Bernhard

My personal experience is otherwise - sure, this doesn't count as a scientific study, but I really did improve my personal statistics. When I started in 1985 we had only one defibrillator in one of four ambulances, no defib/ecg in the others and no real concept for managing arrests or trauma. We just did, what came to mind. Only standard was 15:2/5:1 cpr and that was it. A drug here, some intubation there, occasionally a defibrillation, central i.v. line for the look and declaring death on scene or transporting under cpr to declare in hospital was the result. Only two sufficient long term survivors on my list in those years up to the end of 1990ies, and I was fulltime provider then (now I'm just parttimer). Now we have 12leads, fastpatch AEDs, a scientific based concept for resuscitation including drugs and team management. Meanwhile my personal statistics are about 10 arrests per year, where at least one or two get out alive on long term, two or three others at least make it ROSC to the hospital. Five will be dead on scene, four of them already smell a bit funny, statistically spoken. But it's not just scientific research in emergency medicine and education of the providers but also education of the public (first aid, emergency numbers), technical possibilities (mobile phones, navigation help, AEDs) and the whole system (dispatch standards, more ambulances, decentral first responders). Therefore, my personal opinion: I've seen A LOT of improvements in the last 30 years in our EMS system. Maybe just because it was so crappy when I started back then, it couldn't get worse... However, i would like to see more improvements. This list is a good thing to discuss (it's a little too U.S.-centered to allow me to real enter the detailed discussion). I was in this position (both, the new whiz kid and the long-year-practitioner) in more than one occupational field and I just can say: some people call the errors they make for 50 years "experience"... Now, I'm beeing far away from a whiz kid fresh out of something and try to remember that it almost always is the mix of new knowledge with any type of long-term experience (even the errors, if we know them as such) which makes a good improvement.

Simply ignore trollish behaviour. Sometimes even flamingemt can give a thought. But if everyone just likes to comment, he get's something from it. A ban wouldn't really work. Flamingemt is not someone who gives up early, he tries to make a point, even if it's way off. That's not exact trollish, that may be social unacceptable or just dumb, but that are no reasons to ban him. one could open other accounts anyway. Again: ignore it, if it's not worth the time. Just my 0,02 EUR.

ACK. It's another thing when threatened verbally with violence ("I will find you..." and such), THAT I would file as abuse or something like that, if there is the slightest probability for it to be meant serious. Rarely happens, though.

It totally confuses me always to hear when someone is ALS educated and not allowed to do it just because riding on a BLS unit. This is strange and thankfully, over here I'm not bound to the unit's level but to my personal level. If some fancy equipment is not available, then the fun begins...err,no, politically correct it defines just the line between a helpless medic and a medic who knows the WHOLE stuff. Back to topic: a truckdriver friend once told me how to warm and even cook food on the motor during his rides, involving lots of aluminum foil. Obviously there are some recipes for that based on miles instead of cooking times, maybe even a whole truckdriver cookbook. I remember having found something on the internet back then but can't google it anymore now. It probably is of less use when sitting on stand-by, desperately waiting for a call to get the food in the motor hot enough. On the other hand, truckdrivers may be a good source of information about cheap food on the road.

And where is all the fun then? Even EMTCity then would be just a good place to learn & rethink things, discuss on a professional level, getting new point of views and ... oh, wait a minute... Happy New Year! EDIT: passed my supervisor shift to someone else for (unfortunate) personal reasons, now I'm just covering our volly non-transport responder unit from home with my family, all calm until now. Even the supervisor pager is silent, so my backup has the calm night I wished him to have.

Personally, I had one. Hurts. Now I don't expect to have more. Thankfully.

Happy New Year (finally arrived in Germany 40 minutes ago)! Stay safe, folks! No call yet for my volly unit...could stay a while this way.

Not to forget proper differential diagnosis! Abdominal pain and probable appendicitis can cover a bunch of other problems...

Yes, multiple times. Why/Why not?

Well, another drunk and/or psychiatric case. Wonder, why they jailed her. Either she should be left at home after a severe vocal introduction into "real reasons to call 911" or should have taken to a psychatric ward (decision is difficult just on the report, but I smell a bit more behind this behaviour, they may have more evidence for a psych setting on scene). Anyway, what's this thing with the written statement she should swear on? That's strange. Can someone please explain this procedure to me?

