Doczilla

Double tap.

Actually, 300mg in one vial is a very big deal. You may carry 300mg on an ambulance, but they are in separate single dose vials, not one vial. This sort of vial is begging for a medication error. If you are in an EMS system and want to give 300mg of morphine, there will be a nagging voice in the back of your head telling you to check your math as you line up dozens of vials. These types of medication errors due to mistaken concentration have been implicated in deaths from all sorts of medications (including morphine, and most recently, heparin). Add also that the guy carrying this may not understand the difference in efficacy between IV and PO forms, and may give too much for that reason too. I am not a fan of multi-dose vials of any medication, much less one as fraught with disaster as morphine. 10mg IV is an appropriate dose for many people. While many providers (docs, nurses, medics) get the idea that any more than 5mg of morphine will stop your breathing and kill the patient and revoke your paramedic license and reprogram your DVR and spook your pets, multiple studies in adults and children have demonstrated the safety and efficacy of 0.1mg/kg of IV morphine for pain relief. So she's right, 10mg is a dose. An appropriate dose meant to reduce pain, not a homeopathic dose meant to make the provider feel better. 'zilla

Negative, Ghost Rider. Blackwater does not own, sell, or manufacture that bag. The BW logo was likely added in a misguided attempt by this clown to build street cred on his piss poor disaster planning and soup sandwich of a medical load out. Where you see the BW logo is a small pocket with clear vinyl window for placing identification, etc. This guy probably printed it out on his printer, cut it and placed it neatly in the pocket. BW patches and stickers can be purchased on Ebay or at the BW Pro Shop in Moyock. You don't have to have attended one of their classes to buy them either. BlackHawk is the manufacturer of the bag (S.T.O.M.P.2, to be precise). Though the companies are headquartered not far from each other (BH in Norfolk, VA, and BW in Moyock, NC), and both were started by former Navy SEALs, they have nothing to do with each other. 'zilla

They're zombies. They're already stiff. 'zilla PS: to brush up on your Zombie Hunting skills.... Zombie Targets

I have seen several cases of bacterial and viral (and one fungal) meningitis and rarely see classic "meningeal signs" such as Koenig's or Brudzinski's. 'zilla

This guy's a freakin' idiot. You don't want this kit. It is proof again that money and brains don't necessarily go together. He's raided the local CVS for a lot of crap that has very little utility for the purpose it is meant to serve. Let's hear it for the marketing department at Bayer, J&J, etc. Crap he doesn't need: First Aid Cream Hydrogen peroxide bottle Saline for irrigation. Tap water or water that has been made safe to drink will suffice. Lots of Quikclot Fluorescein dye strips for the eye, but where is the UV light? Bite/sting extractor kit Activated charcoal capsules Plastic eye shield Eye dressings Eye wash How many freakin' tubes of Orabase does he need? Eyewash cup Post midriatic sunglasses Finger splints Sting relief pen, sting relief cream Poison ivy sting relief spray (how many different products with benzocaine does he need?) Burn gel 2 tick removers?! Trauma shears, bandage scissors, folding scissors... How many pairs of scissors do you need? Cold compresses, too many, too heavy. Let's not forget the 9line card, not that he would have any ability to call in a 9 line to anyone. Lens cloths?! Fenestrated drape. He's got one. a) you don't really need it, and he's got wound care supplies for lots of wounds, so why only one disposable drape? Nail polish remover wipes, yet he doesn't have a pulse ox. So who cares if there is nail polish? Separate forceps and sutures for suture removal. Why not just use what you have in the wound care kit? 300mg vial of injectable morphine, but no narcan. Let me know how that works out. Oh look, more Quikclot. Emergency intubation kit. I don't know if it's occurred to anyone here that a) unlikely he's ever intubated or really been trained to, and how will you manage the casualty once intubated in the absence of a medical facility/ventilator? Ammonia inhalants. How quaint. 4 different sizes of gauze pads Cinch tight bandage, H&H bandage, Israeli dressing, how many different combat bandages do you need? Meds: I have never prescribed 8mg dilaudid tablets to anyone. Ever. MS contin is horribly dangerous in untrained hands. Way too little non-narcotic pain control in the way of tylenol and motrin. Why have Cipro and Levaquin? Levaquin dose too low to treat pneumonia. Throat lozenges? Why have a sphygmomanometer if you have no means to treat altered blood pressure? ENT kit, without the knowledge of how to examine eyes or treat any condition you find. Ditto for ears. I don't see any cortisporin or alligator forceps. What is with all the Vionex wipes in every compartment? IFAK. So we've got yet another tourniquet, combat dressing, gauze, etc. Straight from the Department of Redundancy Department. More ET tube stylets than ET tubes Oxygen masks. Without oxygen. Hextend. Mighty pricy. OB kit is unnecessary with all the other stuff in this kit, with the only exception of the cord clamps and bulb suction. 3 different types of combat tourniquet Wait, look, MORE SCISSORS. ALL different sizes of Bandaids No means to purify water. No means to make fire. Way too little in the way of antibiotics. He has one 7 day course of Cipro and 2 7 day courses of Levaquin. You need one set of scissors and a knife. Not much in the way of light. Bottom line: too much weight and cube and money wasted on snivel care, with very little thought to sustainable medical care in the absence of available resources in TEOTWAWKI scenario. This bag is a soup sandwich and a monster waste. 'zilla

