report or not to report" goes, I humbly offer... When in doubt, whip 'em out.

Yes. Don't know, and I'm not willing to find out. I believe so. But seeing as I'm not a lawyer or cop, I wouldn't write it as though a crime had been committed. I would just document what I saw, the bare facts, and let someone else decide if a crime has been committed or not. I definitely have an obligation to report it to the police. Though I believe in our neck of the woods we generally just advise the hospital and they get law enforcement involved. As far as the parents, I would answer whatever questions they had for me--pure facts. "This is what was said, this is what we found..." etc. This is kind of tricky, isn't it? On one hand, drug possession is a crime, on the other, drug addiction is a disease. I'm really not sure what the county policy is on this. Personally, I'm not sure if getting the guy arrested is going to solve the underlying addiction--though I come to doubt more and more that there's a very good chance that anything will solve it.

Oh yeah, they are, aren't they? My bad, no rudeness intended. On another note, Tallahassee is a really beautiful city.

Huh? Sorry, man, I wouldn't know. I'm just an ambulance driver. You might try a firefighter forum, they'd probably be more helpful in answering your fire-related questions.

For the same benefit as flushing any injury--to help clean it. Venom isn't the only danger of snakebites, there's also the introduction of bacteria inherent in any penetrating injury, which is (if I'm not mistaken) the highest in penetrating injuries than any others (abrasions, lacerations, etc). You don't want to treat the envenomation only for the patient to end up with a bad infection that causes more harm than the bite or venom alone would have.

To be honest, I'd have to reread my paramedic school book to tell you, I do know that it does depend on the type of snake. Our protocols don't cover envenomations, so what I would do (and suggest you do) in the situation is have the poison control number on speed dial. I think they cover envenomations, don't they? Well, in any case, have the number to whatever department handles snakebites and defer to their suggestion is what I would do. Oh. I just noticed you were looking for actual cases. Can't say I've run any snake bites in the field, the closest thing I've come to is I know we did have a "patient" with a snake bite at our Field Ops. (I know, you're curious, a post covering it is forthcoming.)

I would VERY strongly encourage you to go with the AAS program. I know that most of the country does NOT require paramedics to have their AAS, but in my state it's a requirement and though I don't know what it's like elsewhere, I would imagine that programs that require paramedics to be Associate's elegible versus those that do not are going to be: more dedicated to education, have a longer and/or more in depth curriculum, have instructors with higher level degrees (Bachelor's and above), and have and promote the attitude that higher education in EMS is the way to go, as opposed to certificate only programs that may be more focused on quantity rather than quality. That you already have your Bachelor's is a big +1 to you, and I honestly feel that ALL paramedics SHOULD have their Bachelors and at the MINIMUM an Associate's. Right now I'm working on finishing up my Bachelor's in Biology and I'm going to be bridging to nursing next spring as well, but I'll tell you this, I AM Associate's elegible (just finished the program in December, getting the actual AAS sometime this spring, whenever graduation for the entire college is, I guess?) and I STILL don't feel like I've learned anywhere near as much as I should have. Education is a big thing to me, and it should be to you too and it obviously is because you've dedicated so much time, money and energy to it. This isn't the time to take any shortcuts, you've made the choice to go to paramedic school so now you need to make sure that decision is a good investment. And the best way for you to do that is to go for the highest available paramedic education you can access. You're part of the wave of newer, smarter, better educated paramedics and you've already done a lot to elevate the profession and yourself by getting your Bachelor's. YOU are the future of paramedicine. So don't back down now and take the dying path of pursuing a certificate alone, get the full degree.

