Bernhard

You really need professional help, then! Go to a hamburger or hot dog stand as fast as you can! Immediately avoid Supremes! SCNR BTW: did you notice that the title caption of the browser changes, when replying to this thread? It reads "Replying to Death". Serious: Since I'm volunteering in our local first responder squad covering around 10.000 inhabitants plus a lot of commuters/tourists with 250 calls per year, I more than once knew the patient personally, including declaring death once on a good friend and member of the squad's youth group and worked several immediate neighbors finally frustrane. Another young fellow I rescued two times until the third accident got him fatally despite our efforts, thus never got the chance to know his then unborn child. I tend to not go on the funerals after such incidents even if I surely have developed some coping strategies through >20 years of EMS experience. On the other side, sometimes It's more disturbing to defend myself against people who virtually say I'm a psychological wreck for working in EMS. Often, this is the real disgusting aspect...I am very often confronted with the public's thoughts in the following order: "Oh, I couldn't do that, to see all the blood and bad things!" (Answer: Oh no, mostly it's not such a mess, and we really can help, at least: hold a hand to ensure someone is there to care. Gloves help a lot.) "You really regularly must go to psychiatrist/priest/... for all those bad things you saw?" (Answer: No. We're trained and experienced to do our work, and if we do it, then it's not to us - the patient or someone other //insert higher beeing here// has to do the remaining...or not.) "But it's all so disgusting and horrible!" (Answer: Sigh...yes. Go, see your most favourable EMS/hospital TV show to see how things really are...). To be honest, I have had far more burn-out moments in my white collar/office job than in EMS. This does not imply that there are no bad or heavy influencing moments in EMS work, but it's not so much as several movies/TV shows/news reports try to suggest. As already said: it's perfectly normal to have one or two bad weeks after such an incident. So, to the original poster: let us know in about two weeks what you're feelings about the case are then. Should get better...

One or two weeks of rather extreme stress reactions are normal in such a case. If it lasts more than this, try to get professional help. After the first one/two weeks it's completely normal to have some light flashbacks/reminiscences - in dreams, in similar settings, triggered by some special sensoric input (often: smell) or when driving near the place. This should not come very often, just once in a while and getting less. If it's happen regularly and/or you get extreme stress with influence on your daily life (and not "only" a bad dream once in a while) from those reminiscences then seek professional help. For our unit we have an informational sheet describing stress symptoms, normal and abnormal signs and some tips to cope (plus pointers to professional help). Every member gets to read this and it is permanently posted on the pin board. If you want I can try to translate it. Basically it helps knowing if you have such feelings you know, you're a normal human beeing...and there is help somewhere if those feelings really disturb your life. You're never the only one experiencing this...

In Germany the most effective ingredients of such energy drinks are caffeine, sugar and marketing. I didn't find niacin on the list, at least for the brand with the bull. Caffeine and sugar sure will give you some fast "energy" as well as the 480 kJ per 250ml can will add significant to your daily body mass balance. But the real magic comes from the marketing effect, I think. However, I must say, that I tested such a drink only once (one mouth full) and spit it away. It simply tasted awful sweet and didn't meet my criteria for a drink - and I'm a passionate drinker of cola (since a few years: diet coke). Compared to other colleagues and especially to younger ones with a significant use of "energy drinks" I can't see a better outcome of them on long moonlight rides and overtime shifts or even at excessive bar nights. Most times I outrun them...without coffee, just with diet coke (except for the excessive bar nights, we use other drinks then, you can imagine). So I hold the marketing department of those companies more responsible for any real effects than the chemical branch. And at least for the German market's product ingredients, I can't see any special bad influence on health other than the usual problems with unhealthy living (caffeine, sugar, minimal sleep, excessive bar nights). I can't see any special benefit in drinking this stuff, too.

