CPhT

Really? You can't believe that in a thread of the Hottest First Ladies, no one else mentioned Hillary Clinton? Yep, what a babe.

Get a Galls catalog, a good set of EMT pants, and get everything that will fit into your pockets!!! Just kidding. I just finished my EMT-B class about a week ago. Things I would recommend: 1. PAY ATTENTION! "Empty your cup", as one of my other instructors would say. I don't care what you know going into the class, be prepared to modify/ supplement it with this new information. 2. READ YOUR BOOK! Don't just go by lectures. It took my class probably 2-3 quizzes to realize that the teacher was including information from the chapters as well as his lectures. This stuff isn't just there to bore you, it's there because you need to know it. Glascow Coma Scale, "Rule of 9s" (infant, child, and adult), normal vital ranges, pharmacology... this is all stuff that your teacher will probably glance over, but it's thinks you'll need to know. 3. VOLUNTEER! When in class, or on your clinicals, if someone comes up looking for a volunteer to do an exercise, do it. When you're doing your third-rides, jump in and get your hands dirty. Take over compressions, hell... offer to wipe down the cot after you drop off the pt. 4. ASK QUESTIONS! There is no such thing as a dumb question, except the one you don't ask. Over the next few (15?) weeks, you'll get to know your classmates. You'll be a tight group. You'll succeed together, you'll fail together. There's no point in NOT learning something because you're afraid to embarrass yourself in front of them. 5. GEAR UP! Ok, the Galls catalog thing was a joke, but not really. I would definitely get a comfortable pair of EMS pants (5.11 or Propper are nice), and a comfortable set of boots (I have the Magnum Stealth 6" Side-zips). Also, get a decent stethoscope. I'm not talking about a Littman Electronic (unless you've got money coming out your butt, in which case, buy me one too), but a decent scope. Littman Classics are pretty good, and you can find them for ~$50. When you go to buy your penlight, get a cheapo 6 pack of the plastic ones off Amazon or something. Nothing will piss you off more than when you spend big bucks on a piece of gear and you lose it your first day out. BTW, if anyone finds a Streamlight pen light, please PM me. Third Rides: Pack a lunch, bring something to read, or bring your Gameboy/PSP, along with your books and your gear. I'm just outside of Detroit in a busy area, and I had a whopping 7 calls over 24 hours. Other than that, learn. Enjoy your learning. Network with your teachers and your classmates. Eventually you might have to work with them, so you might as well get to know them. Good luck!

I just found another article that stated that the scene-to-hospital distance was 20km. http://www.thespec.com/news/crime/article/628527--anzovino-inquest-will-resume-dec-5 The hospital that was closest (by 5km) was closed due to restructuring. 20km, in icy conditions, seems like it might have close to 20 minutes of travel time. The first article only mentions that the medics spent 50 minutes trying to revive, so I can't really make an assumption of how much was spend on-scene vs. en route. I've personally never started an IV (still 8 months out of starting my medic courses) but I can imagine they have SOME justification for starting it on-scene rather than waiting to get in the back of the truck. If it's a big enough deal that they mention it as a deviance from the standard, then (Devil's advocate) they MUST have had a reason. We'll see what comes of it though. I'm really interested now.

Amen to that. I've always said (especially regarding the people of the "great" city of Detroit), if you don't like how things are going, you need to effect change. If the incumbent isn't "getting it done", putting him/ her back into office for 2/4/6 more years isn't going to help matters.

After reading some of the comments, it sure seems like they did everything they could to save that girl. However, one of the things that my preceptor and my instructor always tried to pound into my head was the idea that "if it's not on the PCR, it never happened". Likewise, if it's recorded incorrectly on the PCR, that's the only thing they can go by. I'm not sure about the Canadian lawyers and juries, but I'm pretty sure that a good malpractice lawyer here could tear the defense to shreds on that basis alone. On the other hand, the two ER physicians speaking in defense of the medics really lend credibility. The part that always scares me about if I ever had to go to court would be the "standard of care"; basically, asking other providers what they would do in the same situation. Ideally our answers would coincide, but like this article mentions, there are often events or circumstances which give variance to the "standard of care". All-in-all, it's really sad that the girl died. Accidents are tragic, but they are just that; accidents. Only the people who stepped up and tried to save the girl can really understand what was done, and why it was done. Good job to the medics for trying so hard.

