Bernhard

I "raised" several young folks, some of them now are respectable career EMS in their 30ies. But this one is a new quality, I've never experienced before. We had some adult clowns with full licenses coming in from another unit (after relocating to our village), who fu**ed up things here until beeing thrown out (in one case this involved a real pain in the a** walk through intra-organizational jurisdication). But now I see a kid in the very beginning and really wonder what may come out and if I'm to harsh with the young ones beeing older now myself. Generally I like this discussion around that topic. I could have handled it all alone, but i figured that once in a while every group has a "whacker problem" and why not getting input from around the world? Cool discussion, keep on. No, OMG, no! I once was a silent young kid, beeing throwed into some random first aid situations where I could use my training from youth red cross group. Then the adult group leader asked me to show up in EMS as ride-along at the age of 17. I was totally nervous, got washed up by heavy rain and having no adequate protection resulting in beeing sick a week after the shift. Didn't give up, though. On my third shift they happen to have me as "medic in charge" (remember: still only 17, with only 16hrs first aid training, even no driver's licence!) on a BLS ambulance, for "only an hour til we have the real medic back from his special assignment, won't happen much anyway". I ended up "treating" a MI without additional backup available (only talking, couldn't do much more, EMT partner had to drive the ambulance) and swearing I'll get the best training ever plus never let anyone experience this again (no fellow volunteer, nor patient). So I was the first pure volly in our county getting to medic school, which was the start into my part-time EMS career. And soon after beeing 19 I've (more or less accidentally) got in charge of my squad - then I raised the standards, resulting in one of the best educated volly squads around here. Regularly I "loose" fully educated vollies to our career service. Just for the records, this was 25 years ago, times (and EMS laws) changed, such a "17year-ride-along-in-charge" thing won't happen any more in our EMS system. Thankfully. I'm just considering a bit if i let him show what he can (the one standby duty we had there were no possibility). But it might be a wrong impression since such people tend to behave if i'm present - and fu** up things if i'm not there...

Oh, whow, thank you all for your valuable input here! I don't want to give specific replies, only some additional info - just let the thoughts flow on. I have no personal problem with this boy. It's not that I was pushed around by him or such, I only was rather "non-impressed" by his way he worded his email - most probably seen to much heroic movies... He just don't get it until now, that others may see his "enthusiasm" as pure wrong-guided whackerism. I had a talk to his schools first responders leader, which I happen to know very well, and she doesn't know much what to do with him either - only she has a certain commitment to teach the young ones. As Kaisu pointed out, it's clearly not my job to raise a child. We are the adult league here, and there is no time for child care. I have a lot of childish issues anyway with my 20 year olds and often enough even with my >40 year olds. Age of 16 years is the minimum for our squad, and until 18 they're restricted to certain services and working hours plus have to be under supervision by an adult and experienced team member, not counted as full provider (even if they may have the training already). So there's not much what can go wrong. I had worse adult ones... Additionally, my group isn't in urgent need of new volunteers, we have enough for covering our duties and most of them are younger ones around 20-25 y/o. Training level and standards are pretty high here, which seems to attract people from other villages to get into my team instead of a nearer one. So, I'm able to select. Clothing isn't the issue, since every active member gets the full protective gear in adequate number. For probatory members there are some spare clothes in varying sizes to have them equipped before their first assignment. He knows this (he already did one standby duty once). Service clothing must not be worn out of duty and there are no such things as lights & sirens & bells & whistles for private owned cars (ecept some officer positions), only a small mark for using the parking lot. We have regulations about training and service hours, but he didn't break those rules yet, they are rather easy to accomplish with a bit effort. Anyway in the first two probation years he doesn't need to fail, I can throw him out without giving a reason. But I don't want to base it on my gut feeling alone. I'm still not sure yet what to do with him - is there really a chance to develope him into an enthusiastic and commiting responder or will it just be a whacker in uniform causing trouble in the unit? Since I think about those boy, I try to remember how I were or how some of my friends were in our younger years and if there is some indicator to tell the difference... So I really like it to have some other points of view here. Your input sure helps for my decision and even better, make a good knowledge base for similar cases in other places.

