MikeEMT

After one particular call I will not eat hot dogs.

For work I'll make food and take it with me. It's healthier, cheaper and I know what I'm getting.

That is true, but there are no places in your jurisdiction where you have the occasional indulgence? A fruits and veggies life gets boring after awhile.

One of the things I like about working in Seattle is the diversity of people and food I get to eat. I work graves so not much is open. I do SSM so making most healthy meals are out as I can't properly refrigerate or cook in an ambulance.

I enjoy grabbing a bagel dog and chatting with the locals down in pioneer square. Good PR, and you get to meet some people other than those on a call.

I am sure I am not the only ambulance that has a local favorite food that I like to get at work.

Ok, we all have our guilty vices for food choices on shift. Most likely it isn't healthy and its usually greasy and is a "comfort food". So what are some of your favorites?

Here in Seattle, it is common for bars to put out hot dog carts on weekends and game days. One of these bars in pioneer square puts out a cart that serves bagel dogs. Its a foot long kosher beef dog on a warm bagel bun slathered in cream cheese and grilled onions. Add mustard and relish and hmmmmmm.

Healthy or not, we all have our guilty food cravings. Lets hear them.

Here in WA a new law took effect on Jan 1. It requires all Ignition Interlock devices to be equipped with a camera and to take a photo of the person blowing into the device. They can then take enforcement action against both parties.

Amnesic Shellfish Poisoning then? There are numerous illnesses associated with shellfish especially during a red tide.

The rash makes me think a severe allergic reaction but because of the length of symptoms I would lean more towards poisoning and not an allergy.

my favorite was an EMT that brought a patient to the ER while I was on a rotation down there who said the patient had an enlarged liver and was very sick because of this...patient had gastroenteritis, EMT had no clue what he was doing when he tried to palpate the borders of the liver. I'm all for proper abdominal exams if you've been trained to perform one.

The other statement we love hearing is absent bowel sounds...inorder to classify a patient as having absent bowel sounds you have to listen in all four quadrants for at least 5-8 minutes or so in each quadrant.

The biggest thing that people should take from an abdominal exam is that 1) if it hurts, don't push any more, 2) use it in conjunction with the rest of your exam. I always have epigastric pain on palpation... doesn't mean a thing on me. 3) Use your critical thinking skills.

I palpate all 4 quadrants. I am looking for tenderness, masses, hot to touch, or pain upon touch. I don't try to palpate the liver or anything like that. If I find something pertinent then I will tell the ER. I am not here to diagnose a specific problem thats what the MD's are for.

I don't listen to Bowel sounds either. Its not in our protocol and I wouldn't know what to listen for. Lung sounds and BP is all I use my stethoscope for. Though I am starting to listen to heart sounds, mainly for my own curiosity as I am fascinated with the heart.

I get a kick out of EMT's and Medics that try to act more knowledgeable than they are.

I am pretty sure no EMT is supposed to be going into any kind of situation with drunks or drug users without first waiting for Police to arrive. Isn't that what they teach you about assessing the scene? I would be sitting in the Ambulance not doing a damn thing if I felt it was not safe to be out there. What do I care if some drug user or drunk drops dead before Police arrive.

Seriously? Every call has that potential. If that is your way of thinking then don't bother pursuing this as a career.

There is scene safety and you need to judge the scene for yourself. However, not every scene is going to be perfectly safe and not every "dangerous" patient is a threat to your safety. I see you are a "future EMT Student." When you get to class you will learn that there are legitimate medical conditions that can make a patient "combative."

This field can be dangerous. It is pretty safe if you use common sense. Your given the tools, use them.

For your information I don't call the cops for drunks or druggies. If you can't manage them then your not going to be very successful.

Don't need to be a "hero", keep aware, no where your exits are and manage your patient.

I think a lot of people are making a lot assumptions about how that AAA patient is going to present, and the value of palpation as a diagnostic aid.

Firstly, I'm firmly in the camp that believes that palpation of the abdomen is part of a thorough physical exam. If light palpation causes intense guarding, pain, or movement, then obviously we probably shouldn't palpate any harder, or again. The fact that light palpation elicits guarding, tenderness, pain, writhing, etc., is a potentially significant finding.

