Bernhard

So you had not more than 1 patient this year? Oh, I'm bad at statistics, since 67,98% may be totally made up. Sir, you're the EMTcity man of the year, maybe the decade. I can't even tell B/P within a few points of margin using a sphygmomanometer. I still have to round, but maybe it's for your adorable youth and I just can excuse myself a bit since my legs are gray, my ears are gnarled, my eyes are old and bent . Standing in awe and with most respect, ehh...no. In real world such statements earn you disbelief, at least.

Hey man, keep cool!

Here, police is in charge if someone clearly is suicidal. They have to get him to a psychiatric hospital (they may request the help of EMS if needed). So if making this statement in front of a police officer or if a medic/doctor can witness it and tell to a police officer, the next station will be a psych ward (maybe after treating injuries or intoxication somewhere else). There the psychiatrist is in charge. They can hold a patient for 24hrs, until then a judge has to decide even against patient's will. All in all it's the police's obligation, then the psychiatrist's and then the judge's. NEVER the EMS's or other medical staff's. The others are either legally or medically experts enough to find out what really will help the patient. If they decide to let him go, it's on their decision. Again, not on anyone else's. That may be not the case in your state, or the LEOs simply forgot this (or fear the paperwork involved). By the way, I think that they at least have the power to decide someone is too drunk to let alone. But in any case it is your decision to file a charge. If you want to file charges as an insulted medic, then do it or don't do it - on your own will. Not let you press yourself into something, even not by feeling responsible for someone else. Your job was to treat and transport him, you did this well and all afterwards is the responsibility of either the target hospital or the police who was involved from the beginning. If you choosed to file a charge, that's perfectly OK also. Just remember it was you who decided this, and not the police woman. Don't worry too much, next time you can base your decision on more experience and may have another view on things. And you may point out alternatives - maybe read your law about such things again. Over here LEO's don't always remember their obligation for some reasons, too, and sometimes need a decent pointer... EDIT: spelling and some things cleared up (EMS may help in transport, injuries/intox will be treated first before psych).

Questions depend on call time, if called out at 03:30 a.m. the typical first questions would be: Who am I? Where am I? What am I doing here? Why can't someone else doing this here? Why did they call not at day? Where can I pee?

A call is just as good as the coolest saying in it. We should open a thread about the greatest lines said/heard on scene...who believed http://www.youtube.com/watch?v=-GX-9mItAlQ?

I fully agree with Aussieaid. Freely attempting to commit suicide should be a sure way to a psychiatric hospital where he would be taken care of, so you're not responsible if he gets out and does it anyway. Accusing him on the sexual comments would be something a lawyer could easily tear apart, considering the intoxication. You dealt perfectly with that anyway, clearly stating that it's inappropriate and otherwise ignoring the stuff. Another drunkard, another idiot with no sense for respect. Maybe with real other problems, but that is no excuse for beeing respectless and an idiot. He should get help, but you did your job with taking him to the ER. You're not responsible for him anymore. It's absolutely your own decision what you do now! But having in mind that it's usual for EMS folks to get some inappropriate comments, despite that getting the job done anyway and forgetting the stuff soon plus the probability to realizing exactly zero with filing charges but increasing work for you and statistics for the police: I would do nothing on it. Again, it's your decision (and not that of the deputy), don't let you talk into something you don't want. It would be a totally other thing if something "real" happened, if you needed treatment afterwards: i.e. if you were physically hurt, but this even includes psychological help. Then you should file charges, at least for beeing juristically on the safe side. But I don't see that here.

Yes.