As some of you know, by accident I'm responsible for a bunch of volunteers doing a great work here in my home village, not EMS (which is covered by countie's EMS where I happen to work as well) but non-transport first responding, disaster service, standby covering of events and such. Now I'm confronted with a situation I would like to discuss here - I may have my way to handle it based on my experience, but this time I will take the more scientific approach and ask you all. Situation: we have a new apprentice volunteer since february 2012. He's 16 years old, already member of his hometowns (neighbouring town) fire department youth group, member in his school's medical first responder team and now willing to get into my squad. He already got the advanced first responder course (56hr training, basic level needed for our team) from his school engagement. So far, OK. But he tends to step on my nerves. Every occasion he sees me he wants to get his equipment/clothing ASAP to be ready for service. But until now he actually had no time for a real assignment, always some excuses. After I told him there is a discrepancy between his time/age/training ability to be in service and his eager will to get proper clothing (which he will get when he needs it, sure, no need to constantly push me), he wrote me a large email. In this he did a lot of excuses about how his engagement in fire service and some duties within his family prevented him from attending our team's assignments. However, best thing in the email was a pathetic section how I dare to question his commitment to our team. Oh yeah, and how I dare! Then he described himself as a totally whacker ("even those in fire department say this") to make a proof! On the positive side: he still is young and maybe if he's a bit older he may get a clue. So the big question is: Should I throw him out now or let him some time? Due to our regulations I can give him a probation time of 2 years (!) maximum, within that I can fire him without any reason. What will be your decision or how would you try to find out? I would appreciate any input, especially from those young ones who still may see something from this in themselves. Thank you!

Welcome to emtcity, Fenta! Great to have the german area covered a bit more. Ah, and don't get me started on that "Notkompetenz" thing which doesn't really exist. No, don't. Please. Thank you. Our fellow collegues here wouldn't even understand this urban legend.

What's right about them? They have me. OK, honestly: beside of bad leadership and almost non existing pay plus some lazyness to follow actual trends (which sometimes isn't that bad) they do a lot of things right..in no special order: pool clothing with central cleaning to 100% hygienic guidelines, modern ambulances & equipment, beeing the market leader in the field, having an excellent reputation and so on. They still do a lot of stupid things during the day, too, but on the other hand what would we do when whe had really nothing to complain (beside of bad leadership and almost non existing pay). And, a significant lot of stupid things are done by the employees AKA cow-orkers. Interesting question.

But in NYC noone would really care about or even stop to look, I guess... ...only the button and the sign would be stolen soon.

If it's to silent in your town, this may be worth a look:

Actually, I just had a year of this.

"Never pass the first downed officer on scene".

Did it provide EMS or what was it? Here in Germany, the Red Cross is not only the national Red Cross organization with tasks by the means of Geneva Convention, but the main provider for EMS, mountain and water rescue, medical/social disaster response and a lot of other medical/social activities (blood collection, home care, kindergarten, nursing homes, even complete hospitals and a lot of others). Main task of the local volunteer groups (if not in water & mountain rescue) are covering events with medical care, several social activities and disaster response. Red Cross EMS is career based, slightly supported by volunteers (where the volunteer needs the same proper EMS education for the position he covers).

