Bernhard

Medical call: knapsack + oxygene, ECG/Defi Children: additional child box (replaces most of knapsack, but not all) Medical call with known respiratory problem, involvement of vomit or else like that (including suspected/anticipated CPR) - or if a hand is still free: additional electrical suction unit (for surprises: knapsack contains a manual suction unit). Trauma call in house (or garden, mostly all other than a traffic accident or trauma with different access): same as medical call Traffic accident: knapsack (contains cervical splint and pulse oxymeter) The reduction of equipment in case of a traffic accident is reasoned by: 1. the more equipment you have, the more tends to get into the way - and for a sufficient first monitoring a pulse oxy is all you need in this case; 2. you usually can get the other stuff pretty easy if needed, since ambulance usually isn't far away; No, actually very rarely. Usually only in nursery homes, when the emergency is known as "broken leg" or anything else not needing every second of speed (reliable dispatch message, radio report from medical first responder units). No. On my local vollie unit we optimized the equipment after near-critical incidents (mostly occuring in training), where there may have been a significant efficiency loss. But most improvements there are driven by the fact, that we often respond alone (non-transporting first responder) and I like to have the stuff with me and my only two arms. So we have our knapsack packed with all things, we initially would need, including oxygene. Weighs 18kg in sum, but served well in various situations. Only ECG/Defi and electrical suction unit has to be carried additionally then, if needed - see above. Packing your stuff and having the appropriate things at the patient at time with not too much hands needed is an essential thing in team resource management. A lot of optimzation possibilities there.

Kiwi, I don't agree. Securing & maintaining airway, stopping severe bleeding on extremities and pain control are things you need on almost every (trauma) patient. This simply can't be substituted by a random police officer with a car running lights & siren. Yes, I know the studies about penetrating thoracal injuries and I'm the first to admit, that a lot of providers try to do far too much on (trauma) patients than the above ABCDEs disrespecting transport time to ED/OR, but the solution can't be a non-trained individual transporting someone with a non-medical-equipped car without proper transportation possibility. That's simply fourth world medicine. Plus: LEOs usually have totally other and important responsibilities on such a call - maybe there are too much of them there, beeing able to get retrained as medics and getting equipped with real ambulances? I don't dare to solve the problems of that big city, but the described situation is neither medically, politically, socially, ehtically and not ecologically correct. EDIT: typo.

Well, depends a bit on severity. I actually worked one flood disaster affecting my home town - I happened to be the standby chief of EMS/medical disaster response at that time. After deciding to get in action (dispatch still wasn't aware what happened in front of our houses) I took the time to wake my wife, made sure my parents (one street away) were alert, checked my house's cellar and went to the local fire house where the command post was for such situations. Where I met the countie's fire chief, my neighbour at that time, who did the same with his family/house... We then both tried to turn chaos into proper response and regularly checked with our home. in the command post we had all the information about the real danger to our homes, so we felt more comfortable than we would've sitting at home...and we actually had the ability to do much more for our neighbours. Later on, my brother-in-law, responded with his (neighbouring) villages fire department, found the time to look after my (and his wifes) parent house from time to time, since he was assigned to a location nearby. How would it have looked when my family would've been in actual danger and/or I wouldn't have been able to know the overall situation and/or even communicate? I don't really know, most probably hoping that I could be there to help. But some other thought: if response is good & organized, then my family will be safe. "Good & organized" includes every provider beeing on his place in service and not abandon his post. I would do the same for other's families....I hope. In preparation we usually plan the local ressources to vanish if hit by a disaster themselves. Maybe because the responders may not appear (helping their own family, hurt, lost) or equipment is affected (blocked, damaged, lost). Thus, mutual help over medium or large distances is a well-known concept in Germany since the big floodings of the river Elbe in 2002. But in most and even very bad situations (-> river Elbe 2002 and others) history shows that local resources still are the first to respond by any means, trying to save their neighbours and fellow citizens. Conclusion: never underestimate dedication of local folks / responders, even if they're severely hit. And there my be a large gray area between "Help yourself" and "stay in service". Sometimes you can do both. Beeing prepared & informed surely helps.