I tried to avoid it, because I had troubles with the Fahrenheit unit you used AND I have no experience with wilderness or military EMS. I'll do my best, including some spelling and grammar errors just for you. I can't answer this. I didn't learn it in EMS school, I learned it from my mother. Personally I have no preference how to feel a temperature and constantly am unsure if it is worth anything. I do it anyway, but wouldn't rely on my manual measurement and would like to use a thermometer. So I really appreciate this discussion. That's specific to 9Orangeletters, I wouldn't expect the descripted symptoms at 37,5°C (=99,5°F) coming from the temperature alone. But I didn't read his description as absolute signs of a slight hyperthermia, instead as signs of a relevant hyperthermia. I don't think the usual thermometers are worth measuring local temperature, but it would be worth a try (experiment time again!). The other question is: do I need it? In normal stupid middle-european climatic civilisation-near ambulance based EMS work those are things we either don't see or we don't spend much time caring on the street. If vital challenged or otherwise worth to see a doctor, both cases would be transported without further diagnosing of localized inflammation or frostbite but caring for general vital condition. So I can only throw in two suggestions: There are systems for local temperature measurements. Maybe even your smartphone has an App for it. It's far easier (even for me) to compare temperatures between two parts of the same body than to determine a general body temperature. So maybe even I would be able to feel a local temperature difference. I wouldn't be able to quantify it, though. The question stays: do we need to quantify localized temperatures anyhow? I really don't know what the result or treatment choices would be for different degrees in temperature of cellulitis or frosty toes...but I would be glad to hear how this is a base for a treatment/evacuation decision in wilderness/military settings. If you come up with a certain temperature value: yes. My old house physician (may God rest his soul) always did this to me, telling my fever temperature exactly by a hand shake. So, this voodoo seems to work. But I don't know how - and he always proved it afterwards with a thermometer anyway. Yes, I would do nothing against high temperature because it is not the problem then (99°F = 37,2°C). Such a core temperature (106°F = 41,1°C) surely indicates high fever and if any condition allows the skin to be globally cold, I would treat the fever anyway. Skin could be cold on touch due to exposure to environment or simply because my touching hand is too warm in comparision - or, as I always suspect, my sensoric feelings are totally unreliable. Before answering this, let me explain that 9Orangeletters expected accuracy range of +/- 5° would be inacceptable for me. I have a six year old test survey of non-professional thermometers, it gives an accuracy of not much more than -1°C for the most products, if in laboratory calibration test or in situ. BTW, the mercury thermometer had the best precision... So, the answer would be: 99°F = 37,2°C: no fever treatment, search for other cause 101°F = 38,3°C: fever treatment depends - a child with fast raising temperature will get some antipyretics soon. 103°F = 39,4°C: see 101°F, antipyretic treatments considered for adult as well. Fever treatment includes wet packings and drugs, it depends a lot on rate of temperature raise and other findings (i.e. seizures?!). The underlying cause (infection?) has to be found as well (hospital lab?). The given general symptoms (altered mental status!) would suggest a transport to hospital anyway, if raised temperature or not. In my opinion, preclinical antipyretic activity would depend on temperature, yes, see above, if that's the core of your question. And I would like to base that on a more objective finding than just a touch of my unreliable hand. So, I agree with 9Orangeletters here when he states (quoted from his posting): "Maybe a good idea to get a general tenor of the patient's temperature by using the back of your hand, inside of your wrist or your fingers/palm, but I wouldn't go basing any patient treatments off of voodoo, no matter how you do that voodoo so well..." - with "voodoo" in a more funny and non-offending sense than others may see it here.