Palpation as a tool for AAA is going to be poorly sensitive, and, honestly -- poorly specific. Only a small percentage of people with AAAs are going to have a palpable pulsatile mass, and we are going to be lucky to identify it based on inspection or palpation. Thus, it's a poorly sensitive finding. Many of these patients are going to identified on abdominal XR, CT, or U/S. The sensitivity must decrease as the patient's body mass increases.

It may be a little more specific, perhaps. That is, if we find a pulsatile mass, the likelihood of AAA is probably a bit higher. But I bet if we try to call the subtler cases, e.g. "I feel like there's something pulsating there, but I'm not quite sure", in order to increase the number of patients we detect, then our specificity is going to plummet, i.e. we're going to call more false-positives.

There's also a disconnect here between the concept of acute and chronic presentations of a pathology, in this case, AAA. There's plenty of people walking around with significant AAAs, even up into the 8cm range. These people may have pulsatile masses, but may be managed medically or waiting for nonurgent surgical correction. They may present with abdominal pain from any number of other causes, and the signs/symptoms related to the chronic AAA may distract from the acute pathology.

If we consider AAA, I think it's likely that changes in the quality of the femoral or pedal pulses, or the perfusion of the lower extremities might be more useful than abdominal palpation. I'm sure one of the docs has a more educated opinion on this.

I agree with you on this. I perform "proper" abdominal exams and I have discovered quite a few abnormalities in the process. I am quite frankly shocked by how many people don't perform palpation of the abdomen.

My initial assumption would be something like Hantavirus. Since the place is so messy I would assume that their might be rodents running around. I would look for such.

I wouldn't rule out Menningitis either. Especially since she has confusion. Any difficulty with movement, stiffness?

If Dengue Fever exists down there I would consider that too.

Dirty water makes me think Giardiasis.

Anyone else been sick? What was patient doing prior to onset of symptoms?

Lung sounds?

Regardless I am going to mask up in an N95, safety glasses and gloves.

you'd have to understand the politics behind the joke. The evil empire bailed out of several non profit making contracts recently and Cataldo has stepped in as the new knight in shining armor.

I know about the issue AMR had back there. Something about a health insurance company changing their reimbursement policies or something so AMR wasn't getting paid.

What I don't understand is how a company who serves 12 communities in the Boston area (according to their website) can even claim to be a savior to a company that serves over 2,100 communities across the country.

Must be a New England thing. Kind of like British humor - dry to the rest of the world but funny to the locals.

she stated "Dad is touching her" it is currently happening and her daughter is still living with that man. He is a danger to a child. What good would leaving a child in a dangerous situation do while screwing around and trying to get a lawyer when she clearly stated that is not an option right now?

Yes mari, I read her entire post. Unlike you, I have professional experience in matters like this. Both as a police officer and as a Private Investigator under contract for lawyers. I have spent hundreds of hours in a court room on both sides. I would suggest going back and re-reading what I wrote.

To the OP: Got your message, will reply after I get some sleep.

I don't get this. Is this supposed to be a dig at AMR?

And sad as that seems, those folks are still called EMT's

Thats not always a bad thing. I was one of those students who stayed in the back. Not because I was shy or scared but because I am a take charge kind of guy. When I was in the police academy I had a lot of students complain because I was always doing the skill and not giving them a chance or I was always the lead.

I went into EMT school being fully aware of this and vowing to change and not hog it all. I stayed in back and let the others have their shot at playing.

Don't assume that just because someone stands in the back they are shy or refusing to participate.

As a former cop myself I will tell you that Police involvement isn't always the best. People often misunderstand what the police are for. Criminal charges can be brought forth without police involvement. If this alleged touching occurred recently then by all means call the police. However, if this has occurred months ago then police involvement is not likely going to help. A lawyer can do what a police officer can as far as recommending charges, getting a no contact order, etc.

I am going to be brutally honest, both as a former cop and a as a former private investigator working on cases like this. Your daughters' word wont have much weight in a court of law. Courts rely on Physical Evidence which can be proven. While hearsay and circumstantial evidence can be used to get a conviction it is much more difficult. In addition, the legal process is NOT kid friendly. Your kids will be cross examined on a stand. They will be called liars and other terms by the defense. It is what they do. Many kids who testify require extensive therapy afterwards. I have been associated with lawyers on both sides as a PI. It is ugly.