She could've written this letter very slowly - try again! SCNR

Yeah, could have saved me some time. But, it's a nice answer, so I let it there.

Sorry, nope. The staff with snake(s) is a concept that seems to be mis-interpreted mostly by US citizens...: The staff of Asclepius is the one which represents medical knowledge - it has only one snake...see http://en.wikipedia....od_of_Asclepius. The Hermes or Mercury staff represents mainly governmental/military authority and trade business (associated to Hermes' messaging style) - with two snakes. See http://en.wikipedia.org/wiki/Caduceus. Wikipedia page http://en.wikipedia....bol_of_medicine even states that "the traditional symbol of Hermes featuring two snakes around an often winged staff, is often mistakenly used as a symbol of medicine instead of the Rod of Asclepius, especially in the United States of America". On the other hand, the statement "two-snake caduceus design has ancient and consistent associations with commerce, eloquence, trickery and negotiation [...] sometimes associated with alchemy and wisdom" sounds a bit if it fits rather perfect to nowadays EMS business. And there is noone saying you can't start your own tradition: "The modern use of the caduceus as a symbol of medicine became established in the United States in the late 19th and early 20th century as a result of documented mistakes, misunderstandings and confusion". Seems a perfect rational base for introducing that symbol in emergency medicine. Just my 0.2 EUR (sic!), EDIT: Sorry for double answering - somehow I had the reply editor open since a few days and didn't read the other answers.

Hello dear U.S. friends! A member of my vollie squad will take a year at Portland university and she yesterday asked me if I know someone from Portland EMS to arrange a ride-along or at least a visit. She wants to become an english teacher, so she needs a guest year in the US and already is fluently speaking english, having relatives and some friends (though non-EMS) in Portland anyway. Start will be in summer semester 2013, so its not urgent - but I now just wanted to ask who might be from there. Looking forward to getting some emtcity contact for her, would be really cool! EDIT: grammar. Thank god I'm no english teacher.

