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Bernhard

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Everything posted by Bernhard

  1. 30 years in EMS and I fairly quickly came down to 3 pairs of examination gloves in my pocket, 1 pair of scissors and a pen light on my belt. No more heavy tools - cutting seat belts is possible with the scissors and our O2 tanks can be opened by an attached hand wheel, no tool necessary for that. However, I'm considering to enhance the number of gloves (on trauma calls I put on two pairs of gloves, then I can get rid of one pair after the messy first minutes without fiddling and losing time to slip into another "clean" pair). OK, I have to confess: I carry a small swiss army knife on my private keychain, which contains a very small blade, a can opener, a small screwdriver, tweezers and a toothpick. But all those tools were in use between calls only, so far.
  2. German ALS ambulances have to be equipped with a second stretcher holder, to be folded down from a sidewall or to be placed in holders in the side wall. I used them more than once to transport two laying patients. No young medics nowadays believe this, but I have a copy of the old equipment standards to prove. Then there were those rolling central vein catheters (you have to apply them like turning the wheel of a fishing line). Suddenly vanished somehow, after we stopped punctuating central veins on each and every CPR pt. around end of 1980ies. (Hey, I just realised, in September this year I'll be 30 years in EMS)
  3. I long was suspicious about the HAIX hype most of my colleagues are into, more or less I was getting things done with other brands. Just some itches here and there. Now since a month I have a pair of "HAIX airpower XR1" and I'm into this hype, too. They are perfect fitting (which is not easy with my feet), expert quality and simply great to wear. No itches! I'm glad my employer bought them. In the US online shop they're listed for nearly ~240$, see http://www.haix.com/us/products/rescue/haix-airpower-xr1 (click on "buy now"). But they're worth it!
  4. - Your favourite county where EMS is disconnected from Fire agencies? Bavaria... Hence programs could start in the end of 2014. My current plan is to start the German "Rettungsassistent" (very narrow scope of practice comp. to a US-Paramedic) this November. You're aware that's the last chance to enter a "Rettungsassistent" course? From January 2015 the new 3-year "Notfallsanitäter" is the only professional education (beside physician) you can start in the EMS field and you have to be associated to an EMS agency for that. What if you're failing med school? You can't use a US paramedic training in germany much (at least legally). But as "Rettungsassistent" you're able to get the "Notfallsanitäter" by taking the state exam within the next seven years. You would be fully certified for german EMS then. Which is pretty promising, the job conditions seem to get much better soon. Depends a bit what you plan in your future. If you want to get a job in the US, then a paramedic license there would be the best choice. If you're just curious about the US and confident to get through med school you may take the cool experience in the states. But If you'd like to stay in Germany for your later life and want to have a fully accepted profession there, maybe the german education would be the better way to go. And starting until December 2014 you have the chance for a shortcut towards the new professional level. Whatever you do, good luck and share your experiences in EMTcity.
  5. Just wondering: there is a study about trauma victims' better outcome when transported fast opposite to beeing "ALS" treated on scene for extended time (just as we needed a study about this, but well...) AND there is the need to treat patients on the spot of an active shooting scene? Really? I don't get it. What about simply getting victims out to the staged ambulances? Every police officer with basic first aid training and maybe some additional lectures in how to carry patients can do this pretty good. We know this same procedure in other hazardous situations: rescue the patients from the hot zone by people who are equipped to survive the given hazards as fast as possible. THEN give them reasonable treatment and transport to appropriate facility. Why change this just when the hot zone is no spilled hazmat but an active shooting scene?
  6. Bad thing is: this just STARTS here...my last 20 years in german EMS before 2009 (when they started equipping our units with them) I lived well without any backboard. However they prove useful in certain situations, but not in all - just as any tool in our hands. Still glad, ED nurses haven't much to tell us here...
