BlueSkies

Apparently I have been a member since 2011 and it was Dwayne's fault for dragging me here!! I got lucky with the log in info but tonight has been fun and I even replied to a few threads lol Just remember that take offs are optional but landings are mandatory Also its Snoopy side up and sticky side down for bandaid applications!!!

"Take offs are optional...Landings are mandatory"

I know this thread is old but I do love RSI since it is basically our bread and butter in the Aeromedical world so let me throw my two cents in on this one and see what you think!!! First off, I have never seen or heard of anyone using Versed (Midazolam) as an induction agent. It is simply a bad choice. Number one it is a Benzo and it has predictable effects but it's not reliable. While it does provide the amnesic effect it does not effective kill the urge to vomit which is exactly what we are looking for when we use the term RSI. Remember that the "I" in RSI stands for Induction, not intubation as we are inducing a coma. Propofol has a great place but in the rotor wing environment it is hard to keep up with, we have so many tubes and machines in a small space it is not a good situation if someone is snowed with Propofol and your line kinks or you lose your IV and the patient wakes up and starts kicking the pilot in the neck!!! Let's talk about Ketamine for a second, great drug, great profile, easy to dose, good for kiddos and adults but it is not the wonder drug it is made out to be. Look at the side effects, number 1, it causes hyper salivation so if you're using Ketamine without the premeditating of your patient with Atropine then you may want to think about approaching your Medical Director for a change in your RSI protocols. Number 2, Ketamine if give to a sympathetically exhausted patient will cause hypotension, bradycardia and death if your are not careful. Reminder that Ketamine's mechanism of action is to use your catecholamine stores and if they are depleted your patient is screwed! I have seen a lot of the peeps here talking about Suxamethazone which if you're not familiar with it is nothing more than how they package Succinylcholine outside the US. Been there done that when I did medivacs in Mongolia for over 2 years Succs has some lethal and well known side effects such as being a trigger for malignant hyperthermia, increases potassium, can't use it in renal failure patients or patients with increased ICP or Increased intraocular pressures, penetrating eye trauma, blah blah blah Now let's talk about my new favorite drug!!! SUGAMMADEX (Bridrion) it has been available in the US since Dec 2015. This drug has effectively replaced Sux in my RSI and Difficult airway protocol. It's mechanism of action is to encapsulate Rocuronium at the nicotinic and muscarnic receptor sites and make it moot. So, in the near future you will see most of your RSI protocols changing to include Sugammadex as soon as the price goes down lol Basically what your protocol may change to is something like this: Pre Medications such as Atropine, Lidocaine (you can remove your defasciculation doses now since Sux will be gone) Versed, Propofol, Fentanyl, Amidate (My favorite because it is the only one with a linear relationship, 100 secs of induction for every 0.1mg/kg) Rocuronium (your typical dose of 1mg/kg) Intubate Continue in with analgesia and pain control See!! No SUX anywhere!!! What happens if you miss the intubation and you run into a can't ventilate can't oxygenate situation? Of course the answer is Surgical Cryc lol but before you get there you can admin Sugammadex and the effects of Roc will be reversed in typically less than 3 minutes. Great studies have already been released in the US, the UK and Aussie, check it out for yourself if you don't believe me and as I always say, don't take my word for it, go learn it for yourself!!! Look up the new Difficult Airway Algorithms that have been released here in the US, you will see on them that it leads you to the "wake the patient up." option, This is actually referring to using Sugammadex to reverse the neuromuscular blockade! Sugammadex works with Vecuronium also but not nearly as well as it does with Rocuronium. It is still expensive as it is only marketed by MERCK and so far it is $100 for a 200mg vial and the average dose if 4mg/kg which would be 400mg for a 100kg patient at a cost of $200 dollars for your service. The good news is it is not needed for every RSI case if you can pass the tube through the chords Well this has been way more fun for me than it should have but I look forward to the replies on this thread so return fire at will!

