MikeEMT

I use a Litmann Select stethoscope and while I am pretty good at obtaining BP's I can always improve. Someone told me that the Diaphram on the Select picks up both High frequency and Low frequency sounds depending on how much pressure you apply.

That got me to thinking, are Korotkoff sounds considered high frequency or low frequency?

I normally get BP's without too much thought in what I am doing. Finding out about the Select Stethoscope though was eye opening because there were a couple of difficult ones that I couldn't obtain a BP on and had to use a dual head. I now think this was more to user error and how I was holding the diaphram on the patient rather than just not being able to hear.

I'm curious, and please don't take any disrespect, but how can you fail the NREMT 3 times? Have you figured out what the problem is and taken steps to correct it? Maybe we can help you overcome it.

Retaking the test isn't going to accomplish much if you have not solved the underlying issue as to why you keep failing.

I know a couple of EMT's that absolutely sucked at taking the test. However, they are some of the best EMT's I have met. Very knowledgable and good at the job.

Whatever your reason for the continual problems, don't let it get you down. Concentrate on passing the test then worry about being the best EMT you can be. Always remember, we are here for our patient.

Why are we calling the doctor a "doctor"? Did I miss somewhere where his credentials were questioned? A doctor does have the authority to pronounce death and they are certainly not required to following any ambulance services protocol for how they do this for their patients.

I am referring to him as a "doctor" because I don't know his qualifications. How many people have Doctor in front of their names? What is he a Doctor of? I have had people tell me they were doctors only to find out later they were not MD's. Not every doctor has the authority to pronounce a death.

Doctors don't work under protocols, they use medical judgement. I would have a huge problem with anyone starting CPR in this case if I had already pronounced the pt. It becomes assault/decimating a corpse/whatever your state law calls it at that point and I sure as hell would push the point with your medical director and/or state medical director. It has nothing to do with ego and is all about dignity for the pt and family.

While Doctors do not work under protocols in the sense that we do, they still have guidelines they must follow. One of which is pronouncing death.

You might want to look up decimating a corpse laws before you go tossing that around, especially to someone who spent the majority of his career in law enforcement and criminal justice. I would have a HUGE problem with a medical professional interfering with this. If you took this to a medical director they would probably laugh you right out of the office. You claim it is about dignity. The most recent "OFFICIAL" wishes from the patient is FOR CPR to be initiated. That sounds to me like you are doing what the patient wants.

When I am on scene it is my call, period. I am not relying on the word of anyone claiming to be a doctor, especially if I don't know them. Its not like a SNF would ever make shortcuts or anything. Now if it was the personal physician of the patient then I would give them more credit. That said, when was the last time a personal physician pronounced a death? Most physicians I know would be uncomfortable performing CPR yet alone pronouncing a death. There is a reason they work private practice and not in the ER.

Fortunately for me State Law would be on my side in this case. If I performed CPR while getting Medical Control authorization I would be protected. The bottom line is what can be presented in court. The patient has signed a document a couple days prior to this event that expressed their desire to have CPR performed. Advanced Directives hold a lot of weight in court.

Bottom line, every situation is different. Based on this call with these circumstances and the information presented to me, I would perform CPR. I am unaware of any court that would accept phone authorization from family to override the patients wishes. You are entitled to have your own opinion. Since I am going back to work for my long week it is doubtful that I will respond further in this topic.

Ok...but why? If you are in the ER (or any part of the hospital) and a patient codes...if a doctor there say's they are done and/or not going to work it, will you disregard that and jump in?

This wasn't a random doctor off the street, or even a doctor at an urgent care or clinic; this is a skilled nursing facility with an on-site MD. The patient is under this doctor's care while they are in that facility. The doctor responsible for their care is making the decision to not attempt a resuscitation, and has been in consultation with the patient's family. Explain your thought process please.

I get that you might be uncomfortable making that decision, but if that's the case, why not take your own advice; contact your medical control, explain the situation and let them make the decision. Even better, if you are that worried, contact the family, confirm it, then contact your medical control, let them talk with the facility doc, and then go from there.

And keep in mind that this was not a simple case of the fire department and ambulance doing CPR until they could reach their medical control; I can understand why that would be done even if I disagree. These guys worked a full resuscitation and only called after it was unsuccessful. Poor form I'd say.