  7. Sadly, not necessarily: vacuum mattresses are standard here since the 1970ies, but since backboards were introduced a few years ago, it gets more common to strap down each and every trauma patient on them. I'm fighting against it wherever I can, but can't argue much on-scene when I'm not happen to be the responsible medic. Discussions are fruitless. It's something new and therefore it HAS to be used. ITLS procedures seem to promote this (really?) and a recent external ITLS trainer giving some update lessons countered my arguments with some blunt statements instead of logic and/or evidence. Kind of frustrating how most colleagues follow this "new" paradigm of backboarding here.
  8. Happy new year. I'm working my way back into EMS, so I decided to start reading here again. Missed you all a lot! What has changed? I'm now getting paid for covering the daytime (monday-friday) on-scene officer-in-charge duty. I did it fulltime since my boss (and EMS director) got sick last december and he now isn't allowed to do this task any more due to actual health conditions. I was just the right person (having all the needed qualifications and experience) at the right place (available at the office during work hours). Contract was fixed last week. It's only an additional task to my current office job, but beside beeing more EMS related again, it includes a pay upgrade and a company car...
  9. Really? How come that? How do you do this? Just wondering if that's really in your "job description" or if I just don't understand something. BTW: I see my task in EMS to safely get to the scene dispatch already was suspicious enough to assign a valuable resource (my crew & my ambulance) to, assess the situation and decide if it's either an emergency to be treated immedeately, an issue which has to be transported to hospital or a doctor's office, something we "just" need some ambulatory help (and call a doctor for house visits or point to an open doctor's office - they have to provide 24/7 coverage here), another thing we may offer help (lift patient back into rolling chair, call police, ...) or nothing at all (false alarm, ...). Doing whatever my findings in #2/#3 needs. Preparing for next call. Goto #1. Glad, my system has all those options in #3 and let me decide (if the public or dispatch didn't before). This opens a bunch of possibilities to provide the needed level of care, and yes, you have to be very sure about what you do. Maybe this system is close to this community paramedicine thing mentioned here, just that it's not me who provides that but the regional physicians association. Oh, to answer the OP's question: I'm neither an EMT nor a medic, technically, since those job titles don't exist in my country. I'm a german Rettungsassistent (2 years education, highest level of non-physician emergency care in Germany, so somehwat compareable to a Paramedic in the U.S.). Living in Germany's most southern state: Upper Bavaria, near citiy of Munich. So much for my excuse for lack of understanding, bad grammar and funny spelling. In english AND german...
  10. We once had an excercise where the fluid actually froze in the line. But this was most probably due to the fact, that we didn't used i.v. bag heaters AND the lines weren't running (after all, it just was an excercise - cannulas were applied and connected just for fake). And it was a cold november wind blowing over a large airfield. It never occured to me since then. I think, a steadily running fluid is not very likely to freeze - above a certain temperature... Could be tested easily, though. BTW: a lot of the "victims" were sick afterwards. They were from army and federal police and those tagged black were ordered to "play death" in very loud voice by their superiors allthough shivering from cold. We even weren't allowed to give the "death bodies" blankets...
  11. We carry this in our MCI truck. Heats up a tent in minutes: Meanwhile there are much smaller units, could be stored in a small compartment, needs just to be fueled from a diesel canister, just like this one: Both of them could be used to heat up locally, even outside, when ouput flow is somewhat directed. Disadvantage would be operating them in hazardous or explosive environments...(as a flipped over car could provide)...
  12. One trick I heard of but never used myself yet: mobile halogen floodlights of FD could be used as local heat supply. Mountain rescue around here uses special blankets and i.v.-warmers, due to their usual scenes they're limited in weight & space, to carry much more high tech equipment. In ground EMS we have a storage comparzment for warmed iv's. But not much more beside blankets. Allthough I'm looking for solutions since years... On our mass casualty trucks we carry oil heaters, warming up a tent in minutes. We didn't use that yet for still entrapped patients, maybe a possibility. For providers good and dry clothes are essential. Everyone of my response group has a clothing set fitting local climate more or less appropriate. We additionally can set up a heated tent (see MCI truck above) and may offer hot tea if there is enough time (and no need to treat multiple patients). Mostly used on fire scenes or SAR scenarios.