If you're interested: here in Germany the law is to have full protection gear issued by the organization/company, if paid or volunteer, large city or rural. A public accident prevention & insurance association's regulation specifies this gear (see "GUV-R 2106", linked PDF in german language but includes some pictures). However, this seems not to be known in all services... My rural volunteer service with 24/7 non-transporting first responder unit, event standby medical service and disaster response finally gots rather good on this and issues: sweat shirt, white, long-sleeve (large logo with branch name on back, smaller logo with branch name on front) polo shirt, white, short sleeve (large logo with branch name on back, smaller logo with branch name on front) BDU style trousers, water-repellent (good for warm weather conditions), grey, white reflective stripe on lower leg BDU style trousers, climatic membrane (good for cold weather conditions), grey, white reflective stripe on lower leg leather belt, black jacket, red with reflective stripes (large logo with branch name on back, logo patches on shoulders, small certification level patch on chest), with detachable sleeves and grey inner vest - the inner vest can be worn seperately but looks ugly (we may change to good looking inner fleece vests in red with logo, wearing test starts soon, financial calculation in progress) baseball cap with Goretex membrane, red (small logo patch on front) - ideal for wet or sunny conditions fleece cap, red (small logo on front) - for cold conditions working gloves helmet (german standard, fire helmet), glowing yellow, logo on front and back boots with protective steel cap and sole, oil resistant, slip-proof, covering at least over the ankles adhesive logo patch for the private vehicle's inner windshield (allows parking near the station) dress shirt, blue, long-sleeve (logo patches on both shoulders) Depending on call volume (first responder vs. disaster response unit vs. event standby) there were issued one or more of the above. One person sums up between 350 EUR (medical standby, mostly only one of the above) up to nearly 800 EUR (first responder team members, high call volume -> several shirts and pants). First responders and members of the disaster response team are required to have at least one set of the above in the station. Cleaning and small repair is up to the member, replacement by the service when needed/on request. Protective gear like BSI gloves (each member is advised to have several pairs in the pants/jacket), anti-infection suit and mask is on the ambulance, as well as high visibility jackets and two protective shields for the helmets. We think of buying safety glasses for each first responder, since reality showed, that those two protective shields stored in the ambulance are only put on at excercises... Those responding with the first responder team and the disaster response unit are issued with pagers. Some years ago, each member was given an own stethoscope, trauma scissors, tourniquet and diagnostic lamp (additional to those on the vehicles). This faded out because loss was high and usage was not so common (most forgot them in the station). Now, if someone really wants an own stethoscope he may get one, but it's not issued any more as a rule. Officials and flag delegation are issued a dress uniform additionally (black socks and shoes from own property). Others would go with above even on formal events - doesn't happen often enough to issue a full dress uniform to every member. They may purchase their own, but I don't think anyone does. We started first responding with white plastic jackets and orange jump suits, both a real pain in summer and not good enough in winter plus questionable protection level. Above dress code is valid since two years here and now we're looking good in any condition, it meets all relevant safety standards and could be used in any of our duties, thus making logistics easy. For every thing at least one "second source" exists now (we have had bad experience with "special" clothing manufacturers). Link to a picture of our dress (but imagine white sweat shirt and black safety shoes). Our county career EMS issues state wide pool clothing instead of individual clothing (white polo and sweat shirt, red trousers, red jackets from the shelf at the stations to put on at shift start, cleaning/replacing by a contracted company) and a standard money check for buying own protective shoes. No individual helmets or working gloves but some stored on the ambulance (questionable size fitting...).See this picture (not my county, but it's statewide in this organization anyway).

Cool discussion - keep on! I would agree that the patient has a certain right to know in whoms hand he/she is. But in most cases I encountered the patient was not the aggressor but a bystander or relative. I don't have any business with them, but they're able to identify my name if it's clearly written on the uniform. From the patients point of view, I don't think anyone with an emergency condition tries to read the name tag, even if he would.be able to. I recall only few times a patient calls me by name he read from my name tag or I noticing a patient reading my name. Far more often a non-injured/-sick bystander/relative reads the name tag. Do we have the name tag for them? There wouldn't be a call report for them anyway. As far as involving police should be a help, I'm not convinced. I have the experience, that they won't do anything and to a certain degree can't do anything until it really happens. Unfortunately even in this case they're absolutely understaffed here, so even if I call them in real quick need, they might need more than 20 minutes to arrive. Once I was only four street corners away from police station and they needed >15 minutes (measured by dispatch protocol, my feeling was much more). To answer the question about introducing myself: usually I don't say my name but instead "hello, we're from emergency medical service" (sometimes getting louder and using local dialect if needed), because that's what (I think) the patient wants really to know: there is someone for helping him, Giving a name would add no more information to that. However, if I feel it fits, sometimes I introduce me by name, but not as a rule.There is no real reason to not introducing myself, I just don't do it, and still mostly can establish a calm and friendly setting. If the patient requests my name (friendly), I have no problem giving it to him.