Welcome to the City! I have never personally agreed that accelerated classes for this type of certification have ever been a good idea. With this type of class all you really get is the "cookbook" style of medicine which is very simple, when your patient presents this way you do this. It does not give you a root in focused A&P or pathophysiology so therefor there is no way you could be expected to critically think your way out of an emergency that is not listed in your protocols. I look at those types of classes as scams for the most part and in today's world where we are trying to sharpen our image as pre-hospital practitioners and not just ambulance drivers or in my case "self loading baggage", people like yourself are being taken advantage of with high priced classes and promises of jobs and certifications. I feel bad that you had to go through this junk and that you lost a little self confidence by failing your first attempt. So with all that being said, please do not think I am downing you in anyway, merely the methodology behind your so called "Class", I currently teach FP-C, CFRN, CEN, CC-P review courses for my company and I am fairly aware of what is on the NREMT test for Basics so if you would like, we could hook up on skype and I can help you through some of the things you don't understand and I can provide you with some study materials and prep tests to help you gain the confidence that you need to pass. I make no guarantees and I charge no money but as an older Medic, I do believe it is my place to mentor the new generation such as yourself to take my place when I get even older and more broken down So if you are interested please PM me and I will get started with you. I work a salary job so I am basically free most days or I can make time for you when you're available. I am in Mountain time here in South Dakota. Keep your chin up kiddo, we can all get you through this and trust me when I say that if I can pass the NREMT test, anyone can pass it!!!

Geesh...the poor guy left already..we can't have nuffin nice round here Maybe you guys should stop talking when someone new comes over..set the next few plays out!!!

That is what I am guessing too Bieber. Same way over here. We use baby blankets and just as important is the head cover for the baby. Set the temp high in the back of your rig and prepare to sweat!! Infants cannot regulate their bodies temps yet so it's up to us to keep them warm. Warm IV bags I am sure could work but I think that wrapping up the baby, covering its head, turning on the heat and let Mommy hold the baby to her chest is the best course of action. If Mom has planned on breastfeeding I say let her! Skin to skin contact is great for body heat transfer and it will also help with any vaginal bleeding that may still be occuring to Mom. Put the blanket over baby and Mom for a little privact and you have killed several birds with one stone.

A few things come to my mind on this issue. I will be brief and give everyone else a chance to ellaborate. 1. Long hours at work. Before I left the streets back in 08 there had been ongoing talk for some time about the possibility of insurance companies either raising their rates or refusing to insure EMS services that stil rotated on 24 hour shifts. Long hours and no sleep can and has been proven to be deadly to the workers and the public. 2. How many other professions do you know of besides EMS and the fire service where an 18-21 year old (depending on insurance policies) jump into an ambulance or firetruck, flip on the lights and sirens and take off down the road after a 1 or 2 day EVOC class? The inexperience of some of the drivers are to my mind yet another cause. My two biggest recommendations would be to do away with the 24 hours shifts and require someone under tha age of 25 to have not only an EVOC class but several months to a year of documented supervised driving with a senior co worker. Will these happen anytime soon?? Probably not but that's me on my soapbox for a minute.

Dwayne the world may never know!! That pic was actually during a training day with my SAR team. I was making them trust each other and the systems so I was asking them to descend and then let go and invert after they were belayed off. Awesome day!!!

Kiwimedic No way a brand new AAS RN or a BSN will be able to step onto an ambulance and function. By virtue of education only as you say...seriously? Come on now...lay off the sauce

Brother, believe it or not a lot of us have Dx and UnDx PTSD. You are talking to one right now. The support system you have along with the new exercise program will help but you know as well as I do that stress IS A KILLER! Don't use the statement, "I think I may also seek professional help." Just go...bite the bullet like I did a few years ago and go...SOON! You will feel better and please don't ever hesitate to come post here again with anything else. This took massive courage to admit and we are probably all reading this saying to ourselves, "I have been there or I am there now." Stay safe my brother.