This is a doctor at a SNF. Who knows what protocol they use to determine death. A strip would want to be seen by the docs. I have yet to see a SNF have a 12 lead. Obvious signs of death excluded, this is a case that would require at least a strip sent to the Medical Control doc to make the call. Just because there is a "doctor" on scene doesn't automatically grant him the authority.

Now as I said, I fully respect the on scene doctors opinion. More so if he IS the primary care physician for this patient and NOT the SNF staff doctor, which I have not been to impressed with from the ones I have seen.

Here in the US we are a very sue happy society. People will sue for just about everything, and often us EMS professionals are caught in the Middle. When I was doing investigations I saw people lose everything because of law suits. I work hard for my house and my possessions. I may not be rich, but I am proud of what I have and I am not going to sacrifice that in a lawsuit. In court there is Hearsay and Physical Evidence. Of the two, Physical Evidence carries a lot more weight.

You go on this call, a doctor tells you that he just got off the phone with the family and they don't want CPR started. You listen to the doctor, do your PCR and go back to quarters. 5 years later your called to court and you have to testify why you did not do any CPR. You refer to your PCR and say that Dr. Smith said he spoke to family and to not perform CPR. Now this attorney pulls out the signed Advanced Directive which was signed a couple days prior to event. This document indicates that full resucitation efforts - including hospital transport - are to be undertaken. What do you think the jury is going to side with? Do you think the Doctor is going to remember talking to you or the family? Do you think he will remember what was said? What if the family didn't have Power of Attorney? Just because its a son or daughter doesn't mean that they were on good terms. There are plenty of parents who are estranged from their kids. Their are plenty of kids who do not have their elderly parents' best interests in mind for whatever reason.

Start CPR while your partner contacts Medical Control. 30 seconds on the phone with them and you will likely get your confirmation. You will have a recorded record of the authorization not to mention a strip. You did the best for the patient, which according to the signed document was to perform CPR. Worst case you perform a few minutes of CPR while getting the authorization. In the process you have protected yourself, your crew, and your agency.

I can care less about a SNF or the Doctor working for a SNF. I am not sacrificing my certification nor my families well being based solely on Hearsay. It may be worth it to you, its not to me. The signed document holds more weight than the verbal authorization from a doctor on scene.

Now if family were present...eh, I don't know. That would be a tough call. Again, I think I would side with the signed document until I got medical control authorization.

Bottom line is this - I may just be a basic but I worked my a$$ off to earn that title. I am going to protect it.

As I said earlier, I don't fault anyone for NOT performing CPR in this case - me personally I will do it though for the reasons stated. Excellent discussion.

The 5.11 brand are ambidextorous and have the same pockets on both sides. They also have 4 straps, 2 for each leg. You will find that it won't matter which side you carry your stuff on.

My case I wear my tape on a left leg strap and have gloves in the left thigh pocket front half (their divided pockets). Shears, pens, stylus go on right leg. I am one that uses tape on my thigh to write down vitals etc. so I am always using the roll of tape. I'm a righty.

If you go with the 5.11 get the taclite version.

I agree with those not starting CPR because the doctor has the overall authority. However, I voted to start full resucitation. As is a common saying around these parts, If it isn't on paper it didn't happen. The paperwork handed to me by the doctor and signed by both the doctor and family, states that full resucitive efforts are to be under taken.

While I fully support the Doctors' decisions and his opinion, it won't protect me in a law suit. Until I can either get the doctor to put it in writing or I can get it on a recorded line from medical control, I have to respect the written orders. Who is to say the Doctor would confirm your version of the events if it should go to court.

When in doubt always start CPR. It is easier to stop CPR than it is to start it after several minutes have elapsed. So the bottom line is, until I can get validation on something physical CPR will be performed.

Sounds like everyone did everything the way it should be. The engine crew started CPR and the Hall Ambulance Crew contacted Medical Control and got permission to terminate.

Mike, Excellent response.

And Yes, this is a scenario that has miraculously never happened. Let's keep it on internet pixels shalt we.

Thank you, and yes lets keep it on the internet

So Mike, what if the guy is not willing to be talked down, what kind of take down's are you willing to use?

Consider this scenario-

You walk into the bedroom and then guy now is now in the doorway and you are stuck in the bedroom.

There are too many variables to consider for me to accurately answer the question. Suffice it to say that I would use the techniques I was taught in the police academy to try and talk him down. If it came to where physical intervention was necessary then I would do whatever I had to to keep me and my partner alive. While I have been involved in conflict resolution and have talked suicidal people down in the past I have never had a situation such as this where other lives were on the line. While I am confident I would be able to talk myself out of the situation - reality has a way of not working out according to plan.