Pardon, but a real thermometer should be part of the equipment in an ambulance. Even a cheap electronic one is better than nothing or using subjective "feelings" to determine a treatment plan. A professional licensed device with hypothermal temperature range would be preferable, though (still searching...). Yes, I use my hand (palm/wrist/backside, no real preference) to get a feeling, but it's just before taking a more objective temp if suspicious. I rather would like to be able to take temp on every patient, if our thermometers would be faster (we don't use IR devices yet). In a remote setting, where every weight and space counts, it may be not so easy to carry an additional device. But a simple thermometer isn't the real problem even there, I would think. No experience, though. I don't trust my own feelings much when it comes to determine exact values, they may do for some indicators, but not much more. For real measurements I want to be equipped. And body temperature sure is a thing a health care provider should have in his view. In my view he made a very valuable point. I myself recently made a disparaging remark in another thread against someone who pretends to get accurate blood pressure by manual feeling. The intend of this thread still is valid and interesting: IF using the hand, how to use it? I'm sure Dwayne is aware that a thermometer can be used and should be for accurate measurements. I try to get a feeling for blood pressure by manual pulse check, too - but then measure it with a sphygmomanometer. I rather would use a thermometer. On the long term it would be cheaper, the storage in the ambulance is easier, even transport to remote settings would be more practical and you can use it not only on full moon. It doesn't taste as good like a fried chicken and egg, though (but that may be covered in the thread about food rations on shift).

Sorry for constantly answering on my own posts, but finally I found something I want to share. Following calculation seems somewhat reasonable, at least from a mathematical viewpoint (source: an educational script about accidental hypothermia in EMS by a physician, german language): Fluid volume per body weight reducing the core temperature by 1°C: initial infusion temperature 20°C: 52 ml/kg initial infusion temperature 22°C: 61 ml/kg initial infusion temperature 28°C: 108 ml/kg initial infusion temperature 33°C: 307 ml/kg Do the math..according to this, with a 70kg patient you need ~3600ml (more than 7 bags of 500ml!) of a 20°C (room temperature) infusion to reduce body temperature by 1°C. So maybe the infusion isn't the real problem.

Because it's an indicator for severity of head trauma. A lousy one, but if (temporary) loosing consciousness then the hit to the head was more than just a slight bump and a perfect oriented patient may be upgraded to a possible commotio cerebri or even more, with a bit surveillance time needed. Lousy therefore because initial bystander responders almost never can give a certain report on this (if they even are able to detect lost consciousness). Refer to mobey's posting for the rest.

"I know already" (from supervisor when complaining about missing/defective stuff - yes, sir/maam, FROM ME, because I complain about it the last decade, please DO something about it now!) "DO something about it now, I already told you several times!" (from supervisor - huh? first time I hear this) "EVERYBODY knows!" (from supervisor - sorry, didn't get the memo, beeing sure there doesn't exist something written plus all others don't know it anyway) "It always was this way!" (from anybody - which still isn't proof that this is the best or even a good way). "No! Why anyway?" (from my kid - hey, I never dared to say this to my dad, it always was this way, everybody knows and I already told you several times!) OK, I admit, all of them are not restricted to a specific year. All time favourites. Yes, there are more.

A quick search revealed: mild hypothermia (as propagated in post-reanimation, not below 35°C) saves brain cells (less oxygene need), that's why it is recommended in cardial arrests. any hypothermia has negative influence on blood coagulation (which may be good in myocardial ischaemy, but not with bleeding trauma) more than mild hypothermia (below 35°C) has larger negative influences on coagulation, electrolytes, inflammation and general system functions (including heart rhythm) studies propagating hypothermia in cranial traumata are not trusted much (post-OP anyway) studies around the topic "therapeutic (mild) hypothermia in trauma" are in progress, I found no result yet. So, at the moment, the current guideline obviously still should be: only a warm(ed) trauma patient is a good patient. One article recommends even warm infusions at 37°C. If a therapeutic hypothermia in trauma situations is considered someday there sure is the need for adequate measurements, since the border between good and bad seems to be real thin. Found not much yet on this, but the actual studies for post-CPR hypothermia state, that an ice cold (+4°C) infusion decreases body core temperature ("only") by 1,5°C per hour, when given 30ml/kg body weight. Double dose will give almost double temperature decrement. So, there may be a significant hypothermic effect considering higher infusion volume per time on trauma patients, but then those infusions usually are not ice cold. On the other hand, the rather thin infusion line hanging between bottle and needle should be considered as additional cooling factor, especially in chilly circumstances. Still have to do some calculations for typical infusion volumes and probable fluid temperatures - or find an existing study/calculation covering this. Interesting topic, really!

Just beware of saying "Get well soon!" to people you bring to palliative care or with incurable soon to be final diseases...