Thank you all for the answers and opinions, please don't stop. It really helps me in my decision (I'm not sure yet, but there are a lot of things to consider). My collected replies to some of your all very valuable remarks: In our countie's EMS (non volunteer) nametags are allowed, but not mandatory, velcro is on the jacket. Since several years, name tags are not issued any more. Some colleagues use the old ones, some have bought private new ones, most don't wear any. Police here doesn't wear name tags either. Fire departments (all volunteer) usually do. I'm not exactly a public servant: especially in this case we're a volunteer first responder squad, not funded by public money. County EMS is a private organization contracted by the county, name tags or uniforms are not described in the contract. Even police officers don't wear name tags here (which is a big thing since a nearby police unit was involved in a case, where a lawsuit was dropped because the involved riot control officers can't be identified, maybe this may change things for police). We are able to be identified by call time and location. Central dispatch knows which unit when was where and then the EMS manager can consult the work time log to find out who was when on what unit. It doesn't identify the person, just the team, but in case of some inquiry that was never a problem to identify the indivudal EMT. I had numerous times patients or relatives refuse to let me do what I need to do. In most cases I can talk them into letting me do it anyway. Sometimes I just had to let them go (if they seem reasonable enough - if it get's worse, they would call again, anyway) and sometimes I had to get the police involved (if the patient is not conscious enough etc). But I can't see, what this has to do with my name. However, I have to admit, there was one case, a caller specifically requested me. Yes, I had numerous times patients or relatives want to see my credential. Mostly as a doctor - sorry, I'm just an "ambulance driver" (sarcasm intended). I had some asking me for my qualification and they were satisfied when told. I don't know how many medics have been killed by psycho patients, I go with the imagination of less than 1% as flamingemt states, thinking it is near 0. But I already have been heavily insulted by name and I was threated ("I find you, Mr. Bernhard, and then..."). Up to now those were just drunk people who most probably will regret their language later (special greetings to the australian girl from last Oktoberfest, her friend really wasn't dying from the cut toe, rather from the shame about her friend yelling into my ear). but in especially this case we were threated by a known violent guy living near my home. I don't want to die in an ambulance crash either, but then other things than my nametag might be the cause. Facebook.is an issue, yes. For a fact, some of the persons involved changed their screen name on facebook the same day. Some colleagues even have secret phone numbers, not trackable by the phone book. I'm not so paranoid, at least until this unhappy event, Our full names aren't on the patient care report, only on the work log in the station. Yes, it's astonishing, how a lot of people know you by name and you don't even know them by face. I greet everyone very friendly, therefore. But even after living almost 40 years in our local 10.000 soul coverage area there are a lot of strangers still. Until now, those who know me from private life don't tend to be violent against me (not counting the neighbour who crashed in my car recently, he may get a little angry about the repair bill I'll send him). No, I wouldn't go to a doctor who wouldn't let me know his name if I want to, simply because it would be difficult to find his office then. But in EMS I don't get called personally (rare exception see above). They call "EMS" in general. I don't think that's comparable with a decision to visit a specific doctor. If someone asks me for my name, it would depend on the situation: if he's aggressive and threatening he would only get the office number and the units call sign, which in combination with time/date is enough for a complaint about me. It's absolutely right, that if someone really wanted to know the name of someone who showed up on scene, that there are more than enough ways to find out. But this involves a somewhat intelligent search, which a "normal" violent drunkard who just happens to know my face and organization won't do. With a name it's very easy to search or ask. JPINV, your remark about hiding the name is a false sense of security is absolutely valid. I will consider this, but, what else could we do with the occasional aggressive patient/relative/bystander? At the moment we wear jackets with logo/branch on back plus logo on both shoulders and sweat-/poloshirts with our logo/branch on back and left chest. Name tag is worn on jacket only (velcro), a velcro patch on the jacket's chest states our qualification. On the sweat-/poloshirts we attach our ID card (clip), giving full name and qualification. Both, velcro name tag and ID clip could easily be removed if the individual provider decides so. But I look for a general rule to give to our volunteers. Again, thank you for your opinions (and don't stop), I can take those valuable views into a local meeting. Even if I know, that there seems to be no real solution...

Recently I was part of a small fight with a patient's drunken relative who thought that we didn't treat his family member right - he attacked a colleague of the other ambulance, we others could release him an hold him down until police arrived on scene (needless to say the patient got a completely adequate treatment anyway). This wasn't the first occurence of violence almost out of nothing on scene to me, many more times I was able to verbally calm down such a situation. Including beaing insulterd and threatened ("I know your name I'll find you!"). Up to now, this never really made me anxious since they were too drunk to remember anything and/or from somewhere else out of my home town However, the last one gave me some thoughts, since the attacker is known for violence especially when drunk (including usage of knifes, already had some years in prison) and doesn't live far away from our village, probably often attending festivities (including alcohol) where we are on standby. Chances are high, that we meet him in future (actually I met him two days after the incident in a super market, but he couldn't see me) and even that he could track us down simply in the phone book by our names: we wear them (first letter of first name, full family name) on our jackets... Since I'm able to change our politics here, I now consider to get rid of this possible threat. Some of my thoughts: Names are useful in team work - we wear the same uniform in larger disaster teams or on larger event standby duty, where we don't necessary know the other medics from everyday work. It's helpful to address a collegue by name, so the nameplates sure help in getting work done. Usually we're calling us with our first names, even those colleagues we don't know. So for internal reference the first name on nameplate would be enough. However, if dealing with the public (which we're supposed to), I consider the "first name only" not a professional appearance in a serious business as ours. I have no experience with that, so I may be misleaded here. Now I'm stuck without a real solution and need opinions...please feel free to give me some. Thank you in advance! (actually in the situation above I removed my velcro nameplate while we hold the attacker down, so I might have a chance that he had not the time to read and remember my name, but this is not possible in every situation)