We were taught to use whatever necessary to save our lives. If it comes down to a "fight for life" then you have nothing to lose because if you don't do anything you will die.

Keep in mind that I don't believe in "heroics" or the "John Wayne" syndrome. While I probably have a couple hundred hours of this training under my belt I am in no way qualified to make a diagnosis or to act as a negotiator. Nor am I qualified to offer any advice or training to others.

My training was designed for law enforcement and not EMS. If I were in this situation and had to use the physical, hands on, aspect of my training (going beyond the verbal judo stage) then I would likely be fired from my job after this situation was resolved. I would rather be alive and looking for another job than having my employer make funeral arrangements for me.

I would strongly encourage any EMS provider should, at a minimum, take verbal judo training classes. Verbal judo is a key component in conflict resolution and many law enforcement entities will train EMS and Fire in verbal judo.

I hope that this is a scenario that never comes to fruition but sadly I think its only a matter of time.

Hey guys and girls I advocated and pushed for mandatory education and training for EMT in crisis intervention.

I wrote a resource guide for EMS Professionals

The EMS Professional Rescuers Guide to Behavioral First Aide

My hopes is many EMT and EMS pros can reduce injury and risk when dealing with hostile or a patient exhibiting crisis behavior.

The crisis is never about the behavior. It's available in several electronic formats.

barnes and Noble Nook > ( EMS Crisis Response Team Training Guide )

Amazon Nook > ( EMS Crisi Response Team Training Guide )

And for home computer PDF format.. on Lulu.com > ( EMS Crisis Response Team Training Guide )

Please take a few moments and read the education material its a proven process that deescalates hostile patients.

Sorry, I am not buying this material and I feel it is a waste of time. Way back when I was a police officer we spent 40 hours of training in the police academy on crisis management and deescalation. A 12 page booklet isn't going to provide any substantial info.

You have brought up a very serious topic. Instructors and authors of bona fide training programs have lawyers review the material to make sure it is legal, practical, and within the scope of the job. Additionally, this is a skill that needs to be practiced and constantly trained on.

While I am sure you cover some common sense points, it is doubtful that your "book" has any research to back it up. The training program I went through was taught by an instructor with a Phd in Psychology with an emphasis on criminal psychology. Sorry to be the bearer of bad news.

Hi! I'm new to the site so this is really exciting

I finished up my EMT basic class in December 2012 and was NREMT certified in January. I'm debating whether or not to go straight into a paramedic program or try to get a job as an EMT first. I live in Washington so what do I need to do for either? Advice and suggestions greatly appreciated

If you live in WA you will need to get experience as an EMT first. I don't know of any program that will accept students with less than 2 years of 911 experience.

If your in the Seattle area AMR is hiring, thats where I work. Tri-med also hires regularly.

Experience will help you out immensely. I work with a lot of Seattle Medics and Medic Students and every single one of them has stressed the importance of Basic experience prior to entering the Medic program.

My book its like... at the end.

Last module. Im ready to be done, but im going to kind of miss it.

Well review and mod testing in a week, then review, blah blah blah, NR skills test next month. Then I do my NR test. I am ready, no worried about it. But it has been a big part of my life for nine months. Im getting college credits for this, and I got part time student status. Yay tax break.

Maybe im addicted, but after some of the things we learned, I had questions. I want to know why. We did a lot of physiology in this class to make it a college course, but I still want more answers. So I decided to take A&P.

I can't afford to take official classes but EMT School started my curiosity and drive to learn more. Currently I am teaching myself EKG / 12 lead interpretation (very slowly since I am always having to track down one of our RN's to clarify something for me). I plan on studying pharmacology next.

Nothing beats a "real" course but keeping your mind sharp and always learning is better than nothing. I wish I could afford to take a proper EKG course and maybe I will in the future. I am slowly starting to be able to understand what I am seeing when a medic hands me a strip.

One thing I love about the medical field is you can always learn. Doesn't matter if your a basic, medic or a doctor. Working in a system that is focused on teaching helps out to.

Good luck and don't ever stop learning.

Well considering I am trained in crisis mitigation I would talk the suspect down. This type of situation doesn't really scare me. I doubt he has intention to harm me or my partner. He does have other underlying that he wants addressed and he feels this is the only way to get them addressed. As long as no one plays hero you and your partner will be going home.