OK, you surely have to know your law - good original question, BTW. May I add some views how I would handle it over here (Germany)? Here, there is a law, that everyone has a right about his own picture. So you may not take someones random picture and publish it (poster, internet, press) when he's individually recognizable and/or main part of the picture. There are exceptions, if the person is "part of public life" (i.e. a politician or a celebrity), which often leads to court. But here we talk about some random unknown victim happen to be exposed on a public place: no, there is no right to publish a film or picture of the poor fellow showing him/her identifyable (or, other law: publish the name). This does the trick, because you (as the pictured person or the one responsible for him/her) can prevent picture taking if you can assume, it's for publishing. For what else (youtube in mind) the picture is made then? The photographer can spend the entire time explaining for what he would need the photo until scene is cleared... So, the law enforcement officer, who is the first line in enforcing the law, HAS the duty to protect the patients privacy - if he doesn't take a step to enforce it, I would make a complain so that next time there wouldn't be a discussion. I'm glad, that here the LEOs wouldn't need such things because they surely would take care about it. If not the LEO, then I (if other duties dont prevent me from it - as the original poster constructed the case and as supervisor or nontransporting first responder I'm in fact often enough in that position) would explain that briefly and with fitting attitude to the photographer. No violence, though, even if some actions may even be protected by another law (see below), but that's a bumpy road. If nothing else helps I would take all means to identify the photographer to make sure, LEOs later prevent him from publishing. The other thing is, that the patient has a right (and those who are responsible for him at the moment, if he's in altered mental state) to protect himself even with violence - even his dignity and honor or that of related ones. This, BTW, would cover Dwaynes action on calling his spouse names. However, that's a bumpy road because it needs to be justified (witnesses, recordings?) and could be easily seen as exaggeration. I wouldn't try this on the usual bystander photographer. So, Germans are by far not so defenseless on their own property, health and honor, even if we aren't allowed to carry guns. Totally legal violence! Watch out! On the other hand: everyone has a right and even a certain duty (!) to witness a public scene and especially tax money at work. Don't forget two things: Watching an accident scene, even watching someone other in distress or in pain is a form of human caretaking! We're social beeings, it's in our genes to be interested if someone suffers. It then depends a bit what we make out of that: rendering aid (-> original meaning of social behaviour, karma goes up), breaking out in tears (well...at least compassion, an accepted sign of social beeing), breaking out in laughter (may be a sign of some social dysfunction) or beeing the cause of the pain (totally social dysfunctional, consider a career in clandestine agencies). In modern times, EMS and other agencies soon take care of the "rendering aid" part, so all is well organized and all what's left is the single social human beeing, standing at the side watching, now called onlooker. We, as EMS (or LEO, FF and else) are public services, more or less. We have to expect that someone is watching our deeds - this someone is the public. And we have to be grateful for that. It's one way to remember us and our superiors doing things correctly, dutyful and orderly. It's a opportunity to present our actions! So, just be sure to have combed hair and your shirt tucked in, when you legally and calmly prevent the random photographer from taking detailed pictures in violating the patient's rights. Filming the general scene would be not prohibited, iif that doesn't get in conflict with the patient's or other's plus even the provider's right of beeing identifyable published. Two general exceptions to preventing photography/filming action: The press has much more granted freedoms. Which is very good. They buy it with the duty to care for protection of persons they report about in the proper way. So they're responsible for blurring pictures or such. A provider on scene, assuming someone is going to publish the material against the public right has it easy with some random bystander, but may not interfer with the press. On the other side, it's not always very clear how to identify press (at leat the journalist organization issues ID cards to listed members), could be a bit tricky in extreme situations. Press tends to behave, since they usually want a good relationship enabling their work - then they willingly accept friendly hints. But they even are allowed to endanger themselves! BTW, there was a well-known incident where press took an active part in a hostage situation, which lead to a very restrict self-control of the press (reference: ). It could be technically difficult to identify someone taking pictures. With mobile phone cameras almost everyone is able to do it more or less concealed (and publish it in HD right from the scene). So, you (or better the LEOs) can only focus on single ones suspected of filming details or those who really disturb the work. That's the situation here in Germany and all providers should be aware of that. It's regularly covered in magazines, and I happen to teach this topic once in a while to new EMTs (law citation and paragraphs available on request). BTW, the same laws applies to providers filming the scene. This said, and sorry for the long post, a totally other thought: What would you do, if the patient requests or willingly accepts filming?!? it may be that he/she wants to have something to show to the grandchildren, he/she simply want's to get famous on youtube or he/she doesn't trust you. What would you do then? On a sidenote, in a recent disaster excercise they implemented an injured victim who constantly filmed other victims with her cell phone. A very nice idea (for excercise setup) and I think this may be the truth in near future (or already is...). I solved the issue by requesting LEOs in the tent, they then cared about the cell phone.

Check SpO2 during seizure. If it doesnt drop, chances are high it's not a seizure, but rather a hyperventilation tetany or a fake. Doesn't help much after the supposed seizure, though.

From my own experience in the first 3 years of my sons life: every night with less than 20 apnoe/brady alerts are good nights. Wish you all the best and a lot of zero-alarm nights!

What if it's a lady? So, they can serve and getting imprisoned, too - but is the gentleman code valid for them, too? And what if I'm not a gentleman? Things get complicated now.