Wow! Thank you so much to Dwayne and all of the voters. I honestly didn't expect to be nominated at all, much less voted in. Thanks everyone, I'm very humbled and grateful for all your support, advice, and even criticism since coming to this forum. I'm know there are lots of other guys here more worthy than I for this kind of recognition, but I'm really thankful. I know I haven't been here for very long, but you guys have really gone above and beyond to make me feel at home and welcome here and I truly appreciate that. You guys know how strongly I feel about EMS growing, and I can't think of a better way for that to happen then on a forum like this where the experienced and the newbies can come together and learn from each other. As for challenging me more, PLEASE! I'm green as hell, and more than anything else I want to become a better provider for the sake of myself, my profession, and above all my patients. And I sure as hell can't get better without being challenged.

Well, it looks like I showed up a little late to this conversation, everyone seems to have answered this the same way I would have. But I'll just reiterate what's already been said, and that is to treat the patient, not the monitor. Like some others have mentioned, in the absence of physical signs/symptoms of respiratory distress an SpO2 reading of 92% isn't particularly worrisome. Oxygen, despite what we have heard, is NOT a benign treatment and it isn't for everyone, though many of us--including myself--live under blanket protocols that dictate that oxygen should be maintained at certain saturations (95% of above for me) or that it should be applied to every patient under the sun. This is unfortunate and hopefully on its way out, because we're seeing now that oxygen therapy can in fact be detrimental to certain patients, ironically the ones we've long presumed needed oxygen the most (i.e. AMI patients, and I believe also COPDers). Unfortunately, if your EMT program was similar to mine, you probably just learned the bare minimum of oxygen therapy (that is, never withhold oxygen), and that "all patients get oxygen". Even in my paramedic program, oxygen therapy was not covered as in depth as it should have. It's our natural instinct to have that knee-jerk reaction to vital sign readings that are outside of the "normal" range we're taught in the classroom, but it's important to recognize the difference between benign vital sign aberrations and malignant vital sign aberrations. What I mean by that is that you have to look at the whole picture, including and especially the patient's presentation. That means differentiating between acute illness and chronic illness. The truth is, many if not most of the patients we deal with on a daily basis have chronic conditions that they've lived with for a long time. We're not there to treat those, not unless they're the cause of today's emergency. During my internship, there were a couple of times where we were called to a patient with a LOT of underlying medical conditions that made me want to treat them for it, and something my preceptors really hounded me about was differentiating between the chief complaint and those underlying medical conditions. Yeah, there's a lot of patients with some serious problems, but what did they call EMS for TODAY? What is their medical emergency? In this case, is it this patient's chronically low SpO2 levels, or is it back pain? The next thing you need to ask yourself is what NEEDS to be treated, and what doesn't need our treatment. Yeah, you can opt to place this patient on oxygen, but what's the end goal? If she's in respiratory distress, it obviously needs to be treated. But if she isn't in any sort of distress, what do you think is going to be done in the emergency setting about her chronically low SpO2 readings? That's a long term condition that isn't going to be corrected by the ER, not if it's not her acute complaint today. So you can put oxygen on her, but I guarantee you if she doesn't have any respiratory complaints, the ER doc is going to say, "Yep, you've got chronically low SpO2 readings, you need to stop smoking and follow whatever regimen your general practitioner has set for you, and we're going to treat your emergency condition, the back pain, today." You're going to find, or perhaps have already found, that many patients live with high blood pressure, with problems ambulating and taking care of themselves, and many other conditions that we simply cannot treat and are not here to treat. So a patient's got high blood pressure, big whoop. What did they call EMS for TODAY? If it's for symptoms relating to that blood pressure, then it's probably time to do something about it. If not, then that's okay. It DOES need to be treated, but I'm not the one to do it. Another example would be a patient complaining of, say, an extremity injury whose EKG shows atrial fibrillation WITHOUT rapid ventricular rate or signs/symptoms of cardiac instability. Yeah, they need to get that treated, but that's also something they've probably lived with for a while, and if they're not having any symptoms from it, then I'm just gonna monitor it and treat for their chief complaint. We're not out to solve every medical problem our patients have, we're there to treat their EMERGENT conditions. And it sucks and it's hard to see somebody with a medical problem that we can't or shouldn't treat, but the sad truth is that many of the patients you'll have are in a bad way without the emergency they called us for. Your job is to differentiate between the emergency condition--their chief complaint--and the other stuff that we just can't fix in the field or even in the ER. I WILL say, in your defense, that anecdotally I've found that oxygen can help to some limited degree to relieve pain and nausea, so if you think the patient might have benefited from some oxygen in THAT respect, I'll agree with you. However for the sake of raising her pulse ox alone, I think you've got to look at the bigger picture.