On our career service we even have no thermometers at all on some ambulances, on some just old quicksilver ones...(yes, I know, but meanwhile I'm tired complaining about). On my volunteer ambulance (where I control the budget) we have electronic thermometers, but only standard fever temperature range. Occasionally I'm scanning the market for a real EMS reliable hypothermic thermometer, but did find only one so far which is beyond our budget. Which one (brand, model)?

Every patient gets a blanket in any season unless he/she states otherwise. Ambulance is heated inside when in the bay, I usually turn the additional heating up when responding to an outside trauma call (MVA or such). Heating temperature is above normal room temperature and more than the medic will tolerate, so I put off my jacket when entering the ambulance, only having my polo shirt on, even in winter. From time to time a patient complains that it is to warm. Another thing is to close ambulance doors quick, when getting equipment/stretcher out. And have a heating system that really works fast. Vacuum mattress is stored in the inside, so has about the same temperature as all other equipment. I don't use spineboards (which are stored in the outside compartment) for transport, just to extricate. An issue would be the KED, since it is stored outside, but I npractically never use it anyway. Plus, our ambulances are equipped with a heating drawer, containing at least 2 Ringer, 2 HES and 2 Glucose5% (500ml each) on a temperature of 25°C (some ambulances have a larger drawer, containing more). The emergency kit is stored in an inside compartment, targeted by a heater, so it and its contents are kept warm a bit. Before we had all that, I sometimes heated up infusions on the patient's oven in a pot of water, which peels the label off the bottle (we had glass bottle infusions back then, even microwaves were rare). On a regular ice motorbike standby we even carried the infusion bottles on our body to get them warm. That was before park heaters were introduced to our ambulances. Saying this I must admit I never ever took an initial temperature measurement even on a known hypothermic patient. First: simply never had the time to do it (lame excuse, but at least I had gloves!), second: our thermometers are not really able to measure low temperatures as we would need then. I didn't find a good thermometer for professional and outside use yet. Tips welcome. So I try to get my patients in a warm environment as soon as possible. If you ever were even just a mock victim in a training scenario, you understand why. One should remember that a blanket OVER the patient doesn't help much when his heat flows into the floor. Had an impressive incident, where a young man involved in an MVA laid on the street on a real warm summer evening. I know him and talked to him later when he recovered from his heavy injuries, the only thing he remembered was that it was real cold as ice laying there and he was really glad when we had him in the warm ambulance. Two other things to consider in this thread: wouldn't be a mild (?) hypothermia a good thing on injured people as well as they (at least ERC, but I think AHA as well) recommend it for CPR? I recall a study from years ago, that indicates (as far as I remember), that some 500ml don't change body temperature significantly. Can't find the study at the moment, though. But it should be a matter of calculation body weight and fluid flow. Seems I have to do a bit research again (thanks for the impulse).

I'll try it just after getting a measurement attaching the oxygene meter to the patient's nose. [bTW: I'm impressed - we don't have LP15 or anything like this on public transport vehicles over here]

OK, as promised, I did the test, three pulse oxymeters ("PO") were available. PO#1: handheld device with external sensor PO#2: fingerclip device PO#3: LP12 with external sensor All of them used in the initial scenarios of the original post. The fourth one I still had no access to, will follow someday. My findings, all tested on my own hand on different fingers at the same time, changed several times: PO#1 and PO#2 gave similar readings, PO#3 was totally panicking. Where PO#1 and PO#2 both had a reading of ~95%, PO#3 gave several ascending and descending measurements between 98% and 58%. Remember: it was on MY finger! So I checked PO#3 closely and found a defective cable. OK, that explains a lot, even the long time to wait for a signal. Remarkable: signal was good on waveform and pulse. I got suspicious when the thing still showed a perfect signal and measurements even when taken away from the finger. However, it passed all the regular standard tests at shift change as well as the yearly measurement in the service lab! The other two pulse oxymeters always were in sync, only that their measurements differed around 0-4%, depending on their actual fitting position on the finger (millimeters seem to count) and some random influences. What did I learn: Know your tools, don't overrate them and examine them closely when something seems wrong. Check waveform and signal/pulse relation on pulse oxymeters as additional hints. Varying pulse oxymeter readings are possible with very minimal position changes. A variation in accuracy of 0-4% (at least roughly based on my little test) is to be expected. I will check the manuals for this ASAP. EMTcity is a great place to discuss basic things. Thank you for the great discussion!