Ok from experience with FL and the EMS system there let me give you a little advice. FL is mostly Fire based EMS and if you are applying to a FD they won't even look at your app if you do not have the FL FF Standard Certs. Best avenue for you is possibly consider moving to another part or face a long commute. There are very few county EMS services left. However there is hope for you my friend. Lee Co EMS in Ft Myers Beach is a county EMS, no fire. EVAC in Daytona Beach is EMS and no fire. Rural/Metro in Orlando and West Palm Beach is EMS and no fire. Orange Co FD in Orlando will usually hire for strictly EMS just watch their website. Lake Sumter EMS is not fire based. And of course the largest private service in FL is Sunstar in Pinellas Co which of course is Tampa Bay. They will hire you tomorrow if you just apply. They are always looking for people. There are not many more that I can think of right off hand but what I did was find a county map of Florida and then I searched indivudually on the net for what kind of service they ran. Most of them have decent sized citites in them and you can search for that city and get a lot of info about police, fire and EMS. Also, Okaloosa Co and Escambia Co have straight EMS services but that's way up in the panhandle. Good luck and I hope this helps mate!!! Eric

Dwayne I am proud to say that I know you personally and that we have worked close together on a project. The others on this forum do not realize what a blessing you are to the world. You and your wife are stronger people than I could ever hope to be. God speed your journeys and I look forward to many more years of our friendship!

I know there are some of you here who beleive in different things and I respect that. This isn't meant to start a religious backlash it is simply a joke so have a coke and a smile!!! There was a great flood coming in the mountains. The snow was heavy during the winter and when the spring showers came the flood was on so to speak. It was broadcast all over the radio and TV for residents of a small community near the swollen river to evacuate now! There was one little stubborn lady who insisted that her Lord would save her however. The first day as the streets were begining to flood a rescue truck was dispatched to her house. When the crew arrived at her front door they announced, "Ma'am, we are here to get you out!" To this she replied, "Do not worry about me, my Lord will protect me!" So the rescue crew left. The second day the streets were flooded and the water had begun to rise inside her house so she retreated to the second floor. Soon after a rescue boat noticed her in the window and yelled to her, "Ma'am, we are here to get you out!" To this she replied, "Do not worry about me, my Lord will protect me!" So the rescue crew left. On the third day the waters had rose so high that she had been forced to retreat to her roof. A passing rescue helicopter noticed her and lowered a rescuer and a basket down to her roof. The rescuer shouted, "Ma'am, we are here to get you out!" To this she replied, "Do not worry about me, my Lord will protect me!" So the helicopter left. Soon after the aircraft departed the flood waters completely over took the house and the little old lady was swept away and quickly drowned. The next thing she realized was she was able to open her eyes and standing before her was the Lord. She promptly asked him, " Lord, I have always read that you will protect me from harm, why have you forsaken me by allowing me to die?" To this the Lord replied, "I sent you a rescue truck, a boat and a helicopter! What more do you want?"

I have responded to two of these and was involved in a roll over myself. I never gets easier. Thoughts and prayers for all those involved.

I have always been a proponent of, "If its bad enough to extricate its bad enough to need an XP-1." Which of course isn't always true but it seems that a bunch of advanced providers forget to utilize a great tool. I have talked to several medics who didn't know that it controlled C-Spine once secured into place. Of course I do believe this is lack of education on their respective programs part. Everyone pushes the LSB for complete spinal immobilization when sometimes an XP-1 or KED is a better choice.