Sorry I didn't get to revisit this thread yesterday. I was sitting in the county courthouse waiting for my turn to be one of the 12 angry men, and spent 8 hours in a lobby for $25. Not that I'm not used to sitting around for long, extended amounts of time with nothing to do, I'm just not used to doing it with 200 others. In any case, I quoted DFIB because given the evidence from page 2, that's exactly how I would have handled the call. After you described the "rash", which sounds like a SubQ bleed (large subdermal hematoma, maybe), and then I was gently reminded of the ASA and Plavix, the light bulb came on. Sadly, I don't know how many of my classmates would pick up on that aspect, because our pharmacology section was dreadfully short ("This is oral glucose, this is oxygen, this is an epi-pen, this is an inhaler. Any questions?"). Regardless, I would try for the ALS intercept but otherwise lights and siren, 80mph to the nearest facility. Pt supine or in Trendelenburg, recheck vitals after loading, then every 5 minutes. O2 via NRB if tolerated. Tourniquet the arm, then hope the traffic gods play nice with us on the way. St Diesel, pray for us.

If she's pale, I'm going to make the assumption that she's lost a lot of blood. I can't really place the "strange rash" except for maybe burns. My treatment is as follows: Direct pressure (along with elevating the wound) to stop the bleeding, tourniquet as needed. Dress and bandage. Prepare the patient for transport. O2 via NRB @12L (seems like she's lost a lot of blood if she's pale, O2 probably won't hurt at this point). Watch for signs of respiratory distress in case it is a burn (airway compromised). Vitals and Hx in the truck on the way to the nearest facility. Probably run a Priority 2 unless she has really poopy vitals, or starts losing going unconscious, then Priority 1. Just for giggles, what are her vitals? BP, Resp, Pulse, SPO2?

That's awesome! You should send me a private message. I'd be willing to bet that you know (or ARE) my instructor, or maybe you knew his partner.

I'd be nervous about entering a scene like that, but that's because I'm new. So, I'll treat it like I'm new (bear in mind, I'm a basic. Certified as of today, but not licensed/ registered as of yet). Scene safety, are my spidey senses tingling that something isn't right? General impression; how does my patient look as I approach? Is she tracking me visually? Does she acknowledge my presence? Skin tone? Posture? Do I see any blood? Any evidence of trauma? Making the assumption that this is a normal patient, I would probably begin taking vitals while my lead does the questioning. BP, Resp (rate,regularity, quality), Pulse (rate, regularity, quality), pupils, cap refill? Regardless of findings, I would probably load her into the truck, hook up some O2 @12L via NRB, and head for the hospital, conducting my detailed physical exam and ongoing exam en-route. My findings would just determine how fast I would have my partner drive. So... how'd I do? I'll be back to read the Paramedic response to the situation later.

It's all snake-oil. Buy a Corvette. In all actuality, most of those "wonderpills" have SOME basis in holistic medicine. The typical ingredients that claim "thicker, fuller erections" are the same ones that, in reality, are just treating mild cases of erectile dysfunction. Ingredients like Saw Palmetto, and Yohimbe (now outlawed) have been shown to increase blood flow to the genitalia, and ingredients like Zinc can help men achieve "harder" erections. Males with Zinc deficiency can often have difficulty in either getting an erection, sustaining an erection, or having a full erection (flag flying at half mast, if you will). Tribulus Terrestris, in holistic usage, is said to be a COX-2 inhibitor. Ginseng is another that has holistic usage in ED treatment. Revisiting Saw Palmetto, there is evidence (don't ask me to provide it, I have it somewhere in my stacks of Pharm Tech CEs) that the extract of Saw Palmetto can help with the symptoms of Prostate Cancer. Anyways, the basic mechanism of action for products like Enzyte is that they claim they can "inflate" the erectile tissues in the penis with both more volume and more pressure, and that over time, this "over-inflation" will stretch the penis. Ouch. Let's think of the problems with this though. 1. You have to be aroused to have an erection, or at least stimulated in some way. There are no "passive effects" in play here. 2. You have to overcome the natural elasticity of an organ that is MEANT to stretch and grow, and do so at a frequency such that additional stretching and growth is achieved. There's money in a treatment. That's what they pound into our heads in pharmacy. If the product actually worked, they would be in FDA trials, because after they get FDA approval, they could charge WAY more than $30 a month for the stuff. So like I said before, get a Corvette. At least you can have fun with the car all the time, not just for 10-20 minutes every hour or so.