  13. Throw the BVM out and attend an EMT class if you really want to know more. Performing mask to mouth is NOT easy for an unexperienced person and mostly will fail then, making things worse. Don't compare mannequin training to real patients.
  14. "M*A*S*H", in Germany they aired it without the canned laughter, which was a good decision. I liked "Emergency!". A similar german show was "Notarztwagen 7" from the 1970ies, I really appreciate the old style settings (they even have an english wikipedia article: http://en.wikipedia.org/wiki/Notarztwagen_7, for the opening titles see youtube link at the end). Later german EMS shows from the 2000s were awful, couldn't watch more than one episode each. "Third watch" was OK in the first one or two seasons, then it turned stupid. Same for "ER". As a kid, "Firehouse" influenced our playing a lot.
  15. Dwayne, this is a tough call and you did well. My own experiences are not to be compared due to setting, but my arguments may have included (and a lot of them are already mentioned): Sometimes it is helpful to make really clear, that the patient is able to decide and you will give him the freedom. This will take a lot of stress out of the situation, since sometimes people aren't open for arguments when they think, they have no choice anyway. "Why did you call us in first place?" showing the severeness of the wound - literally. Expose the injury and give a sound explanation. I have this a lot with drunks, bleeding all over from a cut in their forehead or such, ignoring that they should get a trip to the hospital. Since a while we carry a small mirror on the ambulance just for this. The moment they see the wound, nearly 100% cooperate. explaining the medical risks in clear language. Explaining, that pain will get severe and blood loss will be significant after a short time, when initial shock mechanisms release. explain the possible treatment plan and see if there's a problem you can address ("Needles? Your leg is cut off and you still fear needles? That's cool!"). Explain chances of having the leg re-attached or at least saving more of the limb than hours later. Some simply don't know that an ambulance can provide a better ride than a private car ("Think of all the blood on your wife's seats!"). Explain, that you're not comfortable with the situation. "I'm sure it helps getting you to a hospital now and I really feel bad when not giving you the chance". referring to relatives/co-workers and pointing out, that they will have the problem when you leave, including the situation getting worse (more blood, pain, getting unconcious). In case of work related accidents I point out the employees duty to get well soon and to be checked through because of possible insurance benefits in later years...Here a clear word by the supervisor/boss often helps. arguing his reasons. Often it's "can't pay" or "want family to know", sometimes "don't want friend/coworker to get sued" or even "don't want to get away from my workplace". Others are "You just want me to go to get money" or such crap. If the argument is that they won't want to cause work for us: "We already had a tough ride and now are here..." and/or "We get called out for a lot of crap (maybe insert description of drunks wanting a taxi ride) and you have a real injury here, exactly for this we're there!" - that often works for the tough farmers around here. Or "I have more work documenting when you don't want to go with me, than when I can refer you to a hospital!". Sometimes: "Every call makes our job more secure - if you're not transported, someone may decide sometimes, that there is no ambulance needed to cover this area any more...". And so on. In several cases (especially traffic or work accidents) I can treat with police: "Better go with us, or you will go with them". Mostly it's a fake treat, but sometimes work. Clear asking if they want to commit suicide. If "yes" it's legally to force him (police!). If "no", well, at least that is ruled out. Closing statement (in appropriate wording): "OK, you're fully responsible for your stupidity, please sign here and don't hesitate to call again if you then want to go with me". To the bystanders: "Please call again, if he gets unconcious. Thank you, good bye." After all, it's the patients right to be so stupid, but it's my responsibility to make certain that he knows how stupid it is. Dwayne has done a very good job in involving witnesses! For the side question, what have happened if someone get unconcious after clearly stating not wanting help? Depends. I would be legally safe to start treatment then, assuming he changed his will the moment he passed out. Unless there is a clear written statement in place. Where "clear" and "in place" are often the problem then..."Why did you call us? Next time call your doctor who knows the situation."