I do NOT want to discourage you from going forward with legal proceedings if you feel it is necessary. However, I feel that people should be aware of what they are about to get into. It wont be fun for you or for your kids. If you have any questions about the process feel free to PM me.

I wish you the best of luck.

I will admit it mate, your line of thoughts makes the hair in my ass crack stand up and go "hmmmmm?"

You like to piss the media off? how old are you like 12? That sounds very immature.

Unless the patient explicitly refuses themselves being photographed or videotaped then they have given implied consent, especially if they are in a public place. The TV crews here are specifically allowed to do their thing anywhere except inside a private residence or business without express permission of somebody there, not necessarily the patient, but it should be the patient wherever possible.

Now you do have a point to a degree about patient dignity, if they have to have a rectal exam or its a cardiac arrest resuscitation or something then that might be time to whip out some of the magic ambo drawer sheets (handy them magic ambo drawer sheets) and hold a couple of them up or just move them to the ambulance.

But seriously so what if somebody wants to show up and stand on the sideline and take some photos; for all we know he might be a curious citizen or more fucked in the head than I am and he is spanking off to them at night; don't know; and as long as he is not in the way or something then I don't care; if it's in a public place then unless the patient specifically says so then it is allowed and should be allowed.

The actions of the person in that video are disgustingly unconscionably unprofessional and rather disturbing; if it were up to me he would have his professional registration cancelled as well as being forbidden to practice again and In jurisdictions such as the UK and SA (and when it happens in NZ) if the person complained to the appropriate registration body that is probably exactly what would happen.

You misunderstood me mate. I don't go out of my way to piss them off, nor do I go out of my way to help them. The media has burned their bridges with me by doing more than one act that was unprofessional and borderline illegal.

I will not cooperate with media and they know this.There is a reason you don't see footage like this coming out of my area. I will not elaborate on my reasons except to say they are very legit reasons.

Quite frankly the fact that you think he deserves to be disciplined is astounding. For what? Yes saying the "f" word was probably not his best moment. However he has a right to protect his patient's privacy.

A couple of months ago I treated a young woman with a head injury outside a bar. This woman was quite attractive and dressed in a manner consistent with club hopping. A drunk group came up and tried to take a picture up her skirt. I sent PD after them.

Bottom line, just because the crime scene tape doesn't extend to the ambulance doesn't mean it is not part of the scene. I understand curious bystanders and I can't prevent everything. I can control what I witness though and if I witness people taking in appropriate pictures I will deal with it.

In the video above the "photographer" says the job is patient care. How is taking a video and standing in the way beneficial to the patient or the scene? When that photographer saw the patient being wheeled out they should have backed off.

Prior to this job I owned a Private Investigator business. You would be surprised how many laws there are concerning video and photos on "public" property. Here in WA, even though the video is on "public property" the patient has rights to the video and can order it removed. Don't know if NY is the same.

The sign of a true professional is one that can look at the entire picture. It's pretty clear that a lot of people on here are so focused on the video and not the entire picture. Rather than vilify this guy how about you look at the ENTIRE picture. I would be interested in seeing the entire, unedited video.

One of the reasons I don't frequent this site much or engage in topics that are "controversial" is because of people making assumptions.

I don't see any issue with this. He did not smack the camera away he covered it with his hands. The photographer also undoubtedly said something to promote the swear.

You don't take photos of my patient. I will warn you once. Violate that and you will be talking to PD. The "crime scene tape" doesn't make it right. It is about being the patient advocate. I will do what I can to preserve their dignity.

Few weeks ago I showed up to an MVA that had news media there. I saw the photographer videotaping the carnage and victim so I turned my ambulance to block the scene. Pissed off the photographer so he started following me with the camera since he couldn't see the wreck or victims anymore. I just smiled. When we wheeled the patient into the ambulance I had the tow truck driver hold up a blanket.

The media is vultures and I don't respect them. I have even less respect for citizens videotaping with their cell phones or camcorders. The media here are professional enough to cooperate when we tell them to not video victims.

I doubt this video was taken by professional media. I love pissing off the media though.

Mike, I think you and many others would benefit from reading this article. Just because it's past its expiration date doesn't mean it's not good.