Get her to a sports medicine clinic where the physical therapists know something about this type of injury. That's the best advice you'll get. 'zilla

This process starts with a medical threat assessment of health hazards in the area in which the team operates as well as current health issues among team members, operational profile, and length without resupply. I agree with having a modular setup that you can quickly configure based on mission parameters. If you are on your own for <24 hours, not too much modification is necessary. If evacuation of a patient may take significantly longer due to distance, tactical considerations, or available resources, you'll dial down the ACLS stuff (like, to nothing) and increase capabilities for sustainment. ACLS really has no role in the remote austere environment, because it is unlikely that an "arrest" in the field with significant time to hospital (days) will survive, and the cost in weight, cube, and price for lives saved is extremely high. Airway equipment and the like is less important, since you can't really BVM someone for days. Infectious disease becomes the most significant health threat in the remote environment absent hostile fire. Antibiotics are a must if you can't easily evac someone. Oral antibiotics will almost always suffice. Pain management is huge, so copious amounts of tylenol and advil. Narcotics will be necessary for that team member that sustains a serious injury that renders them incapable of continuing the mission and requiring evac. Benadryl for allergies, rashes, as well as sleep aid. It's sometime tough to get to sleep in a large tent of people. You should have equipment to render water safe to drink in the event that this capability is not available in your other team resources. A mission which is extended by unavailability of resources will mean that the water you brought with you may not be adequate. This may be as simple as bringing boiling pots or requiring all team members to carry purification tablets. The MIOX system is another way to go. Ensure basic hygiene through training and proper equipment. I can't overemphasize the importance of proper foot care. The book "Get Selected for Special Forces" has the best foot care chapter I have ever seen, and is a must read if you're going to the field. Really, the best thing you can do at this point for your team is secure additional training for providing care in this environment, which departs from traditional EMS in a number of ways. Go to GMRSLtd.com and sign up for one of their courses (highly recommended), or Deployment Medicine Intl and sign up for their OEMS or DMOC course (also highly recommended. I have no financial interest in either of these companies). It sounds like these courses are exactly what you'll need in terms of preparation for that environment. 'zilla

Feel free to grab a Surefire with a Xenon lamp that runs for MAX 2 hours on a set of Li123 batteries. And if the batteries don't go on you, the lamp does. 'zilla

I don't really examine them anymore. I just use The Force. 'zilla

It can be a rescue tool, but I use it frequently as a primary method of intubation on many patients, particularly ones that meet a certain profile as a difficult airway where I think that the GL will intubate them safely. Our anesthesiologists use it often on elective intubations on the floor as well. Like everything else, it's another tool in the tool bag, one that needs to be applied properly. If it is only used to bail you out of a bad airway and failed intubation, you won't be very good at using it. 'zilla