Both things won't help the arresting patient either. Read good stuff (books and academic papers) - beware, there are myriards of bad examples. Ask your teachers for examples. Maybe there exists collections of former exams? Try to analyze the good stuff: what makes it good, what is the inner logic, the specific wording, typical descriptions. Ask for help on this, let someone show you the specific points until you're able to recognize them yourself. Practise writing, if about actual topics or fictive ones. Let someone read it and ask for feedback. Maybe your teachers will help, if not, ask fellow students (good ones) or someone with experience in successful writing. Four months is not much. But with a little effort you may improve enough until then. Good luck!

Before we do all our lab, X-ray and fancy stuff ourselves (I'm surprised what you really have in your ambulances, whow...): what is the complete diagnosis of the ER docs? Simply "altered mental status" is not their whole finding, I hope... Unless I have a complete misunderstanding of the ER setting at this site. Please correct me then.

Probably nothing. There may be many causes for the leaders reaction, some I can think of (beeing myself in a volunteer lead position): They seem to have no problem getting members, when they're able to interview a group (!) of interested people! So they basically have the luxury to choose and rule out people simply on slight "misfits". They may have other reasons to deny you. Which may have nothing to do with you or beeing anything but reality based. They have had bad experience with career people in volly settings (see below). For my volly team I too want to rule out those we will have to invest much time, effort and money into only to find out we were misused as a cheap starting point for something else. Occasionally that happens. But I only have one or two single person interviews per year, so I have simply not much of the selection possibility. So normally, I would give it a try, if the candidate is still willing after I described the high standards he has to meet. Our training schedule involves a basic medical responder course, which is not very expensive and in most cases we see there and on following ride-alongs, if a candidate is fitting. We have had candidates I didn't want to go to further (more expensive) education then and some candidates realizing that it's nothing for them after this course and ride-alongs. Point 3 above is something to consider. We here have several people choosing the full career EMS path after beeing long-term, valuable and really motivated (plus highly educated) members of our volunteer service, even some in leading positions. None of them is seen often any more, despite said otherwise. Shift plan, family and the will to see something other than blue lights and medical scenes IS a reason in real life. I fully understand this, but from the volunteer squad's view this is a major loss. On the other side there may be the leader's fear, that better educated and experienced career medics could have a bad influence on the volly group (either mixing things up because of bad attitude or really demonstrate that the group is sub-standard). If you really want to get there, I would suggest to give it another try: go there, talk with the leader again in a friendly setting and explain your feelings, reasons and plans. Try to understand his miscomfort. Make clear that you especially like the high level of his squad and how you expect to be able to meet the hourly/meeting requirements later. But be warned: some years ago I had such a candidate - I had a strong disbelief for her motivation to stay longer than the practical ride-along time she wanted to have before entering a medical profession. I wasn't very friendly, made it clear that we want a long-term membership and not beeing misused as a fun experience. She tried again to convince me two times until I assigned her to some shifts. Meanwhile, we're married.

Just checked: "Germany" here means one single school, offering some special first aid courses but no official german medical profession education. No wonder, because this would be observed by state authorities...but it just takes not very much to be allowed to train "official" first aid courses accepted for getting a driver licence and recognized by work security insurances. Tricky: they simply made a german, austrian or swiss medic profession (protected titles) mandatory as entry level for the AREMT certificate program. So, the student at least has a state recognization already and just gets an AREMT certificate on top. But an AREMT diploma alone isn't sufficient to staff a medic position here in Germany. Nobody would know about it anyhow.