  16. Richard, I agree with all of your scenarios. #1 wouldn't be a problem here since help is rendered by people, not by cars or stickers (even if the car is an ambulance happening to be driven by a mechanic). #2 would be a no-go here - EMS dispatchers usually are EMTs/medics and even if not I sincerely hope they all know their general as well as their special duty to act in uniform which does not respect coffee breaks. It would be a valuable excuse to the employer. #3 would be a total violation of multiple laws, the ambulance would have been excepted to call dispatch for a "self witnessed incident, responding" and getting their coffe break afterwards. #4 sometimes happens here but more and more gets followed by a talk to the supervisor...meanwhile there is a clear written company policy against that. Overtime is paid here, so no excuse. Another interesting case, where the solution is not so obvious: Ambulance crew is standby duty on some big sport event (horse riding, motor race), where an ambulance is required to be at the field. They witness an emergency nearby, outside of the sport event area. Leaving the area means the (paying!) organizer has to stop the event. What should they do? We regularly discuss this in our classes for new EMTs. Would be interested what you would do. All possibilities open.
  17. Addendum: I just addressed the "duty to act" for random bystanders (lay person or professional). If you're on-duty shift here, you have 100% duty to act when called and can be held reliable dependent on your level/professional possibilities for almost anything. But I considered this as usual, so I restricted my answer to the random passer-by in t-shirt and shorts.
  18. Team play (and, "leading") for me in those situations is: If the incident is uncritical but wrong: talk to them. In your cheating situation, talk to the cheater afterwards that you don't like the situation he/she brings you in. Let the cheater understand that he is a danger for all involved, because beeing catched during cheating often both parties have a rough time. Warn him/her that next time you will notify the instructors. If the incident is critical as in the O2-situation, make clear that this behaviour shows the partner isn't reliable and you wouldn't accept this and/or getting drawn into it. I would have switched the O2 off before this talk. Warn her, that you will notify the supervisor if she continues. Seeing yourself beeing treated too hard is your point of view. That even may be good, because instructors may feel you beeing a better provider who serves to be held by higher standards - even if this isn't what you want... Get over it, make your test appearance perfect! If there really is a personal case with you and one or more instructors, then try to talk with them or their superior. Things like that happen all the time in classrooms, teaching institutions usually can deal with that. Getting off school is an option, too, but I don't see this in your case yet. Witnessing a malperforming classmate is time to show your partnership and leading skills. Offer tips & help in a friendly manner (and outside instructors hearing range), if they accept it, good, if not, their problem. Don't moan about it. All of this is needed not only in classroom but in almost any real job environment - and such situations happen all the time. Get used to it. Maybe my rule of "1 warning shot, then hit" is a rule of thumb for you, too. Don't get drawn into semi-legal "buddy issues" and keep a clear mind. In the end, it's your personal career you may risk when your so-called partner does shit. She/he can't pretend beeing a real "partner" worth to be covered when intentionally risking your future.
  19. I just tried to sort that out for my setting. And found out that I don't know much about sexual orientations of my coworkers, if I don't happen to know their significant others or their facebook status. One of them is gay and a normal medic (not the best, not the worst). He doesn't make a big story out of his private life. I guess, more than 80% of the others don't know his preferences. Another EMT was my best friends girl friend, then open lesbian for a while and now is pregnant. No problem with that. But, reality is, I really don't care. From most I even don't know their loved partners or if they have one/more, let alone their secrets. It simply isn't of interest. Someone offensive annoying me or patients with personal problems/opinions will get some form of treatment, which would depend on situation. That already has taken place. However, never for sexual orientation reasons. The interesting question if someone would refuse transport because of me or my partner? We would try to find a solution, maybe switch positions if possible, but getting another ambulance would be out of scope - at least I can't make up a situation where that would be really necessary. If they're able to argue about beeing treated and transported by a specific team, they're obviously healthy enough not to be treated and transported at all (when age/psych issues are ruled out)...just sign here, if needed call again, we'll be back. In retrospective, I had some muslim female patients, no problem with them, even if I had to examine abdomen and/or chests. Professionality, staying calm and respectful surely helps. And it's possible to reduce examinations to the bare minimum. As always, a good medic should be able to adapt to a situation.