I have no patience for businessmen without a day of medical training to their name who have never treated a patient a day in their life setting rules and treatment protocols for physicians who actually *cough* examine the patient. Assclown. 'zilla

Those that assume the Glidescope is just an easier way to intubate using normal methods usually figure out that isn't the case by about intubation #2. The tool is a great one, but has its own technique and particular procedures that seem similar but are different than those used during direct visual laryngoscopy. Placement of the blade, fine movements of the hands, threading of the tube, simultaneous withdrawal of the stylet with advancing of the tube to name a few. It, like anything else, is a skill that needs a lot of practice. There are also those airways better managed by direct laryngoscopy, just as there are those better managed with a Glidescope, or fiberoptic bronchoscope, or digital intubation, or whatever. Be careful how harshly you judge those who are just learning a skill. Considering that you're not even sure what the device was, I'd say that your airway experience is limited, and you should probably adjust your attitude when criticizing the technique of others. Please clarify. 'zilla

Pie Jesu Domine, dona eis requiem... *bonk* 'zilla

As a general rule, any medical care provided to individuals in custody is the responsibility of the agency that has them in custody (i.e., the state). The crack dealer who complains of chest pain after being chased down by the po-po? His bill is paid by the state as long as he is in their custody. Same thing with all other prisoners. Blood draws for etoh levels or drug screens, though, are not medical care. These are part of the investigation, and are therefore investigative costs, which will be borne by the police department. If contracted out to the hospital or EMS, this fee will be negotiated. Depending on the fee for the draw and the volume of draws, it may be cheaper to train one of the jailors to do it or hire full time EMTs for this purpose. As far as complications go, I've seen plenty of thrombophlebitis from IV starts, but never from phlebotomy. I wonder what the true incidence is. Couldn't find anything in a quick Pubmed search. 'zilla

This may not be as bad a thing as many are making it out to be. The law specifies what level of certification may draw the blood, not what service does so. The EMT drawing the blood may be the officer himself, a contract or full time employee of the police department, a jail employee, or the EMT at triage in the ER. While I'm sure that some departments would interpret this as we fear and tone out ambulances for it, a meeting between the EMS chief and police chief should straighten that out. I think this law will expedite the obtaining of blood samples on suspected drunk drivers. Not much training is required above the typical phlebotomy training. As far as chain of custody goes, that would depend on who's drawing the blood. We do plenty of exams and collect evidence in the hospital and maintain CoC with minimal training, largely because the officer is right there to receive the evidence from us. For most of these cases, I forsee the officer being present for the blood draw and logging it himself as evidence. In large jail systems, it may be worthwhile to have a full time EMT employee drawing the blood and processing it as another jail employee might log evidence collected among personal belongings. Alternatively, you could send the supervisor in the fly car to meet the cop and perform the draw. Or the officer could stop by the nearest fire station and get it done. This takes only one person and usually doesn't take a medic out of service. In these FDs that are trying to increase call volume, this is an easy way to do it with minimal personnel and expense and minimal liability exposure. 'zilla

Hunks are on backorder. Happy birthday ITK! (she doesn't look a day over 25!) 'zilla

Distance is less important than time. If the patient arrested in the house next door prior to extrication, it would make sense to work in place so long as you can secure the airway and vascular access (IV or IO). These people are not simply a stroll down the street. You have to load them up on the board, then the cot, strap in place, carry [down stairs] [out door] [through yard] to the ambulance and load, then make sure you got all your stuff. In that case, it's wise to stabilize the patient first, secure the airway, and begin working them. If the opportunity presents to get a break and move to the truck, go for it. If the patient is already in the ambulance and is on the pad and 10 seconds from the ER door, just go in. As Ruff said, it's a judgement call. Also, there is the question of the nature of the arrest. If it's a trauma arrest, there is very little benefit to treatment in the field other than stopping the bleeding, ventilating them, and decompressing the chest, and so less is more. We basically have 5 minutes to crack the chest from the time the patient arrests in penetrating trauma if a thoracotomy is going to be of any benefit. As long as you can secure the airway and obtain vascular access, and are properly equipped to run a code, there is potentially some benefit to working a patient in the field, even relatively close to the hospital. Once transport has begun, don't hold the patient in the ambulance longer than necessary. From the legal perspective, out-of-hospital is out-of-hospital once you cross the property line. Once you get onto the hospital's grounds, legal precedent has established (with a good boost from EMTALA) that the hospital has some duty to the patient. This could be interpreted to mean that if you're in the truck under my canopy screwing things up rather than bringing them in, we could be held liable. 'zilla