I was thinking of odd scenarios I have seen in my career and just wanted to share this with you all. Of course any input or observations are welcomed and appreciated. My aircraft was called to the scene of an MVA last summer. Two vehicle head on colision. My patient was the driver of the number two vehicle the was struck more toward the passenger side of the front. This was a moderate speed crash of <55mph with not much patient compartment intrusion. There was extensive windshield and steering wheel damage and the airbags did deploy. Upon our landing and being driven a few hundred feet to the scene we made a quick assessment of the patient after taking report from the on scene paramedics. The patient was being extricated from the vehicle by the local rescue team. After he was properly packaged and laid flat he began to C/O increasing dyspnea. After he was loaded into the EMS unit for the short transport to the aircraft his Spo2 began to decline. (Keep in mind that the time from extraction from the vehicle until transport time was less than 5 mins) He was already receiving 15LPM 02 via an adult NRB. Lung sounds were decreased on the left. I attempted to due a reasonance test but the noise level was too great to make an educated call on what I was hearing. Also heart tones and lung sounds were equally hard to make out. After we got closer to the aircraft and away from the noise of the scene the assessment became much easier and then I was able to make a determination on what the underlying cause of the dyspnea was all about. Heart tones were muffled a little but no rubs, clicks or gallops were noted. No S3 or S4 sounds were noted. Percussion over the left lung field revealed hyporesonance. It literally sounded like I thudded on a watermelon. A little longer listening over the left lung revealed bowel sounds. I had been considering using a Wayne Pnuemothorax Kit prior to understanding what I was hearing. All other injuries were fairly superficial. As I recall I think his left thigh had a laceration but nothing else major. The point behind all this is I try to be as cautious as possible when faced with the need to be fairly invasive with my patients. Always take the time to be certain of what you are hearing and practice pratice practice the things you aren't familiar with like lung and heart sounds. We get so used to hearing wheeses and rales or rhonchi that we tend to get tunnel vision and often skip a throrough inspection sometimes. We can also fool ourselves into thinking we hear something that isn't there. A part of this story that I left out is I asked my partner to listen to all of the above and we both agreed it was a diaphragmatic herniation and therefor we with held any further invasive treatment. We were both hesitant to decompress the chest due to the clues not lining up to suggest a tension pneumothorax or a hemothorax. I would have suspected to see JVD, PVC's or some other sign of one or the other. (I am speaking here of when I couldn't hear so well) This patient was flown to the Level One Trauma Center and received emergency surgery to repair the diaphragm. He spent 2 days in a step down unit and was D/C home on day 3. This was kind of abbreviated to get to the point but I recall quite a bit about this and I have a pic I'll post to give you an idea of the scene but feel free to ask any more questions. Thanks gang!! Sorry I didn't mean to put multisystem, I just meant to write Trauma Patient.

I agree with you Dwayne. Some of the people can be shady when it comes to a quick payday. My client company is massive and a major oil conglomerate so people can get the dollar sign syndrome. I will be able to follow up on this to its conclusion and I will post more info as I get it myself. Today marks 96 hours post incident.

I think this topic boils down to not only respect for the family, the patient, the physicians, nurses and all others involved but the biggest part to me is respect for yourself. Boys and girls you just cannot teach that. I have seen scenarios like this one play out several times before my eyes and I was just completely flabbergasted! Its a sad part of our world and for those of us who understand the concept of professionlism it makes it that much harder for us to change the perceptions of those involved in these types of incidents. Once that impression of "EMS is unprofessional slobs!" has been fixed in someones head it is difficult to correct. However, we should always strive to treat not just our patients with love and compassion but also everyone involved from the family to the ER staff and beyond. My motto is kill them with kindness and if you put a smile on your face and then begin to speak it always sounds better!

Honestly like I told Doc, Compartment Syndrome from the soft tissue damage was my first thought. When the idea of nitrogen bubbles was introduced into my thought process it really threw me for a loop. I did not speak to the Dive Doc myself, this was feedback I was receiving from another employee out here that has no medical experience. Although he is intelligent I am sure that some parts of the assessment and details of the injury were left out when he spoke to the Doc. Being in this new realm of medicine out here is fairly nerve wracking sometimes. These are your friends and family and you grow to love these guys. Any feedback I receive is taken to heart and I try to improve myself as a provider daily. Industrial medicine is a different animal when you mix in all the chemicals and pressurized equipment we have on board. My time frame with the patients and scope of practice grew exponentially as soon as I sat foot into international waters. Factor in OSHA, CFR Rules, Company policy from not only my company but from the client company as well and it quickly becomes a beast. Thank you all for the responses and I am sure I will be picking your brains again in the very near future.