  20. Fab is talking about Germany, but doesn't give the state. Actually, staffing is state dependent, allthough the basics should be the same everywhere: Non-emergency transports: Usually one EMT ("Rettungssanitäter", 4 months education) on the patient's side and one driver (various qualifications due to state). Emergency prehospital care & transports: Usually one paramedic ("Rettungsassistent", 2 years education) on the patient's side and one driver (various qualifications due to state). This can be enhanced by emergency physicians, usually coming by seperate car (some big city systems use ambulances with additional physician on board, becomes rare). Dispatch or requesting of an emergency physician is regulated by a list of indications (critical conditions, possible severe symptoms and/or emergency descriptions). Special units are interfacility intensive care transport, neonatal transport, tox units, those have special regulations. Usually the same as above (medic and physician, both specially trained). Nurses are rare, usually they have to be trained as paramedics as well, exceptions exist in sole interhospital transfer units. Primary EMS helicopters usually are medically staffed with a physician and a medic. Interhospital transfer helis may be staffed by intensive care nurse and doctor, but this is rare in pure form, since most helicopters do primary prehospital care as well. Beeing a nurse doesn't qualifiy you for primary emergency care here, additional education as medic is needed then. All other staffing and additional requirements, especially mass casualty training, are state dependent. The wikipedia article is not quite correct either. A "paramedic's scope of practice" isn't defined because we legally don't need a seperate one (I know, some colleagues may disagree here, because they want to be guided more by restrictions than by our present freedom...). We are bound to same national standards as all other medical professions. So there doesn't exist a list of things we may or may not do, there are no detailed flowcharts or SOPs. The basic rule just is, that we have to call a doctor in certain cases (emergency physician indication list) and pass the patient to a higher level of care - so we may not treat a patient ambulatory (allthough we are able to rule out non-emergencies, but that's not "treatment"). Until the doctor is present, we have to do all to save patients life or protect him from pain - after the doctor is present, we have to assist (hence, the part "assistant" in our job title). ~80% of all emergency calls are handled without emergency physician. So the real scope of practise is our own level of education/training and willingness to argue it (which includes a high skill in documentation!). However, there are some employers which want to restrict employees. I wouldn't want to work there, it would put the responder in a potential legal trap. Some employers or regional medical directors (where implemented) are careful enough to give only guidelines as to set a certain level of quality, which is good. Some really try to keep their employees on a high continuing training standard, which is the best. Most others don't really care, which is reality, but you don't hear much of them in EMS news... BTW, there is a new profession law in the processing, which will enhance the german medic's education to 3 years including beeing professionally paid during education time. This more or less exactly adresses the statement above: they want us to be better educated, the old job law ("2 years") is from 1989, update was needed. Yes, I admit, it's a bit difficult to explain. From U.S. view see it as an enhancement to have a skilled emergency physician on scene, able to play out really all the fancy stuff they learn in med school which surely is above the scope of a street medic, including, sometimes, the arrogance against unwilling patients or family members... With this in mind, the following statements of fab are absolutely right: If the patient needs it, was instructed and is willing to get (or situation implies consent), the provider knows how to use and is able to handle side effects and no other less invasive procedure applies: then yes. Those points including documentation are always the basic things to have in mind when applying pre-hospital care in Germany, for any situation and any provider (especially medic, but physician as well). The "knows how to use" rules out most lower EMT-levels from more invasive things, but generally applies to them as well. It adds a individual component to the level of care, but as a medic you at least have to fulfill a basic knowledge (defined by the job law) which you HAVE to know, including the things fab mentioned. Drug accompanied RSI isn't covered in this defined basic knowledge, but you indivdually may have had additional training on it. If you can justify it, you are legally able to do it (only exception would be restricted drugs as opioids, where applies an additional law). In reality, it is rarely done. We're trained in a lot of things to hold a patient stable until an emergency physician gets there. Especially before RSI we usually have a lot of other things to do, all my RSI's up to now had time until physician (and thus more team members to handle the situation) were present: airway & bleeding control, i.v.-access, pain management, monitoring, extrication etc.