Make slow, methodical movements. Explain what you are doing or going to do. Talk to him professionally and non-judgmentally and more than likely you will have a positive outcome. Take your time, its going to take a few hours so be patient.

When its over, bitch slap your partner for being the "studly medic" and tell him next time he does such a moronic move you will put your foot so far up his ass that he will be spitting leather for a week.

I work for AMR in Seattle and I absolutely love it. I can't speak for other branches but since the regional manager is located in Seattle (the Dakotas are in the same region as us) I would assume to find a lot of similarities to how we do things here.

Expect good training, frequent training and room for advancement. Yes they are a private, for profit company. So is the healthcare field in general. It costs money to treat people, even fire departments are begining to charge patients.

I love my job, Its all about personal opinion though. It is a union job, Teamsters. Good luck.

It appears that I was right in my assumption of an Advanced Directive: http://news.yahoo.com/family-woman-denied-cpr-wanted-no-intervention-013800673.html

Capttohellwithitall summed it up best "media sucks donkey balls." They blew this all out of proportion when it was a non issue.

I will probably get flamed for this, but oh well such is life. Anyway, I don't see why people are getting worked up. We all know how truthful the media is.

First of all let us understand that this was an Assisted Living Facility and NOT a Skilled Nursing Facility. The caller, according to statements by the company, was NOT a nurse but was in fact a manager. Assisted Living Facilities are not required to provide medical staff on site. An Assisted Living Facility is NOT the same a Skilled Nursing Facility. They're different laws and rules to abide by. Its a completely different licensing process.

Second, we have all responded to calls at these facilities. What is one thing that most of our patients have in common at these facilities? They almost always have Advanced DIrectives. I have yet to see anyone ask the facility if there was an advanced directive in effect. Media has not made any attempt to ask and the company hasn't been forthcoming which is to be expected since the facility would probably claim it falls under HIPAA.

I am in no way defending the facility or the 911 caller. However, keep in mind that there is more to be considered than what the media is saying. How many times have you read in the paper or seen on the news a story where you responded only to see they botched everything? I wasn't there, I don't know all the facts therefore I am not going to villify someone based solely on news reports.

Wow Mike, I don't recall saying every patient needed to go to the ER by ambulance. I stated they deserved dignity and respect. To them it is an emergency, whether or not it is to us.

I have been in the field for a while now, even when you were still a student yourself little grasshopper.. Every patient deserves a complete assessment. We can decide then if it is an emergency. Frequent flyers DO have true emergencies. I've seen it.

The anxiety patient, short of breath every week? Can have a heart attack. You respond as you would any short of breath patient until they are assessed. Even then, you treat them with complete dignity and respect. If you can't treat someone with that, you don't belong in EMS.

I was going to elaborate on this but I see others have beat me to it and you now seem to understand the issue judging by your clarification.

I will say this though - don't question my level of experience. You have no clue as to my experience or history.

We take all of our CE's through emsonline.net which is a King County website. Every EMT and Medic in King County has to use the website. The training is very in depth and informative. After you pass the test then you have to take a practical at your employer.

I personally like it. Can't comment on other sites since I don't use them.

Every patient, every call should be treated as a true emergency. Whether or not it is for you, it is for them. Treat them with dignity and respect.

So called "frequent flyers" can call with the same complaint, every week and the one time you let your guard down, have it be something serious.

Oh lil grasshopper you have much to learn. I see you are a student. When you get in the field you will see the real world of EMS.

You are right, it may not be an emergency to me but it is an emergency to the patient. That doesn't necessarily mean they need an ambulance. The laws are written so that if you call 911 and say you want to go to the hospital I must take you.

Why should I waste resources on the homeless guy who calls 911 with a fake complaint so he can get a ride up the hill because he can't afford a bus? He even brags about making up ailments. Why should I rush a patient to the ER with insomnia because she is arguing with her neighbors?

These people need some form of help, but they don't need my help. As an EMT my job is to educate the community. That means I need to know what local resources I have at my disposal so that I can get these "patients" to the appropriate level of care.

Remember, the goal of EMS is to get a patient to the appropriate level of care in the appropriate amount of time.