We have a kind of funeral code in EMS/fire/police/disaster response: a black band attached to all vehicle's antenna for a few weeks. If the person was member of a volly department (EMS/FD), they usually have their local banner with at least three uniformed guards present at the funeral. Unfortunately I had to stand there as such recently when a member died at age 36 from an unknown heart disease. There is no special funeral code for other members than the banner guard, they simply attend the funeral - most EMS staff doesn't have formal uniforms unless they're a fire based service. The volly department banner guard is present on some other festivities as well, if applicable (church processions, anniversaries of local or befriended clubs and so on). Organizational marching bands are known but rare, unfortunately. Other more happy "traditions" include a yearly barbecue. In former years the night shift on christmas and newyear's eve usually found some present from management in the station (usually something to eat, sometimes other useful stuff, I still have the mini-maglite with an imprinted star of life from 1999/2000). Don't know if that's still the case, since I have family I avoid those shifts and having on-call chief/supervisor duty seems not to count. BTW: checking stuff at shift start I wouldn't name a tradition but self-evident... Hah! Just read the original posting and realized, this thread got in another direction somewhere between... Hm... traditions transferred between home and (EMS) workplace? No. Eating meals too fast, having gloves in every pocket, a ritualized system of stuffing things into trousers/jackets, constantly checking if a pen is with me, asking "Request: Loation?" on the phone instead of "Hi dear, where are you now?" and such things? Yes.

We have no policies about tattoos. And, I tend to believe, that most patients don't care, since they have other problems at the moment. As for the non-critical interfacility/non-emergency transport: especially older folks are more tolerant than some of us think. I personally don't want a tattoo on me and I don't really understand why others want to be tattoed - but I don't care. OK, for myself it may have to do a lot with beeing on the wrong side of a needle and I had some good laughs about a tattoo of a little cute bear on a male friend (no idea what he thought of it, it surely wasn't machoism). But generally I really don't care. A fellow EMT is part-time tattoo professional and wears them herself nearly all over, at least arms and neck visible (never checked more below...), most fantasy style and ornaments. Looks strange, but you can read a lot if getting closer - good for long shifts, I suppose. However, an EMS tattoo (or FD or LEO signs) on a provider/firefighter/officer I would rather see as whackerism than as dedication Depends a bit how it's made and how visible it is. On the other hand: what's it worth, when not visible? See, I simply don't understand the concept of tattoos... Just my 0.2 EUR. EDIT: typo & remark on readability of tattoos.

A very good scenario! Remembers of using things we DON'T expect or DON'T see as diagnostic instruments. Great work on this patient to get him a diagnose, Dwayne, respect! BTW; maybe a little lung function test device (spirometer) as used by asthmatic patients would have helped on your site?! They're cheap (~10-20 EUR/$, multiple use) and a real simple test for lung capacity on a complying patient:

Since we have the LUCAS2, too, we simply attach it and the ventilator and can go outside for a talk, a smoke or an occasional beer, just as the patient and his machinery making itself out. Really cool. No kidding: it's not alone about freeing hands but in the first place about accurate inflation and using somewhat basic ventilation parameters you don't (easily) have when bagging by hand, at least not in a regular rhythm and accuracy over the time. Intubating & ventilating is rather common here, not only in CPR cases but in trauma scenarios as well (RSI). Then after first few cycles with bagging the automatic ventilator is attached. Ressources aren't the main topic, here in Germany on critical patients mostly at least 4 providers are on scene (1 physician with his driving EMT plus 1 medic with his EMT partner from the ambulance) - plus a random number of trainees, volly first responders and/or firefighters. Additional ressources are only ~15 minutes away. Never called them for single patient treatment, though (only for lifting manpower, but rarely). And I have to admit, we rarely do CPR in the back of the rig (where we even would have 2 providers then: the physician and the medic, the EMTs are driving their vehicles) - usually, if no ROSC on scene, a patient is declared death right there (exceptions exist, and I still know former times were we transported nearly every body). I don't have any familiarity without them - they've been there since I started in EMS >25 years ago. So I (and Vorenus) might be just blessed on this.

OK, I stand corrected! Sorry Vorenus, and sorry to the others for misleading you all. I have the european EN1789 standard here at my desk and first read only in the "airway management section", wondering myself since I don't know a german ALS ambulance which has no such respirator. Now I read the full standard again and found it in the "treatment of life threatening situations" section, one page further on... ...and here it is: "automatic ventilation device (EN 794-3)", mandatory for type C ambulances (however, not for type A1/A2 and B ). Sorry again. Vorenus is right, at least with european type C ambulances, which most ALS units in Germany are (and probably in other European countries as well but I don't know much about ambulances there). EDIT: the editor turns a "B )" (without space) unintentionally into a smily face. Nice, but not much informative...added a space between.