So the permit and/or the insurance contract don't contain any paragraph about security and emergency management? Usually, they do. However, sometimes not, especially on smaller events like this one - 200 bikers and 1000 spectators are not really much. If you take over the coverage, let them show you the paragraphs about emergency management or get a written statement that there are none. Another thing: unless you have absolute trust in the organizers (and even then I would do it), make a written contract: what do you cover in what time, what do you take with you (equipment/staff and qualification), who pays the needed stuff and your meals/drinks, where do you take position, how can you reach the organizers and other security/emergency services on the spot or outside plus what this will cost... Yes, we do it all the time. It's the base of our funding as a volunteer red cross group, since we usually don't offer the service for free (even if it's a free event), only with rare exceptions. Germans law on providing care as a licensed person seems to be totally other than in U.S., so I can give you just some general tips to cover such an event. We have several rules for such events. Such an event I would cover with a medical post providing some coverage when treating patients (tent or ambulance) including equipment of an ambulance and at least one additional mobile team with an emergency kit and a stretcher. This is based on my pretty large experience with such events here. There even are algorithms to estimate needed equipment and staff, one of them, the "Maurer-Algorithm" (named by a fire chief, who came up with the idea) gives around the same numbers. If the coverage is needed more than 10-12 hrs., you would need replacement stuff and a shift plan. Be sure that your main medical post is visible/marked - but do not use protected logos as the Red Cross or maybe the Star of Life when not specifically allowed to. Equipment should include communication devices for internal team communication plus reaching organizers, security and other emergency staff as well as dispatch center. It may be helpful to notify dispatch about your existence, maybe they can make sure that you're additional notified about individual emergency calls from the fair ground to provide first responder service: people may call 911 if they don't see a medical post or if they just don't think of going there. Those question should have answered by someone knowing local law. Maybe ask a lawyer. Over here it's covered by several laws and regulations. Another question to ask would be, who covers you when you're injured on your chosen duty? Do the organizers have any numbers or rough estimations of injured/sick people from the last events? When doing new things it is a good idea to ask others who have experience. You did this here on Internet, but maybe you should look for someone covering/having covered similar events and ask them for their experience. This can you bring in some concurrence situation, so take care and take into account that they may not want to give you their information. If there is some official authority for EMS you can try to ask there. If there is no possibilities to guess the actual count of people, risk is a bit higher. You may choose to be flexible here with having background staff available you could reach on short-notice. I'd expect several bruises with the bikers and would be prepared for a single more severe trauma (broken bone, head injuy, maybe even a real polytrauma, ...). The spectators are more likely subject of regular medical problems, depending on age, weather (hot, humid, cold, rain, ...) and ground (meadow? concrete?). The occasional fall of someone should be considered (especially kids), maybe allergic reactions or such depending on local flora and fauna. Let them give you a map of the location, including access routes and posts of emergency management, organizers office, security posts and such. If toilets are included, it's a plus - people for some reason tend to got to medical posts to ask for the toilets...Every team should be equipped with such a map, it may be a good idea to give one to the next EMS station or even dispatch. Every thing you treat should be documented. At the end give the organizers a report about number of treatments and some statistical data about cases. Pay attention to confidentiality obligations, data protection and time requirements for report/data storage. See local law/regulations for this, feel free to ask me. Yes, that's not easy to follow...and a reason why it's usually done by some organisation/company here. Actually I'm trainer for courses about medically covering of events and contributed to a book on this topic. Don't underestimate this - shit happens. A stroke or a heart attack can occur anytime/anywhere. Have luck & fun! Maybe give us here a report about your experiences.

Scaring other cars out of the way by lights & sirens is only good for winning time at intersections, traffic jams and traffic lights (low speed!). On a free road, the signals don't help much (high speed!). That's essentially what I tell students: no need to risk something with high speed, you win time only at the low speed situations. So, the main thing is addressed: our risk. For patient care, there are patients who might profit by a minute faster response times. But they are rare - and I consider this a very theoretical part of the discussion, because the system looses more time in (remembering &) calling emergency number, taking and dispatching the call, getting the ambulance on the road, finding the target (street name, house numbering) and getting into the house/flat (5th floor without escalator?). So, next thing I tell my students: If the patient's condition really relies on every second, then he won't make it anyway. Again, no need to risk our health! Basically I use lights & sirens to not wait on the traffic situations above. That saves me the minutes maybe lost elsewhere and with a lot of interceptions and traffic lights this sums up pretty high (see Vorenus' statement about city vs. rural setting). But no need to risk our health or the ambulance - reaching the patient is a key concept in EMS... Next thing to save time is patient care. There is a discussion about this somewhere else, it depends on the situation, but I'm no friend of "stay & play" (playing is not what we should do in EMS anyway) nor "scoop & run" (running is another bad thing in EMS) but to "treat & go" (if I may call it that). Sometimes the "go" has to be much sooner than other times. On the way to hospital I rarely use lights & sirens. The patient is in most caring hands now in the ambulance, we have a lot of good stuff to keep them alive and stable. Sure, there are cases where time to OP room is essential: hemodynamically instable/internal bleedings, perforated thorax or abdominal injuries, non-manageable respiratory insufficiency, raising intra cranial pressure, severe hypothermia. We simply can't fix or even stabilize those conditions, so we have to win another few minutes by passing through intersections, traffic jams and traffic lights without much delay. They'll loose those minutes in hospital anyway, so we have to hurry (that was cynical and I have to admit that hospitals improved a lot meanwhile). The above conditions may be an indication for fast HEMS organization especially if there is a better trauma center somewhere else further away and ground loading/driving time is much more than HEMS'. So, the answer is more complex than a simple yes/no/why/when. Efficiency is the key. That includes team & resource management and other things that can be prepared (Does the team know what to do when, why and under who's responsibility? Is your bag stuffed in such a way that you have and find what you need? ...?). It involves a lot of organizational stuff, pre-call (times from accident to starting the ambulance, making sure to reach scene without much hassle, concept for door-to-scalpel-time at hospital) as well as in-call (treat & go, notifying target clinic, organizing HEMS early enough to make sense out of it, ...). And so i tell my students: Safety before speed! Lights & sirens may outrule the traffic laws but not the laws of physics and they sure do not improve the average level of dumbness in the world. (there is a statistic by German National Traffic Authority: as far as I recall, risk for an accident is about eight times higher with L&S on)