In a professional environment and as a professional provider (and this is even true for a professional but unpaid volunteer setting) I would expect at least a basic form of risk management: Have tools that are good and certified for professional use. No cheap lay use-at-home crap. Get them regularly checked, calibrated, cleaned or whatever the technical manual and manufacturer regulations say. Check them on shift start. Check them as they should be checked (see manual). Fast check them before application. Know them, their scope and exceptions. Have fall-back options available (my LP12 pulse ox sensor failed, I used my handheld pulse ox - sure not possible with every thing in every situation) Have replacements available. If battery powered: have extra batteries with you. Know how to change them. Have improvisation fall-back options available. Know their limitations. (hmmm...difficult with pulse ox). Know how to do stuff without the tool. Know YOUR limitations then. It scares me when I hear someone doesn't know if his ambulance is fully stocked or if something is defective/not available (could happen, but at least the team should know it). Every professional car repairman follows the points above, especially the availability of good and fitting tools. Would the professional car repairmen change a tire without a torque wrench, just because he knows how to? Most probably not. Why should a professional medic not rely on his tools as that what they are: tools, to perform his job better? The topics above cover a lot of organizational problems (ensure a stock of fresh batteries, replacement tools at station, ...). This, too, is an indicator for a professional service. If a provider can't do anything without tools or uses his tools in a wrong way or isn't able to use his tools as true support for his diagnosis, then there's something wrong with that provider, not with the tools. My case#2 was a good example for a straight cascade of diagnosis using tools, leading from a bit sick looking man to a high risk patient by several steps: manual assessment: 4 x oriented, bit pale, no pain, bit nausea, known history of heart disease, "sick since the night before", "just went up to the bathroom, sure can I go!", "no real problem, my wife called you because she always is so anxious!", "maybe just a flu". pulse: 70/min, very arrhytmic (hm...OK) blood pressure: 150/0 (Huh?!?!!) ECG 3 lead: A-fib (ah!) ECG 12 lead: Left branch block, rate 140/min (oh!!!) Pulse ox and blood glucose level just ruled out some side problems. But without a 12 lead there would be no real indication, that this man is probably short before a V-tach/V-fib. You now could argue that everyone with a probable heart failure (could be everyone!) should be treated like a raw egg, but that leads to a somewhat inefficient point of view ("scoop and run with everyone") and should be outdated long enough. What if I have nothing with me for some reason? Well, I can help anyway since the most important tools are permanently attached to me: my hands and my brain. But I can use a lot of other tools, too, and I would hate to have them not, not available or not working maybe just because I was too lazy to check them at shift start for beeing so cool and educated and that I don't need them anyway, if they don't work. Why do I bother to carry them around in the first place then?

Good idea. We use the sheet all the time in confined spaces, never thought of it to use for bariatric patients OR for better securing on a spinebord. Will try it! Great suggestion, thanks, man. The B.E.A.R. thing is "just" a professional looking restraint for bariatric patients. We don't have it. We use additional belts (maybe plus the suggested sheet in future) or our regional bariatric ambulance. But the problem with "abdominal mass hanging" is the same on a stretcher. I like the idea of using the carry sheet as a restraint aid, should be possible, if taken sideways under the regular or expanded belts.

That test or that we are perverts? BTW: I don't even find a word for #1 that is "dirty" in any kind. What could it be?

Usually between 500 and 700 meter over german normal zero. However, I don't know at which altitude the German Resuscitation Council was when giving out this 94%-98% range in their guidelines. BTW: I still have to read the original english text of the guidelines. I meanwhile don't rely on the translation here either. EMTcity makes you (general "you") very suspicious...

That wasn't quite the problem. The problem was, that my initial assessment (case#1) didn't meet the pulse ox reading BY FAR. Plus an other pulse oxymeter gave a more probable reading instantly on the same finger. Inital assessment: pretty OK, no problem breathing, no sign of O2-need pulse oxymeter #1 (technically OK): 60% pulse oxymeter #2 (technically OK): 95% The total and large variation of values made me wonder. I didn't hesitate to put the 60% away as crap value, so no harm done. But I wondered what a pulse oxy will give me when I have to rely on a 1% delta (is it 98% or 99%?) and what sense it really makes when we have this small range in mind or in the guidelines for deciding between yes and no. That may lead to a wrong understanding of tools. There are conditions you can't detect without tools. I prefer to know my tools and to use them in an appropriate way. Sure, I'm able to help with bare hands and naked, but that isn't what I want to do when arriving with an ambulance (OK, my employer would be happy when I would do the job without any tools...not naked, though).

Whow, great discussion! Thank you!. You're not getting the point of my posting. Beside that: our EMS bought pulse oxymeters around 10 years after they bought me (very cheap, I have to admit), and we already did have oxygen in those days. Well, that's somewhat the point. Should we really do this? Guidelines say, that too much O2 (>98%) will be not good - so I usually now leave O2 away now even in myocard infarct and stroke settings when SpO2 measures 94-98%. That said, my experience with the unexpected false-low reading in case#1 and the very bad signal in case#2 gave me something to think about the reliability of the pulse ox readings. I'm still remembering old days when O2 was given to practically every patient. Having no problem with accepting new guidelines, I simply have a problem with believing a tiny tool dangling from someone's finger to be exact about a delta of 1%. And sorry, no, flamingemt2011, I don't believe that you are able to have even this accuracy. Yep, but I still am a bit unsure what the thing is really telling me, if it shows 98% (OK) instead of 99% ("too much"). Well...yes on the street I don't have a real issue with that (the 60% reading WAS an issue), but Dwayne simply got me thinking... I think, those basic rules make a lot of sense and I will take them over in all their shortness, remembering I already heard them somewhere but confess, I did not follow the pulse/waveform criteria. Thank you very much (BEorP too for mentioning the waveform criteria first)! I think, that's the other real point, even if we can't trust on total accuracy, we can monitor changes. My question #3 actually was targeting to this answer, thank you for having it that quick. Plus, a pulse oxy is a great basic monitor device when you have not much space or have to move the patient (crash rescue, steep stairs) where a full ECG would get in the way. (Dwayne & DFIB: glad you survived your experience - I continue to hear about such incidents, so maybe Dwaynes prophecy is correct). Note: any spelling and grammar errors made intentionally for identifying purposes only.