EMS is not for every patient. We do no good for the patient if we codell them and ship them off to the ER. Can a minor complaint be serious? Yes it can. It is up to you to weigh the patient's condition with what they really need. If you think taking frequent fliers to the ER - and that there is nothing wrong with that - then you got a lot to learn.

To the OP, I am an EMT with AMR in Seattle. I am fairly new (was hired in october) but it has already driven me to further my knowledge. Currently I am teaching myself (with the help of some very awesome Medics at Medic One) EKG interpritation and pharmacology.

Enjoy the field, learn something new everyday. Being an EMT doesn't mean you have to limit what you learn.

Mike, our friend the OP lists his location as "the Middle East".

Good question. Chase cars are usually smaller, non-transport vehicles that carry almost everything an ambulance carries. Their purpose is to supplement resources on the scene of an incident with extra hands or medical equipment. In some places they serve as paramedic back up to EMT ambulances so that if the EMT crew determines their patient needs additional care beyond what they can provide en route the paramedic on the chase car can meet them on scene or on the way to the hospital.

I worked in a place that used BMW motorcycles as chase vehicles. It was kind of a neat concept. Although, given the geography of the area it was not very useful.

Yeah I saw that. I am assuming that they still have some requirements - espeically if he operates under NATO, UN or other private contractors.

Start with your state legal requirements. For example here in WA chase cars are legally obligated to carry all the same equipment minus a stretcher. Then consider other functions of the car, i.e. supervisor and account for that equipment. Look at the options you want inside (i.e. computer mounts, consoles, storage drawers, etc.) and see what vehicles they come standard for. It is expensive to custom make equipment.

As said, Tahoe's and Expeditions are used for this function. Their is a large selection of equipment already designed for them. A pick up with truck cap is an option as well.

We use a Ford Expediton that carries backboard, BLS kit, Oxygen, Stairchair, MCI equipment, Spare stretcher batteries for ambulance crews, and various other supervisor equipment since supervisors use them.

Cars are ok but you need to be careful how you organize it.

I don't bag conscious patients. Not saying I never would - I just haven't found it clinically necessary to do so yet. If a patient is hypoventilating they probably aren't conscious anyways, and if they are they won't be much longer. If they are hyperventilating I will put them on oxygen and coach their breathing. I recently had an adult patient with an anxiety attack breathing at 42 times a minute and shallow. I got them down to about 24 / min before we even left the scene. Fire was impressed. At ER arrival they were breathing 14 - 16 times / min.

Obviously it is impossible to give you a cover-all answer. You will need to do what is in the best interest of the patient for their presenting condition. If you bag a patient you need to do so at the normal rate (about once every 4-5 seconds for adult). I dont like bagging a conscious patient for a variety of reasons. Mainly the perceived fear of the bvm and the increase of gastric distention. I would think gastric distention would be minimized in a conscious patient but I don't know. A bvm is a last resort in a conscious patient for me.

Dfib hit it - ultimately you need to find and correct the cause.

This measure will surely save lives. I just could not believe that people would help a person who had been drinking to operate a motor vehicle.

EDIT: Well, I can believe it but it was still a little shocking.

Believe it. Just like the people who use drugs then have other people urinate for them to pass a drug test.

My squad and I enjoy the Pita Pit.

Pitas stuffed with anything you want, Fresh veggies, mmmmmmm I always get the prime rib Pita with sauteed Onions and mushrooms. Top it with fresh Guacamoli, lettuce, hot peppers, tomatoes and sprouts!

That sounds like a place I would frequent. Makes me wish we had something like that here...maybe we do and I just haven't found it yet.

They sell a very nice 12 volt plug in cooler at most auto stores or camper places that will keep your food @ 38f . not much bigger than a 12 pack of canned beverages. They cost in the neighborhood of $35.00. Ought to be able to find room to store that in the ambulance. Unless your sitting in a parking lot in a type II van. We have one in our ambulance for chilling fluids.

I do sit in a type II sprinter in a parking lot. Most of our hospitals do give us access to microwaves but I can't guarantee that I will be there.

I have yet to find a cooler that will keep food cold enough to satisfy me yet is small enough to fit on our ambulance. Though I am looking.

I am obsessive about food safety and quality. I don't normally frequent "street vendors" However this particular guy is part of a brick and mortar restaurant that has a very good reputation. Besides he only uses Kosher ingredients and cooks the food right in front of you. Its hot and fresh.

I prefer to eat decent meals, but after a stressful call I turn to a bagel dog. Some turn to beer.