Sorry, I left out one small detail and I tried to edit it but it just kept putting my new post under my old one. I would love to erase the top two scenarios and only have the 3rd. You're my hero Doc! Compartment syndrome had crossed my mind as well but I did not realize that this would have been a surgical emergency. As a matter of fact, surgery was not even suggested until this afternoon and today was greater than 72 hours post injury. I was with this patient all total 2 and a half hours and then he had a helicopter ride with another medic that was 1 hour and 10 mins. So all total before definitive care was 3 hours and 40 mins.

I recently had a case offshore that I want to share with the group and hopefully get some different aspects and opinions. Hx: 47 y/o male patient was working with a high pressure Nitrogen tubing line and an on/off ball valve. The equipment had been just been pressure tested @ 3000psi. The patient was in the process of bleeding off the pressure when the tubing came unseated from the ball valve and basically exploded in his hand. The tubing was 1/4". Injuries: The patient sustained two seperate puncture wounds to his right wrist and hand along with several superficial abrasions and small lacerations to his right hand. The entrance wound was approx 1mm medial of the radial artery at the wrist and the exit wound was approx 1" away on the palmer side of the hand just medial to the base of the thumb. The entrance wound was 1mm in circumfirence with the exit being approx 2mm. There was also a large hematoma to the right anterior forearm just distal to the elbow. What I think happened based on the evidence found: When the line became unseated and broke apart the fragments caused the superficial lacerations and the abrasions. The puncture wound was either caused by injection pressure or a fragment. The contusion to the forearm was caused by the line whipping toward the patient and striking him in the arm. His hard hat was found about 20' away from him but I believe he actually knocked it off himself with his natural reaction of pulling hs hand away from the danger. Assessment: The Pt revealed intact PMS in the right hand. Cap refill was normal at &lt;2 secs. The amount of edema did not appear to be abnormal. The hemorrhage had slowed to almost nothing and he was complaing of more pain around the contusion on the forearm than the hand. He had full ROM in the right arm. There was no subcutaneous emphyzema noted in the wrist or hand. He suffered no LOC changes and all other assessments were unremarkable. Tx: Co-workers walked him to the infirmary under his own power. He was pale, cool and diaphoretic and anxious. He kept repeating, "I have hit my artery!" The co-workers had a towel placed over the injury and were doing an excellent job of holding pressure to the wound. I readied some sterile 4x4's and asked them to remove the towel. To my relief the hemorrhage was oozing dark red blood. The patient was calmed down and the wound was cleaned thoroughly with sterile water and sterile 4x4's. His hand was dressed and bandaged. I placed his arm in a sling and swathe. His initial pain was a 10 on the 1:10 scale. After the cleaning, bandaging and calming down the Pt's pain reduced to 4. He was given 1 gram of Tylenol and Local Cold Therapy to help reduce the edema and pain further. He was airlifted off the platform to the closest appropriate facility to see the awating ER MD. Outcome: Xrays reveal no debris in the wounds. He now C/O numbness to the thumb. He received 3 stitches all total and the wounds were not totally closed to allow for drainage. He was D/C home with pain medication and antibiotics and told to F/U with an Orthopeadic MD a few days later to assess any long term damage. F/U 48 hrs later: He is now suffering from complete numbness and a significantly reduced ROM in the right wrist and hand. His fingernail beds have a tint of purple in them all and the edema has reduced a small amount but seems to have increased at the wrist. My Questions for you: A diver friend of mine suggested hyperbaric treatment within the first 24 hours of this type of injury to due the long term effects of introduced Nitrogen in the wrist and hand. He is also a friend of this patient and has spoken with the medical director over the divers on our location. This particular MD treats diving injuries pretty exclusively and does hyperbaric therapy quite a bit in his practice. His suggestion was based on Nitrogen bubbles will impeed blood flow and thus slow the healing process. I was kind of busy when we were discussing this