This is here-say from a guy in my EMT-B course (actually, he was taking it as a refresher, he failed NREMT 3x), he says that your sections are graded as "Passed", "Nearly Passed" and "Below Passing", or something to that effect. Now, I'm not sure if you can fail a section, but still pass overall, or if it's a "fail one, fail all" kind of thing. I'm still in the dark about the whole test, because I have yet to take it. I just wanted to lend a bit of credibility to the OPs question. I've heard this referenced before, and it was from someone who had done the computer-based testing. You get a pass-fail within 24 hours of testing, then you get a printed breakdown of your score within 4-6 weeks in the mail.

I don't know so much about the commercially available OTC stuff, with the exception that many of them are herbal supplements with the disclaimer of "Product has not been evaluated by the FDA". Now the Rx/Legend stuff, like your Levitra, Cialis, Viagra, etc, that stuff works. Sure, it can't overcome some issues, like psychological, trauma, or cancer, but it can definitely put some "ding" back into the ding-a-ling. Then, we also have what we lovingly call our "cement mix", the injectable ED medications. You better keep an open schedule if you inject this stuff, because, and I quote a patient, this stuff will "make you harder than a Chinese spelling bee". These medications include Prostaglandin E-1, Papaverine, Phentolamine, and the occasional Atropine or Pentoxifylline. Our usual strengths range anywhere from PGE10mcg-40mcg, PAP10Mg-40Mg, and PHEN0.5Mg-1Mg, all per mL of injection. Typical dosage is 0.1ml, titrating up by 0.05ml until desired "effect" is reached. Now... would I ever want to stick myself with a needle in that particular region? Hell no. If the time comes in my life when my only option is to poke my poker before I poke her, then I'll tie a white flag around the end of it and call it a day. Some of my patients are actually quite fond of it though, and are more than willing to drop $99 a month, plus syringes, just to keep the dream alive.

In hopes that the frequent fliers would stay out of our hair

I agree with the need for overhaul. Being on the back side of the program right now, I feel like they tried to cram a year's worth of education into 15 weeks, and it shows. If nothing else, it should be a two semester program. The downside is that I'm not about to spend a year (or two) in an educational program to make a whopping $9/hour. If the organisation, as a whole, decides that it needs to up the educational requirement for EMT-B, then they need to reciprocate with pay. The one thing I would disagree with is the professionalism aspect. It takes more than a classroom to teach that, and either you have it, or you don't.

CPhT comes from my current certifcation, which is Certified Pharmacy Technician. The avatar pic comes into play too, as it's a mortar and pestle, my most commonly used "tools of the trade". In a couple more weeks, I'll hopefully be undergoing a name change though, incorporating my new title.

I wish I could have found out what the PT was on. The family didn't know, the nurses took the bags with them when the left the room, and the attending doc sure wasn't sharing any info.

We weren't 100% sure that they (the family) would actually go through the process, and that our rig would be given the assignment. We thought it would go to an advanced rig, so they could do IV and monitors. My lead tech tried to explain that very thing to the attending doc at the originating facility. They would hear nothing of it though, and still sent us on our way with just a signed AMA form. That was the part where we, as the crew, dropped the ball. We did NOT notify the receiving facility of the incoming patient. We just "showed up". Luckily, the receiving hospital had plenty of beds. Also, it was a non-profit hospital (St. Something-or-other Mercy), so they would have taken the patient regardless of if they could pay or not. Actually, I think that's law here that ANY hospital has to take and care for a patient, regardless of if they can or can't pay for the care. That's a good question. I'm honestly not sure how we would go about that subject, or if it's even the crew's responsibility here. I'll have to check with them when I ride again on Sunday. I found out later that the basis of the dispatches argument for having our BLS truck run the call was that the pt had stable vitals, within normal limits, and had no chief complaints except the bad service she was receiving at the originating hospital, and her HX of heart surgery. Dispatch made the case that her prior history alone didn't warrant an ALS truck, and that we were close enough to the receiving facility that even if things went wrong, we would be able to switch from priority 3 to priority 2/1 and still have a good chance. It made sense to me, and seeing how the patient wasn't as big of an issue as she could have been, I accepted the answer without any further questioning. Things may have been drastically different if she would have gone sour.

That's good food for thought. I really appreciate hearing that side of things too. I have no intentions of taking up grievances or complaints with the hospital, or anyone for that matter. I think the lead tech I was riding with did everything in his power, as did the other tech. The family was demanding better care, and we were simply the "middle-men". I would hope that the staff at the hospital were acting in the patients best interests and not acting out of spite for the patient and/or her family. The attending Doc at the originating hospital was very condescending to the family, as well as our crew, but it's nothing outside of the ordinary (sadly). With that run, I think I may have just had my first lesson in "shut up, load up, and keep your fingers crossed", with the realization that the patients level of care increased 10-fold by going to the other hospital.