  21. It's foldable and fits in an easy to carry knapsack: (the yellow back thing is stored just cross over the other things, not seen here).
  22. Allthough it's an old thread... I have my educated medic brain with me all the times. You don't? BTW, Vorenus isn't quite right with his description of the situation in Germany. There is a legal duty to act for random bystanders, if they're lay persons or professionally trained. But even if doctor, medic or EMT you are protected under the same conditions as a lay man. There is a bit of a grey zone: if you act totally stupid this may be held against you more than against a lay man, but depends on situation. However I don't know a single case where a bystanding first aider was successfully sued - courts usally respect the intention to help. On the other hand there are a lot of cases against non-helping bystanders (unfortunately mostly dropped because lack of evidence). So, in Germany, when you recognize someone in an emergency situation, are able to help and not restricted by other important duties (i.e. control of small childs) or the need to endangering yourself (!) you have the duty to act. If layman or professional. No restrictions (as long as in scope of your practise and common sense), at least an emergency call (in europe: 112) should be possible to everyone. In the case of own loss or damage/injury you are covered by public/state insurance (which usually is better than a private one). BTW, in Germany obtaining a driver's licenses requires a basic first aid course. Plus: every car has to be equipped with a first aid kit and this is controlled, since it is a valid possibility for police to let you open your trunk - I have mine under the driver's seat... In summary: yes, I would help even with only shorts and t-shirts on (I already did...) - fashion doesn't matter to bleeding. Give reliable sources! My sources: German criminal law §323c, road traffic law §34, road traffic licensing regulations §35h, driver's license regulation §19, public insurance book SGB7 and several comments on those.
  23. When I first heard this story I laughed so hard. "Poor woman, strange medical/technical/tactical response..." I thought. Then I remembered some strange things I see with some of my fellow colleagues here. Even if we are allowed to clear C-spine in field by standards, the new EMTs and medics here still learn "c-spine control in any way". And some or even most of the young ones see this as the high wizardry of care, instead of using their brains. So it could have happened here as well with newly released medics. Recently, a new EMT from my volly group (in german: "Rettungssanitäter", 540hrs edcuation) had to be wise enough to not follow our local training ("think!") but to secure every c-spine he finds to pass the state tests. Especially new providers are so classroom trained on heavy polytrauma incidents that they often forget that the majority of our calls is the light stuff, And that modern cars are built to survive. Maybe we have a problem in education here, when training kicks in - it's good to know the ABCDE's in depth, but it is much more important to know WHEN to apply and/or adjust it to reality. BTW, they probably cut with something like this: (at 1:40 the interesting part starts). PS: We needed 1,5 hrs to get this one out just yesterday night (collision between two trucks):
  24. Generally: don't believe TV dramas to show the real EMS world. And a word on relationships: that isn't a "job" thing, it's a thing between people and their will to work on this...(BTW: family is the real hard job in life and more or less noone really can teach you this). Try a ride-along or some kind of internship as soon as possible, maybe on different stations/areas. That will give you a deeper and realistic insight in your personal feelings with this area of work.
  25. I'm not old, only birthdaily challenged. Had and partly still have. Physostigmine was in our tox box until they threw the box away (never in use and we have tox specialists & equipment within ~10min by air, ~30min by ground). Nifedipine is in the regular drug box, I used it on several occasions (hypertensive crisis) - but very rarely, can't remember the last time (indication: hypertensive crisis & no i.v. access possible & no contraindications present). Are there any news other than contraindication in MI/AP (some years ago N. was banned from using in those cases), I should be aware of?
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