and I of course did not catch the entire reasoning. So rather than just Google it I thought I would present the case to you and see if there were any other ways to treat this patient. What would you have done differently and why? Do you think the acute onset of numbness and limited ROM is being caused by Nitrogen bubbles or just plain old edema and possible nerve damage or impairment due to edema? Have a great night gang!!! I recently had a case offshore that I want to share with the group and hopefully get some different aspects and opinions. Hx: 47 y/o male patient was working with a high pressure Nitrogen tubing line and an on/off ball valve. The equipment had been just been pressure tested @ 3000psi. The patient was in the process of bleeding off the pressure when the tubing came unseated from the ball valve and basically exploded in his hand. The tubing was 1/4". Injuries: The patient sustained two seperate puncture wounds to his right wrist and hand along with several superficial abrasions and small lacerations to his right hand. The entrance wound was approx 1mm medial of the radial artery at the wrist and the exit wound was approx 1" away on the palmer side of the hand just medial to the base of the thumb. The entrance wound was 1mm in circumfirence with the exit being approx 2mm. There was also a large hematoma to the right anterior forearm just distal to the elbow. What I think happened based on the evidence found: When the line became unseated and broke apart the fragments caused the superficial lacerations and the abrasions. The puncture wound was either caused by injection pressure or a fragment. The contusion to the forearm was caused by the line whipping toward the patient and striking him in the arm. His hard hat was found about 20' away from him but I believe he actually knocked it off himself with his natural reaction of pulling hs hand away from the danger. Assessment: The Pt revealed intact PMS in the right hand. Cap refill was normal at <2 secs. The amount of edema did not appear to be abnormal. The hemorrhage had slowed to almost nothing and he was complaing of more pain around the contusion on the forearm than the hand. He had full ROM in the right arm. There was no subcutaneous emphyzema noted in the wrist or hand. He suffered no LOC changes and all other assessments were unremarkable. Tx: Co-workers walked him to the infirmary under his own power. He was pale, cool and diaphoretic and anxious. He kept repeating, "I have hit my artery!" The co-workers had a towel placed over the injury and were doing an excellent job of holding pressure to the wound. I readied some sterile 4x4's and asked them to remove the towel. To my relief the hemorrhage was oozing dark red blood. The patient was calmed down and the wound was cleaned thoroughly with sterile water and sterile 4x4's. His hand was dressed and bandaged. I placed his arm in a sling and swathe. His initial pain was a 10 on the 1:10 scale. After the cleaning, bandaging and calming down the Pt's pain reduced to 4. He was given 1 gram of Tylenol and Local Cold Therapy to help reduce the edema and pain further. He was airlifted off the platform to the closest appropriate facility to see the awating ER MD. Outcome: Xrays reveal no debris in the wounds. He now C/O numbness to the thumb. He received 3 stitches all total and the wounds were not totally closed to allow for drainage. He was D/C home with pain medication and antibiotics and told to F/U with an Orthopeadic MD a few days later to assess any long term damage. F/U 48 hrs later: He is now suffering from complete numbness and a significantly reduced ROM in the right wrist and hand. His fingernail beds have a tint of purple in them all and the edema has reduced a small amount but seems to have increased at the wrist. My Questions for you: A diver friend of mine suggested hyperbaric treatment within the first 24 hours of this type of injury to due the long term effects of introduced Nitrogen in the wrist and hand. He is also a friend of this patient and has spoken with the medical director over the divers on our location. This particular MD treats diving injuries pretty exclusively and does hyperbaric therapy quite a bit in his practice. His suggestion was based on Nitrogen bubbles will impeed blood flow and thus slow the healing process. I was kind of busy when we were discussing this and I of course did not catch the entire reasoning. So rather than just Google it I thought I would present the case to you and see if there were any other ways to treat this patient. What would you have done differently