And vorenus isn't even from Bavaria... Even in germany where we have a lot of nation wide regulations in EMS there are a lot of details specific to the different federal states. So you will find significant and sometimes disturbing differences between state's EMS systems and sometimes between one district and the other or even from one village's company to the other. Despite the fact, that education levels and requirements are the same nationwide, there is a standard for vehicles (even EU wide) and only four large organizations have 90% (just my rough estimation) of the market. So even here in our little country the understanding of the whole EMS system "en detail" would be a lifelong task. Continuing changes included... If you try this for the "EMS world" as you stated, and that means really worldwide (surprise: there are more countries than the U.S. having an EMS system), then prepare for some real strange experiences. Just to have a general impression about varieties in medical/EMS systems, read Wikipedia.

Had the opportunity to see a patient from this same hospital, didn't meet the nurse in question, though. The patient seized (generalized epileptic seizure) and the doctors intervened at once, breaking the seizures. My world is in order again.

Several (most?) commercial available routers can act as a simple hub for local computers. There even are simple ones just for this purpose. Go to any computer store with just more than apple computers and ask for it. Advantage of a seperate box is that your laptop's wifi antenna is very restricted, especially if built in. There are external antennas for the laptop but they most probably won't reach the tiny spot in your accomodation. An external box may be placed almost anywhere, has a good antenna (choose the longest possible) and can get low signals better plus sending better over more distance. You will need a LAN cable too hook up to the hub. If you have some money to spent, you can look for an outdoor receiver, but most probably won't find that in a simple computer store. Then the signal will be not disturbed by any wall, only you have to fit the cable somewhere through the window or elsewhere. Some self built direction reflector out of aluminium foil (be sure to eat the pringle chips before!) may serve, but - as always in life - size matters and nothing beats long antennas. Good luck!

Thank you so far, maybe she meant to wait some time before intervening. Our guidelines (which are national guidelines and valid for hospital care as well) state to intervene in a status only, which is defined as more than 5 minutes of generalized or more than 20 minutes of focal seizures. When we arrive as EMS and still see a seizure, then it most probably lasted longer than 20 minutes... In a neuro ward this is another case, they see seizures from the beginning. But the nurse didn't sound like she talks about just the constraint of 5 minutes until intervention (they were discussing generalized seizures). The patient was very irritated. OK, may have to ask for their protocols to find out more.

Midazolam, ketamine (no problem with hypotension), lift with scoop stretcher on a vacuum mattress (no problem with comfort), if long/bumpy transport and appropriate flying conditions call a HEMS soon (at night just expect a bit more effort with preparing LZ). Anything else? Next, please! Yes, I love my vacuum mattress and my scoop stretcher, won't trade them for a spine board, which has it's advantages but just not in transporting patients on it. Oh, I love my drug kit and an available HEMS at night, too. Yes, I hate it, when those available tools aren't used properly...(BTW, in our yesterday's training session we coincidently played with all available splinting systems). Whistling classic Star Trek theme when helicopter starts: priceless.

Possible findings inside: usual bowels and contents of a male human body fat, lots of beer My diagnosis on view: severe adipositas (gives volume) with breath taken in (gives shape). I can do that, too! But no space for a bottle on top, yet. By the way, the balancing skills of this guy seem pretty good.