Dwaynes post on another topic made me think again (thank you) about two recent calls, where we used four different pulse oxymeters. Call#1: >80 y/o male, felt to the floor, 4 x oriented, some bruises on the head, nothing else, pulse and BP pretty OK (don't remember, but nothing special). The initial SpO2 reading was 60%! However no indications for a real need of oxygene from general patient appearance. Totally awake, sat on the bench, normal breathing, no record of lung or breathing problems, no acute indications for additional O2 other than the pulse oxy reading. The pulse oxymeter was one of those finger clips, we use in our staff transporter (just happened to be nearby the scene as it was dispatched, so I did first responding). The finger clip fitted well, reading didn't change after resetting and re-applying, it had fresh batteries and usually gives good readings when tested. It is licensed for professional use as well. Despite this, according to the perfect patient state I gave no oxygene. The reading on the responding ambulances pulse oxymeter (other brand, hand held - no finger clip) was perfect in the 95% range, as expected. Call#2: On a patient ~70 y/o male suffering from "something with the heart" (totally unspecific) I attached the SpO2 sensor of our LP12, but couldn't get a decent signal. After fiddling some seconds, I re-attached to our hand held pulse ox (other brand) and it instantly got a signal of >90% and a pulse of 70/min. That seems very reasonable according to the patients general appearance. Then from the 3-lead ECG we got a first A-fib diagnosis, from the immedeate following 12-lead it was a clear additional left branch block. BTW, heart frequency was 140 and pressure 150/0 (zero!) - nice exact cook book view of a "half pulse" palpation and on the critical edge of a compensated heart failure (patient just walked up to the bath room in the first floor and sat there fully oriented). In this scenario I blame the LP12 pulse ox for not getting any signal (just some bleeps, but no measurement) where the other still was able to. On the same finger. Would like to have thought of additionally attach the other pulse ox on another finger, but that was not the time and patient to experiment. I since then feel I can't trust our pulse oxymeters any more...(they all are well known brands and licensed for professional use plus checked regularly according to manual). Sure I'm somewhat able by myself to see if a patient really needs oxygene and I always take general patient appearance in count (first half of my EMS life there was no such thing as a pulse ox!), but with todays doctrine to not force SpO2 over 95% - my own senses ability simply are not that exact on every %... So I have following questions: How do YOU really know to trust your SpO2 readings? Dwayne states in the mentioned posting, that "to many times people are/were suffering, and/or dying because providers didn't treat them because the pulse ox said that they didn't need to." How comes this? Beside true application errors (including deflective finger nails), the only real false-high reading of pulse ox I know is a CO poisoning. All other problems would give no reading (no signal) or false-low readings - how can this lead to provider's not giving oxygene? In my case#1 I decided so because of the general apperance (and was correct), a less imaginative provider may have given O2, because of low reading, but most probably this wouldn't have done any harm. Do we really need pulse oxymeters or the SpO2 value (if we can't trust it anyway)? Would like to hear your thoughts (I will share mine later), thanks! (P.S.: I will check all our four oxymeters on one test person soon, just getting curious)

See his homepage http://www.multileadmedics.com/, in the section "seminar handlouts" you find scripts which may give you some information about your questions and about what's covered in the book.

I always expected he turns into santa claus.

Here they are on the ambulances key ring, handing over is checked on every shift change. No medic has an own one. Our controlled drug boxes (morphine and fentanyl, not ketamine, that is not a controlled substance here) are installed in the ambulance and can't be withdrawn without a key. The key unlocks the box in it's bracket AND the box itself. Often, punishment is based on needed "criminal energy". If it's too easy for them to get to the drug, then they may get away cheap. If they have to break something or need heavy tools and some genius tricks, they may face more prison/fines. I remember two breakins on our EMS equipment, both when ambulances were in the station: once a remote station without duty staff was accidentally left open by maintenance staff, someone simply took the opportunity, stepped in on pure daylight in a crowded street and got two ampules of diazepam out, including syringe and needle, leaving them on the desk after usage. Police collected it but they never found someone. The other incident was more violent, our staff noticed action outside and checked, then suddenly were attacked by the thieves. Nothing was stolen and noone was severly hurt, but unfortunately the thieves could get away despite immedeate police tracing.