I see. Known here between the different companies/organizations, too. Until reality strikes. I smell another systematic error here. OK, I agree that a fast transport is better than nothing, but that puts the system way back to the very beginning of EMS. We have volunteer first responders here, too (actually, I volly in such a team), but they are not counted for arrving time in official statistical evaluations. Only the public EMS counts (private companies/organizations are included into the public system). And: always an appropriate unit has to be given the call, any minor unit may serve as first responder but would be backed up by the appropriate one. So the evaluation is done by time (including call taking and turn out time) AND level of the unit (by the way, including "too much"). The volunteer first responders don't do transport and they are not financed from public sources. Well, the needed public units are available here (law given maximum response time 12-15 minutes for ALS units on normal roads, exception only for some islands and high mountain areas) and there is constant evaluation in selected EMS areas plus every few years for the whole state. Surely the population density here can't be compared with rural Australia... OK, sounds familiar. We have to be trained on every medical equipment brand we use, so a normal unit simply can't transport complex patients requiring special equipment because the medic isn't trained on (mostly involving complex breathing parameters, variety of i.v.pumps and special monitoring devices). In the far past we either tried with our equipment or took hospital staff with us. Since some 10-15 years we have enough specialised and equipped intensive care units and helicopters for those cases spread around the country. I miss the baby incubator transports, though (I had the training for). But, back to the discussed case: Are there really EMS providers not able to handle a simple extremity i.v.-access? That is so basic, I can't imagine this. I don't write of poking a hole in the patient, but simply of taking care for an accessed i.v. line. What could happen? If something goes wrong, then stop the drop. If the needle falls out, then treat the wound. Just wondering what could be the cause for such a regulation. And if they really may not handle a simple i.v.-access, why are they allowed to draw the needle then? Sounds very strange and I doubt it as well as you are. But I think the thread just gets another focus on certifications instead of the given case.

Sounds really bad. But, happens sometimes, yes. Just be sure to be not that a**hole next time yourself (with lack of sleep/food/toilet/luck some people simply tend to get nasty out of nothing - not to say, this should be an excuse for bad patient care). Yes. Should be reported, doesn't help to ignore on the long term. A good EMS agency should have a quality management system which has an answer to such incidents sufficiently solving issues instead of just punish someone (hopefully...yes, I'm dreaming sometimes of such things). Beside that individual fail, I see at least three other trouble causes here: Why did they send an ambulance with no appropriate staff/equipment to such a scene? Not sufficient information given in the call to dispatch (improve next time!), really wrong dispatch (another point to report) or simply no other unit available (sh*t happens)? If there really is a protocol, that doesn't allow ambulance transportation with i.v. access (depending on EMT level or not), then THIS is a major systematic error. If this is really the case (I almost can't believe it!), then try to change this, maybe make it public! The original poster (Penthrox) seems to get easy pissed off, from what I see in the other posts above. Maybe there were some other more personal issues additionally leading to the unhappy event. Again, no excuse for bad patient care, but we have only one side of the story. Well, if the venting helps... But please, just don't get on the "volly vs. paid" track here.That's not the issue in this case.

Actually, I constantly whistled the tune of "Convoy" when rolling to help in the big flood of Dresden 2002. The whole Autobahn full of blue lights flashing from up to the horizon in sunrise was the perfect fitting scene (more than 1500 staff in around 500 vehicles from state of Bavaria responding in the first few hours). My driver didn't like it, though (8hrs to go).

With some experience in event standby medical service, responding to surrounding youth camps (even completely evacuating two of them since) and in EMS: if you're thinking a tenth of a second to consult EMS, call them! Some additional advice: a decent medical post with somewhat trained people (at least frequent first aid courses, maybe there are EMTs or other medical personnel with your guests available, at least on short notice) is a good idea. tell the EMS providers in this area that your camp is there. Makes finding easier and they may understand your problem. Maybe they're even willing to assist with good tips, supplies or staff (provde free lunch! ). I don't think that you will gain a bad reputation from EMS providers if calling EMS frequently. They may be better prepared if they know, that there is a gathering. Transport policy is locally different as I understand. Ask the locals then, let them handle this. Setting up standards is difficult and will require professional advice (both, medical and law). Some general advices would be enough for the start ("if unconcious any time...", "still bleeding after 5 minutes...", ...), I think. A good thing may be to educate your first aid staff with several practical training examples before (or even during) the gathering. Good luck!

Enough funny things in my logbook, but this was the most recent, happened last week. My team finds it funny since then so I give it away here as well. And, I never liked the line "Paramedics save lives, EMTs save paramedics", but now I must admit, that finally it seems to happen, at least once. Time was 03:40 a.m., patient with multiple coronary problems (written medical history of past doctors and hospitals lists 8 critical diagnoses with potential of leading to immedeate death) sits in his chair, so far conscious and still stable. Called because "short of breath" which was a clear indicator his doctor gave him to call EMS. So far, so good, we were there, all basics done, transport soon to begin - I just wanted to interpret the 12 lead ECG. But: the strip is completely strange, I don't get a single clue, staring at the strip for several time. Something seems to be really weird here... Finally, my friendly partner (a "Rettungssanitäter", 540hr, something like EMT-B or -I) just points to the strip and says calmly: "I would turn it around". I realized that I just tried hard to interpret an upside down ECG strip. After turning, the ECG was still strange (this may serve as my excuse), but at least I could read the letters on it. Well, it didn't make a change, a real careful transport to a specialised center followed without problems. BTW: this was the patient who told me on our arriving, that we may not find a blood pressure on him. Strange thing was, he was right (and it was mentioned in his medical history as well)!