Legal and local protocol question. Here we have several possibilities, including all of your given answers. In exactly that scenario I would: notify dispatch, request another ambulance, request notifying supervisor and PD secure scene (done) carefully assess other driver (done), if in any doubt that he may be injured: do NOT leave the scene (we may rule out minor bruises, we're allowed to rule out C-spine injuries). carefully assess own ambulance, really able to drive on? check with dispatch for other ambulance's ETA (in this scenario: still far too long), decide if patient is time critical (in this scenario: yes, vitally challenged) leave written information about our side (license number, driver name) to the other driver explain situation to the other driver and ensure that he knows others are on the way take a picture of the situation (see other thread! one of the rare exceptions i would take a picture), maybe do some marks on the street (german mandatory car first aid kits actually have crayons in it for that purpose) leave the scene and deliver critically patient return to scene afterwards as "out of service" Normally we have the option to wait for another ambulance, it should be there within minutes and thus during the whole initial scene assessment (if requested early!), but this may be not the case in any situation (dispatch information/decision). Supervisor normally is on scene within 10-20 minutes, same for PD. Could be far too long for the patient (my decision). Again: here the critical part is to request assistant as soon as immedeately after crash. Then backup should be available just when it comes to the decision to drive on or not, instantly making this decision needless. Had several such situations, thankfully not as involved ambulance but as backup or as supervisor (even some when ambulance actually left scene with a critical patient). Carefully check your local protocols! There should be a policy about this. And as always in EMS: know your options.

"A picture is worth a thousand words,": yes, but only the words you have to describe what is IN exactly this picture. A picture can't tell, what's not on it. So, should medics really care about scenes, lights/shadows, camera resolution, angles, distance, color, details and so on? If I had the eyes for such things, I would be a better photographer but not a better medic. Patient care should be based on actual patient status, this includes the event. Mechanism of injury (and Dwayne: you're not alone!) could be well descripted by the medics if they actually pay attention to it - it's not about every detail of a crashed car but about some significant technical issues: cause of the crash, other vehicle/tree/structure, direction of the crash, airbags deployed (belt worn? helmet worn?), length of flight/turn over/sideways, crashed steering wheel, dent/cracked front window in head height, head rest available/crashed, seat depositioned, entrapped/enclosed/thrown out, injuries of the other patients involved and such. It's rare that a real treatment decision could be based on the picture of a crash - I tend to believe that when this is the case either the medics did a very bad description (or pay no attention at scene) or the ED is somewhat ignorant. And if they want to see some of this out of curiosity, then they should get out to the street. If there is some chance for a hidden head injury by mechanism of the crash I would treat it on scene as such and would expect ED to continue treatment or ruling it out with their tools. BTW, with modern cars you can't tell the impact on the passengers by severity of destruction very well, as long as the passengers compartment stays intact (and it may not look like it did). And yes, talking about lights/shadows, camera angles and so on: even my family pictures are a mess.

Having the knowledge and passign tests are two things. Train both. Take a test like you take a call: assess the "patient" (read the text of each question carefully, don't oversee typical and not so typical signs, get the whole picture) and make your "differential diagnosis" (read all possible answers, not only the very first fitting one), then decide for the correct one and...be fast. So, it's just like any multiple victim scenario. You can train taking such tests. There are books about, maybe even a test training book for exactly this exam or even exactly your EMS book. Maybe you can get hands on old tests of the same style, then you should practise them over and over to get familiar with the wording. Think over why you failed - you read too slow, you were too nervous, you mixed up answers? Remember what causes this stress (hint: parasympathetiic reactions have a lot to do with that). Training test situation may help: just sit down for your own testing like in the real test (desk clear, pencil available, time set, start with writing your name/id on it, ...). Maybe you have to adjust your strategy before the test a bit, getting enough sleep or so. This is individual, you have some experience from your other tests, but now - especially when you're nervous - it's getting more and more important. Regarding reading aids or such - I personally tend to get more distracted with any aid, but that you have to try for yourself, too. If it helps, why not - but try to check it out, not to get confused. Maybe you really have some form of dyslexia and can get more time for passing a written exam? Analyse your situation and optimise. You already did...maybe some of the above or a training book about taking such tests (they exist!) may help. Good luck next time!

Thinking over, it DOES make sense...if he works in funeral services business!