Not in my area and not in those nearby I know. We're thinking of adding it to our disaster response equipment, but we're still far away from realizing it. In military combat situations it's commonly used, but mostly on otherwise healthy young people (soldiers). In german EMS I don't know anyone even considering it (other than you and me), can't remember any article or conference topic about it. We usually have not that much deep chest/abdominal wounds, where I think would be the main indication. Explosive or gun shot wounds and stabbings are very rare in Germany. However, I simply would like to have the additional option.

Ask a German Bundeswehr army medic, maybe he/she can provide you with more information and maybe an example (as my friend did): they use QuikClotACS+[TM] from Z-Medica Corporation, Wallingford CT/USA, see their WWW page at www.z-medica.com for more information (includes video). European representant is EMERGO Europe, Den Haag, german office here: EMERGO DEUTSCHLAND GMBH, Poststrasse 33, 20354 Hamburg, Germany, Phone: +49 (0) 40 2261 1652 (no german homepage, though). On the Z-Medica homepage there are several study abstracts available, mentioning anti-coagulated patients. Plus the contact address of their Chief Medical Officer for medical professionals with further questions. EDIT: added last paragraph.

Reminds me of an old saying here: "The forth and back makes the meter" (or 3 feet for those who are not familiar with the metric system). So, simply have fun!

You mean things that were abandoned and came back later? My personal experiences were: Cramer wire ladder splint, were replaced by air splints, those were more or less replaced by vacuum splints, then the Structural Aluminum Malleable (SAM) Splint became common which in basic is the principle of the old Cramer splint again. Glucocorticoid spray: in my early days it was considered the best thing in world to prevent toxic lung edema when high dosed for smoke inhalations, then it was thrown out because no effect was evident, now it's back because it "at least does no harm" CBRN awareness: mid 1990ies we didn't need this cold war stuff any more. ~2001 we realized having forgotten hazardous materials in industry usage (and some terrorist media hype adds pressure) Disaster awareness: mid 1990ies we didn't need our federal wide large disaster unit concept = cold war stuff any more. End of 1990ies we had some larger calls to be forced into having additional response structures again for MCI's, 2001 the attacks on NYC and Washington/DC reminds of probable real high victim number disasters, 2002 floods covered several german states and reminds of probable inter state mutual help requirements. Now we have a strong interstate response concept (partially) alive again. Wet gel "Burn Pack": first it was the best thing on market for burns, then studies saw no need and maybe more harm than good, now we have it again on board, because "had still several on stock" and "maybe, just in case if...". Never used it any time, though. And probably never will. Epinephrine dosage: going up and down several times over the years. Traction splints: had it in my basic education courses, in "real" EMS they told me that this old stuff isn't needed anymore, now since some years it is propagated again (not yet on our ambulances, but we use the air splints a bit in the same sense). plus some things I even have forgotten to having forgotten once... I've seen a lot stuff first coming and then vanishing, too, but that was not the original question. Now I'm feeling a bit old, thank you...

Making more or less appropriate or funny comments about fire fighting is absolutely on topic in EMS forums. Considering other topics here, it's fitting perfectly.

First of all, Vin is totally self responsible for his decisions. So it's not CM's problem, and she should not make it her's. She may give help, council and all of that, but Vin sure is old enough. Plus he seems to be weak on several basic issues, so he should not wonder to have difficulties. The relationshipof CM to the other two is crappy anyway. CM should accept this, and not worry but move on in life. Sometimes you simply have to decide if someone else is important enough for you to make you troubles. For the constraint, CM never could be sure if the issue really was this way. Did Vin understand this right, did the mean that, did they actually really say it or does Vin make something up (for whatever reason, even by dumbness or wanting to sound interesting up to completely misunderstanding the whole thing). Even if it really was the case: CM learnt something from it and that's all. No thing to really worry about too long afterwards. Jake and Rad are the way they are, no issue for CM to change this. The school project already finished anyway, so no harm anymore. Just my view...

What if I drive through that city and my car gets on fire? Would they let burn it down simply because I don't have a membership? What if it's a mobile home? The other thing is: is it really enjoyable for the fire fighters to watch something burning down? What are their feelings? Wouldn't it be at least a good training? And: are they really legally/morally able or even willing deep within their heart to decide so? It IS a very emotional thing watching someones property going in flames. 3rd thought (from someone who's tax euros and mandatory social fees pay the public risk management AKA police, fire, disaster and EMS): isn't it considered environment pollution to let it simply burn, including all the stuff inside? So we know why it's named fire FIGHTING.

Give me your address (by personal message) and promise to send one of your patches back. If you have a real interesting patch or more than one different I can send you another one of our local disaster response unit (but they're limited, don't have much of them left).