Fearless paramedicine to me seems somewhat different than it seems to many of you. Practicing fearless paramedicine to me means standing up and taking responsibility for our actions, our interventions, and our knowledge. It means "owning" our practice, expanding our education, and having the knowledge and the confidence to know what is best for our patients. It seems that today more often than not what we really practice is "cover your assology", not paramedicine. We're undereducated, and it shows. Instead of knowing without a doubt the best course to take for our patients, we "cover our asses" because we (often rightfully) doubt ourselves and defer to physician judgment. Which isn't a bad thing in and of itself, because whenever in doubt we SHOULD be deferring to a more knowledgeable provider. However, it IS very telling when we have to defer to physicians because we simply don't know as much as a competent provider ought to. Practicing fearless paramedicine to me means increasing our knowledge base, and being able to confidently make independent decisions--tough decisions--for the sake of our patients and being willing and able to defend our actions before our peers and supervisors. Practicing fearless paramedicine is what the Kiwis are doing, what the British are doing, and what we in the U.S. sorely lack. And that is the education to need physicians less and less, and the confidence of those same physicians to trust our judgment and to know that that trust is well placed. To me, practicing fearless paramedicine would mean I have the knowledge and the ability to no longer need a "cookbook" of protocols It would mean instead of rigid rules that I must follow, I instead have guidelines. It would mean that instead of a list of MOI's for determining trauma triage, it would merely say "per paramedic discretion"; it would mean instead of needing to use an "abdominal pain protocol" or "chest pain protocol" to give anti-emetics, my guidelines would merely list the indications, contraindications, and cautions for administering Reglan, or any medication for that matter. It's not about being unregulated or supervised. It's about having the education and the skill to not need as much supervision, and to be able to practice without as much restriction and with much more trust in us; because we've proven ourselves competent to care for our patients without needing someone holding our hand the whole way through. Practicing fearless paramedicine to me would mean that we've reached that point in our education and standards that we're no longer ashamed to call ourselves paramedics; that we've reached that point where we respect and recognize our profession as just that, and that we've reached that point where we no longer advise paramedic hopefuls to "just go become an RN instead". We're not practicing fearless paramedicine where I work, and I suspect many of you aren't practicing fearless paramedicine the way I see it either. But we could be, some day.

...Dwaaaaaayne....!

It's as simple as asking yourself do you want to be an EMT or do you want to be a paramedic? Paramedic school's tough, I know, I just got done with it. And I wish I'd had some experience as an EMT prior to doing it, but you can get experience working part time as an EMT while you're going through paramedic school. Follow your heart, and do what makes you happy.

Wow, what a great gift, Dwayne! That's awesome for them to offer you such a great gift, and even more awesome of you to share it with people on these forums. Like you said, it's unfortunate that everyone can't get one, but it's still great for you to share it with those you can. Looking forward to see who the winners of this competition are, and good luck to the people coming up with the nominees.

That looks like a Ford chassis to me.

If you're looking for quality EMS education, you need to look into the full EMT class; not an accelerated one. Shortcut yourself, shortcut your patient. Have a good day.

Out of curiosity, how do your firefighters feel about paramedic school being obligatory?

I think that with quality CPR as evidenced by one of the new little gadgets they have for new monitors that measures the quality of CPR would be enough. The only time I could see it as being all that useful would be if you're doing a code in a type II ambulance, but for the most part that shouldn't be an issue if you're doing the right thing and NOT transporting dead people.