RE the nurses: I've had better luck with trying to teach my dog to speak Spanish. Ruffems, you've been to my area. Does the abbreviation SGH on W. Outer Dr. ring a bell as far as facilities? That's who we're talking about with the originating facility. I did have the pleasure of listening to the attending ER doc at the receiving facility tear the floor nurse at the originating facility a "new one" via telephone. I was working on cleaning/re-sheeting the cot and getting paperwork signed, but the gist of the conversation was "how dare you try and use HIPAA to get around doing your job, and sending a high-risk patient out on the streets?". Pretty amazing to watch. I have no problem outing myself as a bonehead , I just didn't want to say anything potentially damning regarding the crew or the company. My crew was pretty awesome, and the service seemed pretty straight forward too.

In all honesty, had I been more than a student in this hypothetical situation, I would have definitely requested at least the advice of a supervisor. The originating hospital's position on AMA/ HIPAA aside, we could have treated the patient as any other IFT, read vitals on scene, recheck in the truck, recheck at interval until handing off to the receiving facility. As it was, the lead tech requested that we at least kept an Alpha rig (advanced team) on standby in case things went south and we needed to do an intercept. Overall, the patient was easy going and was eternally grateful once we arrived at the receiving hospital. The only thing that I can see, as an outsider, that made the receiving hospital uneasy, was that we didn't call it in enroute and just sort of "showed up" with this patient. I'm not familiar enough (shame on me) with HIPAA yet to know what my boundaries are, and when I should "raise a stink". The lead tech tried to make his case to the charge nurse, and the attending doc stepped in and shot him down. My disclaimer regarding the "coincidental nature" of this post... that's just to protect the innocent. Names of pts, techs, companies, hospitals, and schools are withheld, call sign of the rig has been changed, and the situation has been modified sufficiently to represent something that was CLOSE to a real situation, but didn't actually happen. I want to learn from mistakes, so that I am not doomed to repeat them. Thanks all for the advice/ comments!! Keep em coming!

*This is being written from my point of view, as a student third rider aboard a private company basic rig* THIS IS A HYPOTHETICAL SITUATION AND HAS ABSOLUTELY NO BASIS IN REAL LIFE, AND ANY SIMILARITIES TO A REAL CALL ARE PURELY COINCIDENTAL. While finishing paperwork from a previous run, a citizen knocks on the drivers window of the truck. Bear in mind, we're still sitting in the emergency lot at the hospital, it's dark, and this is the west side of Detroit. Citizen: "Hey, can you all take my mom from this hospital to (other hospital on east side)? She had surgery about 7 weeks ago and isn't getting any better, and we want to take her to a better hospital." Tech 1: "Well, we can't just go in and get her. She has to be released first, then we can take her wherever you want, but it still has to go through the proper chain of command. We have to take the call from our dispatch." Citizen: "We're going to sign her out AMA so we can take her to the other hospital. She's been there before so we want to go back." Tech 1: "OK. Here's our number for dispatch, and here's who you need to call. If you go through the proper chains, they'll send someone back out to get her and take her where you want to go." Dispatch: Bravo 7, cleared at (west-side Detroit hospital), return to post at (suburban hospital 30 minutes away). *29 minutes, 30 seconds later, as we're pulling into post* Dispatch: Bravo 7, priority 3 at (hospital you were just at) for patient transport to (east-side hospital). Tech 2: Copy priority 3, en route to (west side hospital). *30 minutes later, we arrive to find the patient on a recovery floor. PT is late 80s/early 90s, female, 7 weeks post-op on open heart surgery. All patient-related medical questions are being answered by the family, as the staff is now refusing to answer any and all questions about the patient. Any questions are answered with either "I can't tell you because that's a HIPAA violation" or "She already signed out AMA, that's not our concern". When we arrived, the nurses were taking her off her IV, taking off her monitors, and even went so far as to take away her food tray. After getting an initial impression of the patient, the lead tech used the truck cell phone to call dispatch for advice on whether this would be a call better handled by an Advanced rig, but we were told to handle it. We loaded the pt into the truck, took history and vitals, and started on the way to the new hospital. Turns out the pt has a hx of HTN, 2x CVA, 2x MI, all within the last 5 years. Her vitals were surprisingly normal. A/Ox3, P70, BP112/60, R18. PT was high as a kite because of her Fentanyl patch, but otherwise in good shape. Maybe it's just my newness, but both the tech driving and me were concerned that the long drive (30 minute transport) combined with the nature of the patient might have been a bad combination. All in all, the patient made it to the other hospital just fine, and they were happy to take her. We were paranoid, but rightfully so. Now for the learning experience: 1. Regarding what the first hospital was saying with HIPAA; since we were requested by the family, and we will be assuming care of the patient, were they wrong in withholding the patients information from us? 2. Would you, if you were an EMT-B, given the situation with the patient, have requested that an advanced truck take the patient? We were thinking that if the patient was on a monitor at the hospital, it would have probably been wise to do the same during the transport. 3. (Something the receiving facility mentioned) If a patient is released AMA, is it technically illegal for an ambulance crew to go into the hospital, pick up the patient, and take them to another facility? We were told that basically, it would have been more "legit" if the family had taken the patient out of the hospital, gone across the street to McDonalds, and called us from there, but that it's a grey area to actually come and get a patient from one hospital to another without medical orders to do so.