I recently overheard a talk between a nurse and an epilepsy patient, where the nurse states, that "nowadays we don't do something when a patient seizures, just wait and monitor". She actually said this twice in the talk and acted like this was actual knowledge and commonly known in the medical field. The talk was about the patient with a known epilepsy, wanting to debate the procedures in a (his) possible emergency. It is a neurological ward, the nurse is the chief nurse on this ward. Unfortunately I couldn't ask the nurse for some real source of this statement. At home I checked the most-recent national seizure guidelines, covering pre-clinical as well as hospital treatment, and they give a fast intervention as standard (drugs, oxygene, ...), with the target to break the seizures as soon as possible. However, those guidelines are from 2008 (last updated/revised, originally they are from 2002). Does anyone know about new treatment strategies to simply wait for a seizure to stop for itself? Some years ago I had several discussions with fresh medics from one specific school, who told me that giving no oxygene in seizure would terminate it earlier, so giving oxygene would be false treatment. After beeing confronted with 1) guidelines and 2) the question for the base of their statement, the discussions usually went silent soon. Some neurologists I asked and finally, our organizations state-wide chief medical director made clear, oxygene still is within the treatment plan of seizures if indicated by cyanosis and/or low SpO2-readings. So I smell another strange thing here, only now it's not some fresh minted medic from just one school with a possible misunderstood teacher, but the well respected chief nurse of a neurological ward... As soon as I have the chance and time, I will get back to this nurse or someone other of this hospital/ward to check things, but maybe someone already has some insight here. Would be great!

As long as my voices speak to each other, it's all OK. If your voices speak to me, I'll tell you.

My standard answer: "You mean the pictures or the VOICES??!!"

Never argued for that, i just said "pay attention to differential diagnosis". And I see that as an integral part of my job before any doctor sees the patient. Sure we do pre-clinical diagnose, basing pre-clinical treatments on that. Sure, we don't make final treatments on (more or less) full confirmed diagnoses, that's true as well and that is job of the hospital/doctor with all their possibilities.

Acute abdominal pain is very unspecific (BTW, sometimes even with all fancy hospital equipment and lab tests). Typical DD for appendicitis would be: A: kidney stone, urethra stone, Meckel's diverticulum, morbus crohn, ovarial cyst, extra uterine gravidity, ovar/uterine tube inflammation B: internal bleedings, perforation, sepsis C: myocard infarct Depending on age, consciousness (incl. emotional state) and other factors, it may even be almost anything in the abdomen which is really the cause. Some of them will change my prehospital treatment plan as well as my decision about transport medium and target clinic drastically (especially type B and C above). So we have to check suspiciously and not just treat what is to be seen, even if it seems to be clear. I'm still proud of the dude presenting with abdominal pain and clear localisation of appendicitis (not talking my language, on the way with a tourist bus with a challenging time frame). This was on a standby duty, no ECG or other equipment available, only EMTs (and I was the youngest one, fresh out of school - it was long ago). Despite all others I diagnosed lead symptoms of a myocardial infarct and insisted to get him transported to an intensive care unit. Which most probably saved his life. Between since then and now I had some more of this type - including myself. No, we have a lot other tools & choices: do I give blood thinners, which pain medication would be better, do I prepare for intubation/resuscitation/defibrillation/newborn (including maybe backup staff), do I go to a cath lab, do we need immediate OP capacity or just a willing ER, surgical/medical/neonatal unit, very next hospital with a surgeon available or the other hospital the patient wishes to go, do I choose HEMS or ground transport and so on...? At least a 12 lead and BP + SpO2 monitoring should be standard on every abdominal pain patient, please. BTW: the "do i prepare for ... newborn" is not a joke. Was a real surprise, for ALL (except one) involved.

That's actually THE question of my life... Thanks for "un-confusing" me to ERDoc and Dwayne, for a short moment I thought one of THOSE things happened to me again.

Edited by Dwayne. Somehow I managed to hit the 'edit' button on Bernhard's post instead of 'quote' and nuked his post...though his thoughts will be obvious in my response below. Sorry Brother...it's what happens when Admin gives moderator privileges to simpletons... Dwayne