I tend to find almost only female anatomy pictures with google... :) Sorry, couldn't resist...

I like this forum, making you check over the basic things... Just took a look in our local used skin desifection's product data sheet to verify. It's an alcohol ("Propan-2-ol", Isopropanol) based desinfectant with bactericide (incl. MRSA), fungicide, tuberculocide, virucide (not all but incl. HBV, HIV, HCV) and sufficient against rotavirus. We have it as 250ml spray in our EMS equipment, in our disaster response equipment we carry alcohol pads containing the same. The data sheet states for punctuation/i.v. access on arms or legs: "soak the skin wet, wait 15 seconds, wipe dry". On dirty skin we first use the agent to mechanically clean the skin and then repeat above procedure. However, the data sheet states other times for other puncture locations and OP usage (up to ten minutes). Only for i.v. access at arms and legs 15 seconds seem enough (due to low density of sebaceous glands there). Significant reducing of germ density lasts over 24 hrs, so I'm on the safe side when cleaning the skin and then start searching for a vein as I usually do, thus giving the desinfectant even more time than 15 seconds. I didn't measure "access time" yet, so I only can assume that if I take my time its about 1-2 minutes, sometimes longer, sometimes shorter. The spray is optionally available with an additional marker fluid (maybe helping in identifying veins also), but that's not what we have. The use of iodine is not common here in prehospital settings. For the "choreography" part: in the emergency backpacks of my volunteer squad (no transportation first responder plus disaster response) we have it organized in such a way that all we need for i.v. access is collected in one sub-bag (desinfection, i.v. needles of three sizes, crystalloid fluid, tape, swab). Makes things easy - just take the little pack out and work on the patient's side, leaving the big backpack for the other providers and/or out of the narrow space. Unfortunately this tiny little idea didn't made it to my countie's EMS provider yet...

That's indeed my main concern here, since pain is causing a lot more stress to the body with unhappy side effects - if released, then we (and not to forget the patient) usually have far less future problems. 8/10 is a lot, especially wtih elderly males usually understating. But I agree with all others on a fast transport indication despite some quick i.v. & basic medication as described in my post. This patient has the potential for several bad surprises, better let them happen in the emergency room than in my ambulance... It's common here to give a minimum oxygenation to patients >95%, the minimum is dictated by the masks and is 6l/min (less flow would not make it to the patient). Target is not to increase the 95%, but to hold it. Sloppy speaking, the O2 need for brain & heart may be higher than the SpO2 tells for the fingertip. So, we give O2 for almost all patients with more than minor trauma/illness (exceptions apply). If SpO2 falls, then O2 flow would be higher, usually the next step would be 10-12l/min if SpO2 decreases. I don't recall the exact scientific papers, but as far as I remember one recently read, especially with elder patients, ASA increases head trauma bleeding and has a significant mortal outcome. The drug information sheet on our ASA talks about general amplifying with other thrombolytics (no surprise). I simply wouldn't recommend ASA on bleeding traumas, since one of the two effects is contraindicated (thrombolytic), the other (pain control) can be reached by other (& better) drugs. Why my plan uses Nitro: Nitro (we use isosorbiddinitrate=ISDN) enhances the O2 reception on the heart, and decreases O2 need of the heart - if there's a heart problem, that's what we want. Dilatation effect of larger/distal vessels (and therefore possible enhanced bleeding) is not the main issue with ISDN, allthough a risk. So it has to be used very carefully in this scenario, even if the probability of a STEMI is high, there still may be other trauma hidden - but this is rather unlikely (from what I read in the scenario). I would make sure to have a stable blood pressure >> 100 systolic, a running i.v.-line and a close monitoring. Ruling out contraindications as acute headache, high probability of bleeding and such. Then in the given scenario I would give it rather late in the process (after detecting the ST elevation and some plus time to get a feeling for the stability of the patient) and initially only 50% of regular volume to see whats happening. All in all, the nitro effects are exactly what a heart needs in developing STEMI (see ECG) beside calming the patient with pain relief and a quick hospital access.