and why? Do you think the acute onset of numbness and limited ROM is being caused by Nitrogen bubbles or just plain old edema and possible nerve damage or impairment due to edema? Have a great night gang!!! I recently had a case offshore that I want to share with the group and hopefully get some different aspects and opinions. Hx: 47 y/o male patient was working with a high pressure Nitrogen tubing line and an on/off ball valve. The equipment had been just been pressure tested @ 3000psi. The patient was in the process of bleeding off the pressure when the tubing came unseated from the ball valve and basically exploded in his hand. The tubing was 1/4". Injuries: The patient sustained two seperate puncture wounds to his right wrist and hand along with several superficial abrasions and small lacerations to his right hand. The entrance wound was approx 1mm medial of the radial artery at the wrist and the exit wound was approx 1" away on the palmer side of the hand just medial to the base of the thumb. The entrance wound was 1mm in circumfirence with the exit being approx 2mm. There was also a large hematoma to the right anterior forearm just distal to the elbow. What I think happened based on the evidence found: When the line became unseated and broke apart the fragments caused the superficial lacerations and the abrasions. The puncture wound was either caused by injection pressure or a fragment. The contusion to the forearm was caused by the line whipping toward the patient and striking him in the arm. His hard hat was found about 20' away from him but I believe he actually knocked it off himself with his natural reaction of pulling hs hand away from the danger. Assessment: The Pt revealed intact PMS in the right hand. Cap refill was normal at &lt;2 secs. The amount of edema did not appear to be abnormal. The hemorrhage had slowed to almost nothing and he was complaing of more pain around the contusion on the forearm than the hand. He had full ROM in the right arm. There was no subcutaneous emphyzema noted in the wrist or hand. He suffered no LOC changes and all other assessments were unremarkable. Tx: Co-workers walked him to the infirmary under his own power. He was pale, cool and diaphoretic and anxious. He kept repeating, "I have hit my artery!" The co-workers had a towel placed over the injury and were doing an excellent job of holding pressure to the wound. I readied some sterile 4x4's and asked them to remove the towel. To my relief the hemorrhage was oozing dark red blood. The patient was calmed down and the wound was cleaned thoroughly with sterile water and sterile 4x4's. His hand was dressed and bandaged. I placed his arm in a sling and swathe. His initial pain was a 10 on the 1:10 scale. After the cleaning, bandaging and calming down the Pt's pain reduced to 4. He was given 1 gram of Tylenol and Local Cold Therapy to help reduce the edema and pain further. He was airlifted off the platform to the closest appropriate facility to see the awating ER MD. Outcome: Xrays reveal no debris in the wounds. He now C/O numbness to the thumb. He received 3 stitches all total and the wounds were not totally closed to allow for drainage. He was D/C home with pain medication and antibiotics and told to F/U with an Orthopeadic MD a few days later to assess any long term damage. F/U 48 hrs later: He is now suffering from complete numbness and a significantly reduced ROM in the right wrist and hand. His fingernail beds have a tint of purple in them all and the edema has reduced a small amount but seems to have increased at the wrist. My Questions for you: A diver friend of mine suggested hyperbaric treatment within the first 24 hours of this type of injury to due the long term effects of introduced Nitrogen in the wrist and hand. He is also a friend of this patient and has spoken with the medical director over the divers on our location. This particular MD treats diving injuries pretty exclusively and does hyperbaric therapy quite a bit in his practice. His suggestion was based on Nitrogen bubbles will impeed blood flow and thus slow the healing process. I was kind of busy when we were discussing this and I of course did not catch the entire reasoning. So rather than just Google it I thought I would present the case to you and see if there were any other ways to treat this patient. What would you have done differently and why? Do you think the acute onset of numbness and limited ROM is being caused by Nitrogen bubbles or just plain old edema and possible nerve damage or impairment due to edema? Have a great night gang!!!