It's hard for me to provide much treatment on scene as our scene times are closely watched and it's our times that we're evaluated on in our performance reviews. Unless it's something critical that NEEDS to be done on scene, I reserve most of my treatments for in the back of the truck because of this.

Well, the only problem with that is that the science is saying that oxygen is NOT a benign drug and that in certain patients it actually CAN be detrimental to their long term mortality. I'm not saying to break protocol, and unfortunately my protocols force me to give oxygen to certain patients regardless of the science, their SpO2 or their presentation, but if you have the freedom to be a little more selective than I then I would strongly suggest you review some of the current literature. I agree with oxygen when in doubt, and that it does seem to help calm patients and relieve nausea to some degree, but don't be afraid to think outside of the textbook. A couples of liters by nasal cannula doesn't sound inappropriate to me in this scenario, especially if he wasn't presenting with any sort of respiratory distress. Anyway, in the end, you did all you could and that's that. I don't know if you read my post about a month back about my little ethical dilema regarding a patient that we transferred from the hospital back to his home when they weren't able to adequately care for themselves, but believe me when I say I know that it's hard to see a patient make the wrong choice. Ultimately, we can only do so much. My preceptors were very big about "after the call's over, the call is OVER". Be done with it and move on to the next call. Take care, I'm glad to hear everything worked out all right with that guy. Just don't let this hardship come back tenfold when you have a patient that refuses treatment and really suffers for it.

While I'm right there with you on not giving oxygen unnecessarily, I would like to anecdotally say that oxygen does seem to have some therapeutic effects with regards to pain and (maybe especially) nausea. Don't know what the science says, but a little oxygen does seem to be relaxing for some of my patients.

"Sir, do you understand that you could have injuries to your spine or other internal injuries that we cannot find on physical examination and that that tightness in your chest could be due to a heart attack and that refusing treatment and transport via ambulance where we could monitor you and provide treatment en route could result in permanent disability and death?" Honestly, there's not much else you can do. I've been there, it sucks, but the guy has a right to make stupid decisions. You can ask him over and over and lay the consequences out out cold and honest, but in the end you can't make him go. There seems to be an art to getting people to accept transport that I haven't yet figured out, but maybe some of the more experienced people could give you (and me) some pointers.

Don't usually bring it in on seizure calls, but I've never arrived to an actively seizing patient. Occasionally I'd have one seize again on me in the back of the truck, but the most I ever had to do was manually open the airway of one of them following the seizure.

Richard, no matter what the ADA laws may say, your first and foremost obligations are to your own safety and to patient care. Though, in all fairness, I don't think that the situation often arises where it becomes a problem.

Competent patients have the right to refuse any treatment no matter how detrimental it may be to their wellbeing. I'm not going to learn about every religious custom out there and intentionally adhere to them to avoid offending my patients, and if a patient requests me to withhold a treatment that I think they need I am going to do my best to change their mind, but ultimately if they request that I withhold a certain treatment in observance of their customs that's their right. It's no different than those folks (the Mormons?) who don't believe in blood transfusions, or (the Jews?) who refuse to get a pig valve. Now, with regards to taking my boots off before I enter a facility, or as far as me or my partner not entering based on our gender, that's just not going to happen unless I am specifically barred by the owner of the place. We've got a job to do, period. And I'll explain that to them. And it's not an anti-Muslim or anti-Hindu thing, because I've got no more problem with them than I do with Christianity. I'll even pray with anyone that asks me to, Muslim, Hindu, Christian, Buddhist, Pastafarian--whatever. Not because I believe in any of their gods but because it seems the decent thing to do. You've got a job to do and you got to do it, but we shouldn't ever forget that we are only permitted to do as much to our patients as they allow us to. If you can go the extra mile for them without damaging patient care, there's nothing wrong with that.