Just two more to make the magical number of 10 complete (unfortunately can't edit my prior posting?): Take a piece of paper with you! Write down anything you might need afterwards: number of patients, injuries (briefly), special problems to be solved (mark, if solved), names/call signs of following units and much more. You will get too much information to remember correctly. Another issue is, if you note it, the other party will see that you take him seriously (and maybe doesn't bother you any more). Plus, you get time to think while writing or looking on your writing, looking busy. A prepared form may help, but a blank sheet of paper does it as well for the first phase. Note: A pencil may even write in wet conditions where a ball pen gives up. Re-evaluate yourself afterwards! If noone else does an investigation of the scene work, do it yourself, and if it's just for your own education. Be sure to include a summary with at least one topic which was very good, one which wasn't, something you want to point out, one event you feel uncomfortable with and at least one suggestion to improve something. There always is at least one each - but if you don't have to improve anything, then you don't need to remember those 10 points anymore, because most probably you're living them. Congrats. Hope, that helps.

Just read this thread, sorry for warming up an semi-old one. I know those situations well, from a on-scene-commander's as well as from a first responder's view. Meanwhile I'm considering me pretty experienced at those types of calls ("less than 50 patients are still fun"), but there always is something new to learn, even if I teach this stuff now. There already were a lot of good tips mentioned in the postings above, I just want to add some basic principles I find helpful: Call for help early! A common mistake for first responders is to work and work and work (and sink in chaos) but letting dispatch not know whats happening. The later you call for additional help, the later you'll get it. Smile! At least don't get visually angry. A calm and friendly appearance may offend some, but in general I have found out, it employs an area of calmness around oneself. Speaking loud and clear isn't contrary to this, yelling and beeing rude is (adding more aggressivity and emotions to a scene always is a bad idea). However, don't overact - an oversized grinning face may look more dumb than cool...maybe you have to train this in front of a mirror. Establish a clear command post! You don't at first need a fancy command truck for this, just take what you have: yourself and a paper notebook or clipboard. This does not only include to be available as meeting point for following crews but having them know your position (radio advise). Colored vests help, if available. Tell others (and yourself) clearly, that you assume command until maybe a higher rank arrives. Focus! ignore things, which aren't helpful at the moment. Get back to them (minutes?) later, if they have importance -> handle one problem after another (again: this may change within minutes, but be sure, you are the one who is deciding what and when). With more and more experience I have got a kind of selective hearing. My wife doesn't love this... Follow the circle of command! Assess/identify needs, plan actions, act/give order, check - and start from the beginning again. If somehow lost (most common: trying to get more and more information while forgetting to really act), interrupt and start again. This needs some sort of watching himself, not easy. Taking frequent short rests help, see below. Take a short rest! Common for inexperienced ad-hoc-commanders is tunnel vision. You will get out of this if you actively "take you out of the scene" for a moment. Take a deep breath, ignore all around you for a moment and look around. Those splits of a second are enough, for you it will seem like minutes and you have the possibility to re-evaluate the scene, think over your actions and starting the command process again. Train! Take part in (good) drills, set up your own drills, get hands on scene reports from other calls (EMS magazines, internet, news) and imagine what you've had done, make up scenarios in your head and try to solve them. You can't control everything! If some detail doesn't run the way you would do it (i.e. some "medic" applying any sort of strange medicine) but isn't yet totally out of control, let it go, before you loose control over the rest of the scene. And a lot more ("10 commandments of EMS tactics" would be a good number, but I have no time left...). I strongly suggest the "training" point, to have all the things available and your adrenaline under control (well, sort of), when things go bad. Good luck!

I really like those vids! At the moment, one of my favorites beside the already posted ROCKsponse is the following: I recommend the channel of Jocelyn F. (BlueJ) to see some other good educational videos, obviously done with a lot of fun. Unfortunately, youtube blocks this video in my country due to "content from Warner and Sony". Can you make it available on another server (here?) or mail it to me, please? Oh yes. We recently had a recertification class, where the EMTs were almost as dead as the resuscitation dummy...I consider some sports now in our monthly training schedules, seriously. I'm just on the way for making own videos, but this would be more or less for public relation and education - not primarily for fun. But we'll see, where we get.