81/100

I'm actually not familiar with either of those products yet (we don't use too many common/ commercially available products in my pharmacy, most of our work is either low-production or one-off). However, just looking at the anectine, it looks like it's an IV product, most commonly sold in 20mg/ml, 10ml multi-dose vials. MDVs, in our side of things, all contain preservatives, and will actually last longer than a SDV (single dose vial). The downside, is that per FDA regulations, once a multi-dose vial is punctured, the expiration date automatically changes to 28 days later. The rationale behind the 28 days thing is that no matter how clean you're getting the septum of the vial and the needle itself, you'll still introduce a small amount of bacteria into the vial. After 28 days, the bacteria may have grown to the point where injecting the mixture has a high likelyhood of causing infection. Have we had patients inject after the 28 days? Oh yeah we have. On several occasions. We've also had people take their vials and keep them on the shelf for almost a year (6 month non-punctured expiration on these products typically), use it once, then let it sit for a month and use it again. The expiration dates for most of our products are just what you'd expect; they are a way for us, as a pharmacy, to cover our butts when either A) a product has lost it's efficacy, or they experience an adverse affect from the product.

For the most part, the article is correct. The basis of most expiration dates is the actual potency of the drug. For example, we have an algorithm we follow when establishing the "beyond use" dating on our compounded medications. The algorithm takes into account the base of the medication (water based or otherwise), the form of the active ingredients (compounded from manufactured tablet vs compounded from a base powder), the storage temperature (fridge, freezer, room temp), and the sterility of the product. We can range from as small as 24 hours (high risk non-sterile chemo med compounded from a powder and into sterile IV form), through 180 days for most of our low risk meds (capsules and other "dry" medicines). All of our medications are tested by a third party laboratory to determine if we can actually use a different (longer) expiration date. They test the product for potency at the date it was made and every 30 days thereafter until the product loses 10% of it's labeled potency. Once the product drops below 10% of it's labeled potency, we can establish that as it's expiration date. Now that having been said, would I use a medication at home that was expired? Short answer; yes. In a pinch, expired medicine is better than not having it at all. Long answer; it depends on the product. If it was ever a refrigerated product, no. If it was a sterile product (eye drops, IV or other injection), no. If it was a narrow therapeutic index product, no. If the problem was severe enough that I really needed to trust the efficacy of the medication I was taking, no.

See, I loved growing up on the west side of Detroit in Brightmore. About the only place more ghetto than that was the Jefferson Projects. We sold our house in 1996 for $3000 cash and it's the ONLY house on the block still standing. I like talking to some of the people in school and in public who hear me say something about the ghetto and get that indignant smile like "what do you know about the ghetto" and then I kindly inform them. A conversation at work one day went like this: Coworker 1: "My parents only bought me a BMX bike for my 10th birthday". Coworker 2: "I had to cut the lawn for a month, then my mom got me a mountain bike". Me: "Holy sh*t, you guys had bikes when you were kids? I didn't get brand new CLOTHES until I was a teenager". -You might be ghetto if you still think Gov't peanut butter is the ONLY peanut butter you can use for cookies. -You might be ghetto if you've had more than one neighbor raided by the BATF or DEA. -You might be ghetto if you've ever had more than one dog stolen. -You might be ghetto if you've ever had your house broken into more than once on the same day. -... if there was a murder/suicide on your front lawn. -... if the outlaw bike club moving in next door was the reason your crime rate went DOWN for a year or two. -... most parents told their kids not to play more than a couple houses away, where you weren't allowed to leave the driveway. -... your neighbors had more, and better, guns than the local police department. -... EMS/ Fire had police escorts to every call, as did the local utility companies. The ghetto is fun. Once you're able to crawl out of it, you really have an appreciation for everything you ever get from them on.