I'm with Vorenus: german ALS units usually have automatic transport respirators on board and it's common to use them on intubated patients. It's no big hassle for the transport time we usually expect (<1h), makes hands free and provides continous ventilation at desired rate without getting tired. Known brands here are "Weinmann Medumat" and "Dräger Oxylog". Only correction to Vorenus' posting: it's not a "must have", european standard EN1789 doesn't require an automatic transport respirator on ambulances (and the old german standard before 1999 didn't as well), but somehow they are available since I could think EMS-wise... On ICU units there are far more advanced respirators needing more knowledge about intensive care ventilation, since the patients often have specific parameter settings which should be continued on transport. That's not an issue in normal ALS emergency respiration.

Regarding splitting up crews: been there, done that. Regularly. Usually I'm the one taking command if #providers < #patients, since I've got the training and regularly do supervisor/commander shifts. Even, if I'm the higher leveled medic. So, when arriving on a scene, I let my partner carry the medical stuff (jumpag, oxygene, cervical collar), I only take a notepad and a pen (plus a flashlight, if it's dark). We both go to the first patient and check, if he/she's in critical condition. If not, we give tips to bystanders/firefighters for first aid and both move onwards to the next patient. On the first patient needing acute intervention, we split up - my partner starts treatment (even if he's only BLS licensed, but in almost every case my partners can handle at least basic issues including first steps in extrication scenarios pretty well) and I go to the next patient alone. Often the first critical patient is laying beside others (i.e. one damaged car with several people in it), then my partner has to care for all of them somehow and I'd move on to the next bunch of patients. From that on I won't treat other patients personally, only order bystanders or firefighters to render basic first aid. I would count patients (notepad is useful!) and get back to the ambulance giving report (we don't carry portable radios, yet). On my way back I usually check my partner's work and may update him on the scenario and maybe assigning him to another spot where his care is needed more (rarely). After giving report it get's a bit tricky: with one eye I have to look at my partner, with the other eye check the bystanders/firefighters aid and with the third I look out for arriving other ambulances. Those additional crews will NOT be split anymore, but assigned to critical patients, then to those my partner is working on (which are critical as well, see first step) and then to the remaining ones. I use this if I'm the first EMS ambulance or in my first responder service. Works pretty well and organized. It gives a scene overview as fast as possible and does as much medical help as possible for the moment - including advising for first aid. But it has to be said, that we have additional ambulances only 10-15 minutes away and can call multiple helicopters within in a 15-20 minutes radius. Only one incident I can recall where this went a bit strange was when I had a very new EMT on board (just his first day from EMS school). A byciclist hit by a VW bus, which flipped over (don't ask me how) and blocking the direct sight line between ambulance and patient plus a helicopter who needed constant radio contact because simply not understanding where to fly until he finally hovered directly over me (don't ask me why - had to explain our location in all possible and impossible ways). The bus' driver was uninjured so it was only one patient, happened to have a "standard injury" (broken leg, nothing more) and the new EMT did very good - but since I didn't know him and was supposed to supervise him I instantly grew grey hair not beeing able even to watch what happens.

Great scenario, just read the whole thread, unfortunately too late to participate. Especially great since I had a very similar case recently and this made me think a lot over it again (89 y/o female, known COPD and CHF, home oxygene used - we applied CPAP and it significantly increased SpO2 soon).