I was merely making the statement of an RN's education is based in long term care and not in emergency medicine. I wrote the statement afterwards because I do know they can specialize. We are starting to use quite a bot of EBM. Most of the new ACLS, CPR, and PALS changes are EBM. So the argument of a Nurse led EMS team will lead to greater improvements in medicine due to EBM instead of rituals is kind of nil at this point. Now my wife has a BSN and I am sensitive to others feelings when it comes to RN vs. Medic disagreements so I'm not willing to get into a large debate about all this. Take what I say with a grain of salt.

I have precepted a lot of students in my time. At one service I was paid extra as an FTO and at another service I was the senior medic on my particular shift so it was laid into my lap with no extra pay. Luckily I would do it for free anyway. I enjoy teaching new medics and EMT's. I still teach CPR, PALS and 12-Lead ECG for Zoll although being offshore I don't get to teach as much as I used to when I was still the PALS Faculty Member at UTMC. I basically was the one that taught all the new PALS instructors how to teach PALS. I got to mentor them and advise them on different teaching methodologies. I have always considered it one of our assumed duties and an honor as a seasoned provider to teach and mentor the newbies that are coming into our field and show them that we are not the all powerful paragods that they had assumed. I hate to hear stories from students that say their preceptors acted like that didn't want them around. It has nothing to do with you in most cases, it merely another person forgetting where they came from and that someone had to teach them how to be one of us. I think other medics may feel threatened by a student who can talk the talk sometimes better than they can. Its a sad story but please don't walk away thinking we are all like that. Some of us love and even live to teach. We teach not only the art of paramedicine but how to deliver caring and compassionate treatment to the masses and bring order to chaos like only a paramedic can with just his body language and demeanor.

I have been a medic since 2002 and I had to retake the NREMT-P written and practical when I started flying in 2007 because Kentucky required it when we flew into their state. I used a few review guides and even bought access to a testing site that was used by our local college. So after I spent almost a grand of my own money and a few sleepness nights of worry I went into the test site on both days and passed everything the first time. Its all like riding a bike I guess, you just kind of do it all by second nature. I'm sure you will do great with the rest of it and congrats on passing the written portion!!! I hate that they don't give you a score and show where your weakness lies but luckily the guy that passes by one question is still called a paramedic. That guy is me!!!!

On the topic at hand I do think that RN's can bring a lot to the table. Having flown with RN's they tend to know their strengths and weakness just like the rest of us should. I understand that some ar anti-paramedic being in the ER just like we are anti-RN being in the field. I do believe that most of this comes from our inate sense of job security and self preservation. Pro's: As previously stated it does aid in the ER "overcrowding" issues. How you may ask? Simple, an RN's knowledge of disease and illness pathophysiology far outweighs the average paramedics making it more likely that the Pt can be left to their own vices at home, ie OTC's and things of that sort. They are also able to take a seat in the call center and play an "Ask-a-Nurse" role and phone triage most calls instead of sending an ALS unit emergency traffic to the corner payphone at 0200 just because the cold homeless guy used the magic phrase of "chest pain". Cons: An RN's education is geared more toward long term care. I do understand that RN's can specialize. All I am refering to is their base knowledge. An RN's skill base isn't as large as a paramedics when it comes to life saving procedures. Again I understand they can specialize and broaden their scope. As a matter of fact, like I said previously, the RN's I flew with knew where their skills were lacking and generally let the medics lead on scene calls and difficult airways. Although there were some strong RN's on the aircraft that could do as much if not more than we could. So back to the point at hand, generally RN's do not want to be in pre hospital care so as far as RN's one day taking over the EMS world I do not see that happening in the states. The lines are kind of drawn in the sand here and although like Dwayne said it would go hand in hand with raising the pay and benefits I really don't forsee a mass of RN's suddenly wanting to ride the ambulance anytime soon.