The heavy pain (8/10) alone tells, that there is some more than only a none or minor injured patient. This always is a good sign for non-trauma related pain and leads me to check for cardiac reasons. However, there is a chance for some arterial rupture, which also usually does not respond to palpation/respiration. Our coronary syndrome standards include nitroglyzerine, but considering potential trauma, I would leave this for the moment. So here would be my next actions: O2 inhaler mask (6 l/min, if SpO2 reads >95%) at least one i.v. line considering pain medication: we have s-ketamine, which is contraindicated in coronary settings and aspirine, which is not trusted in trauma. So I would like some opioid, but for that I have to call an emergency physician to the scene -> do this. In the given setting, fentanyl already is available for me, which then would be my (only) choice here -> give it (analgesic dose). repeat the trauma check if possible (at least when in the ambulance, depends), close watch on thorax, lung sounds and abdomen. preparing transport: putting patient on a stretcher with upper part of the body elevated, calling dispatch to check with one of those PCI/trauma hospitals. very close monitoring and prepare to meet the following: cardiac arrest or heavy shock. start of transport Since the patients conditions now get worse, I'm thankful that I kept a close eye on him. Not very different from the above, the diagnosis of a coronary syndrome just gots the number 1. So, if the patients blood pressure is still stable >> 100 systolic and my repeated trauma check doesn't show anything, I probably now would try nitroglyzerine. Transport already is in progress, if traffic is stuck, with lights & sirens. Consider more O2 if SpO2 gets lower than 95%. Try to sufficient release pain (may be a bit more Fentanyl, depending on the situation). Monitor vitals and ECG closely. Calm him down verbally. Document. Know where my defibrillation and intubation equipment is - if veeeery suspicious, consider applying defib patches to be prepared. Is there any evidence for a diabetic (history, medication and/or equipment found, i.d. card, shunt for dialysis, typical needle marks)? There are rare cases that the symptoms may lead to another solution then, however, this wouldn't affect my treatment anyway. How does the patient now? Following options are in mind: still unhealthy but more or less stable -> continue the above and hand him over to the emergency room worse, more and more unstable, but alert -> additionally repeat trauma check (abdominal bleeding? pneumo-thorax? or still just the coronary problem?) losing consciousness -> additionally intubation cardiac arrest -> reanimation, full program

Interesting thread...I just took the opportunity and stuck my nose in the books. In Germany it's as following: Three questions, three simple answers: No. No. No. As clearly given by national law, for a german medical professional the patient's will is (mostly) all what counts and I may not tell something to others the patient doesn't want me to. If I would report against patient's will, I would be liable to prosecution and it would be even questionable if the information given could be used in a court. In court, I even would have the right & duty to refuse to give evidence. Exceptions: I may, if the patient allows me to do. I may and depending on the situation I even have to, if it's in his/her "obvious" interest, if usual (i.e. letting know the relatives which hospital we transport to) or if the patient can't clearly declare his will (due to unconciousness, minor age, dementia, alcohol intoxication or such). I'd have to be very careful here! I may, if it's in my interest (i.e. beeing target of a lawsuit involving the case). I have to report a "major crime" (well defined by law, such as murder or rape), but only if it's still ongoing or I have reports that it is planned for the future and my report could still prevent the crime from happening. Physicians have to report distinct infectious deseases (specified by law). This doesn't apply to prehospital care, since this usually involves laboratory diagnosis. This answers your scenarios as following: The girl seems aware of her situation (at least she contacted the camp nurse and/or called EMS) so it's no need to assume I have to protect her from herself. If there is a crime, it's already done. I must not give information to anyone, law enforcement or even the parents, if the patient doesn't allow me. (By the way, the minimum age of consent is 14 over here.) No. The drug use was done, there is no immediate danger for others. I even would be liable, if I report this to law enforcement. A regular occuring case (to me twice last week) is a police officer asking, if the victim is drunk. Most police officers understand it, when I say "go, smell yourself". But last week, one got real angry at me as I said, that I'm not allowed to tell him (it was clearly against patient's obvious will). I then just pointed to his alcotest equipment - I can't measure alcohol as good as he can, so he has to check it anyway. No need to ask me...(result: blood alcohol level of 2.4 g/kg, despite that the patient was alert, fully oriented/responsive and on his feet without any problem).

Thank you all for the warm welcome! It's really great to find an active forum with such a good professional level. And thank you for your suggestions: I certainly will try to avoid acronyms, hoping the ones in my post above are usual ones. Several years ago I discussed a lot with colleagues from around the globe and especially from the U.S. so I may have developed some bad habits in misusing abbreviations. And I'm glad that World War II is over since 1945. Crazy, what the word "German" is releasing still up to now. If you feel more comfortable, then for you I'm just a Bavarian (and yes, I know the real Oktoberfest from the visitor and from the medic side). Would be perfectly OK for me... I already read some posts here about german and especially bavarian EMS in this forum and think they are pretty accurate and still true. But don't hesitate to ask if you want to know something about the way, we do things. I'm instructor for tactics in EMS and disaster situations including HAZMAT and therefore forced to know some legal glitches and the usual misunderstandings, that even my fellow colleagues may have. Looking forward to a lot of interesting knowledge, Bernhard