They taught me the shock index in advanced first responder class in my very beginning and made a big thing out if it, even beeing an item in the tests up to more advanced levels. In the field I never used it directly or even calculated it on-scene, but I used the general comparision between heart rate and systolic blood pressure as one of many indicators that something may be going downhill. As others pointed out, there are several signs for that, a good one is a significant changing in continous monitor results, which includes heart rate and blood pressure. After a bit research now I learned that the SI seems to be a more or less obsolete concept, generally speaking. OK, but I never did see it as a real value to be calculated on scene anyway, so I will not miss it. Using it for teaching? Well, in a historical context, maybe yes. A lot of books/texts do mention the shock index, several studies and some algorithms do as well - so the student should know what it is. On the other hand I doubt it's usefulness in teaching something about the physiology of shock...the raising heart rate and dropping blood pressure or the simple fact that the two compared are giving an index is just one small part of the whole mechanism. And not a very reliable one. So, yes, teach it, but don't give it more meaning than it has.

Hm, whistle is the correct term, I guess, yes. So, not those ones: But something like this: The Uhura analogy may be just fine, yes - only louder.

If first patient not breathing AFTER checking (and if needed: opening) the airway, then he would be seen by the second ambulance to arrive. And most probably then declared death on scene (after having a ECG applied and asystole approved). The first ambulance to arrive would instantly be pointed to patient #2, who still lives. This is generally speaking, in reality it strongly depends on circumstances. And I think as ambulance provider I would check both patients myself instead of let me beeing assigned by a random first responder...

Correction: we have and I use them since beginning of 2010. Just confused years. Addition: I still use e.t. when LT is contraindicated, but that now has more or less been reduced to trauma with pharyngeal bleeding or instability or other concerns that a LT may be not fitting enough. Last week we had a burn victim (70-80% 3rd/4th degree) needing RSI, where due to confined space situation beside the railway track and within the bushes the e.t. effort wasn't successful but we were instantly able to sufficiently place an LT without hassle from the accessible side of the head. I see the LT as a real useful additional (!) tool, working both as fast primary (if indicated) or as secondary/backup (if e.t. doesn't work) attempt for securing an airway. Don't want to miss them anymore.

I have since they have introduced them here in 2011. Its fast and Easy, I use it instead of a bag valve mask. In 2 incidents we couldn't place it but had difficulties with e.t. as well (obese/noneck). In the first year we replaced the LT just before transport, following the then accepted knowledge to not have a LT on a automatic ventilator. Now it depends, if it fits, we leave it in place. Saves a lot of time, generally.

In german disaster response services, following standardized (and borrowed from german army, I'm pretty sure, most probably even before world wars) hand/light signals are common, meanings vary a bit according to context. Some of them are: hold one arm up in the air (and/or steady white light): "Attention!", "Watch me/make contact to me!", "Acknowledged/Ready!" - this may be accompanied by a short pipe signal or a shout to get attention. wave arm over the head (and/or waving red light): "No!/Error!/Didn't mean it!", "Didn't understand!", "Not ready!/Wait!" crossed arms over forehead, ellbows on the side (or blinking green light): "Prepare for beeing ready!" hold one arm up and make large circles over the head (blinking white light): "Come together! Line up!" hold one hand up and make small circles over the head (dunno light signal): "Sub-leaders to me!" turn one arm circulary beside the body (and/or turn a green light beside the body): "Start work!", "Start engines!" one arm on the head, ellbow on the side (or blinking red light): "Stop work/movement!", "Stop engines!" push up one arm beside the body multiple times (and/or push up green light): "Get in vehicles!", "Start moving!/Faster!" push down one arm beside the body multiple times (and/or push down red light): "Get out of vehicles!", "Stop movemen!/Slower!" and others... They're pretty unique so someone understands the basic ones even when not beeing fully instructed. It's not designed for detailed EMS work, but for more general far distance signaling when working with convoys or several dislocated groups/engines (i.e. long distance pumping). Additionally there are several standard signs for aiding a driver when backing up and so on. Common danger signal on scene is a piping or horn signal, alternating high/low (or on/off), meaning "Drop all and leave area!". Emergency signal are long (high) tones for "Help me!". Signal pipes were common until the 1980ies, now they're still stored somewhere and in official equipment lists, but rarely known/used unless some leader still has a thought about radio equipment failure. For more detailed information such as number and condition of patients or area information I would use written messages and a runner, if electronics fail.