You people with the grammar thing are making a soup sandwich out of an otherwise average thread. P3 said it right. If there is something that is immediately correctable, perform the intervention and move the patient inside. If you are sitting out on the ambulance ramp running a code rather than coming inside my ER with the patient, you will have a difficult time hearing anyone yell "clear" over the sound of me chewing your ass. To say that EMS can run the code better in a cramped space with limited equipment, limited light, and limited help rather than in the ER is arrogant. Thinking that all ER doctors are on the same level as every dentist or FP doc who ever took ACLS is asinine. Medics with that kind of attitude typically fail to see their own limitations, and have no clue how little they know. 'zilla

We see many patients from different companies who are routinely drug tested after any workplace injury. The guy running the press at the newspaper, the gal climbing a ladder stocking shelves at the hardware store, etc. We don't see the results since they are sent to an independent lab by the company to maintain chain of custody and protect both the worker and the company. Seems to be standard practice at all sorts of companies. 'zilla

"And I thought they smelled bad on the OUTside."

"Clamp and cut" is a pretty simple, safe, noninvasive way to correct the problem you describe. Unless you run into a monster shoulder dystocia as well (sorry about your luck), the infant should deliver easily within a few seconds after doing this. I would prefer the medics clamp and cut than spend any time thinking about transporting with a nuchal cord that is unrelieved. 'zilla

If you have a nuchal cord, reduce it. If you can't, then clamp and cut it. Same thing goes for a cord around the baby's head that is preventing delivery. 'zilla

Thank you for the kind words all. Yeah, the OB was trying to make it up the 4 flights of stairs, but Julianna wasn't waiting for anyone, so I had to deliver. Unfortunately, my malpractice insurance will cover me in prehospital environments and in my own hospital, but probably not other hospitals. If I decide to sue myself, I'm screwed. I'm just glad the birth mother asked us to be in there for the delivery. And, of course, that she is allowing us to take her baby and raise her. Babyzilla. I think I need a onesie with that on it. 'zilla

I'd rather put a PA in triage. We'd have a much larger impact on the volume and throughput of an ED. At least, I think so. I think that an extended care paramedic would be useful in certain situations, but really, how many calls are we talking here? What volume of patients would not still require a trip to the ED? Would we really impact ER wait times that much? Add in the extra training, certification, oversight, etc., is this worth it for a 911 provider? And if they are providing this advanced care, would this lengthen or shorten on scene times and overall call duration? (factoring in the amount of time the medics have to wait at the ED with the patient to get a bed) In my ER, ambulances pile on patients when things are already difficult, but the EMS patients are not the cause of our overcrowding. Our real crush comes walking (or dragged) in through triage. While having a medic that is able to divert some of this in the field seems appetizing, think of the additional burden on the EMS system. The "urgent care" type of patients are many, and urgent care docs see up to 60 of them in a shift. In our "less acute" station, I will see 40 in conjunction with a PA, and that's at a really good clip (most ER patients, I average 3/hour. In that station, I'll average 5/hour). Factoring in response times (longer, since you wouldn't want to go to these with lights and sirens) and scene times, as well as paperwork, I don't really see them seeing more than 1-1.5/hour, and that would be if they stacked up in the call que and ensure a steady volume. This will be less with the natural ebb and flow of patient call volume. I don't think having extended care paramedics treat some of these in the field will impact the volume we see significantly, at least, not in a typical 911 system. In a very remote setting, where transport times are very long and volume is low and one call can rob an area of an ambulance for quite a while, there is potentially more benefit. 'zilla