ETA: There are also programs out there that will take expired medications and send them to charitable medical organizations for use in third world countries. Again, just because it's expired doesn't mean it's not good.

I have heard that before. When it comes to medication I can't take justify "expired" meds. Maybe its the terminology, maybe its my fear that once I introduce it into my system or a family members system I can't take it back.

Will anything bad happen, I don't know. Am I willing to risk it, no I'm not. Most expiration dates are long enough that it is a non issue, though I don't take anything prescription.

When it comes to life saving drugs, specifically epinepherine, I won't risk it either. Epi may not become toxic on a specific day. If a person is in anaphalaxys I don't want to give them something that may not be at full strength. I have already given an epi pen to a patient and seen how quickly he deteriorated before the pen.

I agree fully with you and the article, I just can't do it though.

Well you could always get law enforcement intervention and force him that way, at least here in US.

If it were me I would try to find out why he doesn't want to come with me and may try to address it that way. Otherwise, not much you could do.

That is awesome

I can't see the photo

So I received a reply the other day from the Doctor (sorry its my long week and I haven't had time to post).

His reply was that it was put in there as a cautionary statement. If we on scene feel that the need for palpating an abdomen exists then we should do so even if a spinal injury exists or is suspected.

I guess more of what I was getting at was that do you know what to feel for when palpating a liver? I would expect you to know which quadrant the patient is having pain in and what you've done for that pain...It's unrealistic in my opinion to ask an EMT or Medic to know how to palpate the abdomen to a doctors standards. It will also have minimal impact on your treatment in the field.

With regards to the AAA, a light touch midline will reveal a pulsating mass or not, no need to do much more palpation that that. On the super skinny elderly, you should be able to palpate a pulse from the AAA and should correlate with their Apical pulse.

I apologize if I seemed harsh with my comments, I'm just against causing more pain unless it's necessary, and in most cases in the field it won't change your management or transport criteria... Maybe one of the more experienced medics around here can help. I am absolutely for a thorough exam and learning as much as possible.

What more is the hospital looking for other than LRQ pain, patient hx of general abd pain, n/v, possible appy... all of that can be done without causing further distress to the patient in the ambulance and increase their anxiety/pain level before the doc gets to see them.

Edit to fix my tired spelling/grammar...

No worries, didn't think your comments were harsh. Your right, palpating wont change our treatment especially at the Basic level. It will however change how we transport, where we transport and whether patient is seen by a Dr immediately or in 10 minutes. Here the hospitals put a lot of faith in us. I had a patient, male, with LUQ Abdominal pain that increased upon palpation. Pain was non-radiating but would radiate to RLQ upon palpation. No masses felt, no pulsating felt but skin was hot to touch. This was relayed during the HEAR. Upon arrival at ER, a MD and RN were waiting for me. Pt was transferred to a hospital bed right there in the hallway and taken away (I am assuming to a MRI or possibly even OR).

I don't remember much about that patient as it was one of my first and I didn't think to follow up on him. I do remember it showed me the importance of doing a proper exam on my patients. Palpation doesn't have to be hard or necessarily painful. I use common sense when I palpate.

Mike, when you go to bed tonight, take a few moments to lay flat on your back and look at your bare belly.

Let me know if you notice anything interesting.

Doing a thorough abd exam is certainly important, but palpating without knowing what you're palpating for is like driving through a dark tunnel with no headlights.

What will you do if you confirm Appendicitis? AAA? Cholecystitis? Hepatomegaly?

gotta go, more later

In my case I see a beer belly lol.

Because whoever wrote that CCE is a moron

Our medical director - a nationally known and well respected doctor wrote the CE. Our CE website allows us to ask the doctor through a blog so I did that. It can take 14 days though to get a response so I figured I would ask here. Maybe somebody knew something I didn't.

I never deep palpate the abdomen if there is a complaint of pain. If they have abd pain, what would palpating it reveal? They'd guard against your palpation, so it'll be rigid and it'll just hurt them more. Why would I want to intentionally cause greater pain to my patient?

Light palpation might reveal a AAA, but so could visualisation.

Palpating the abdomen is part of our protocol in our exam. Ask patient where it hurts and palpate that quadrant last. While the goal isn't to hurt the patient it is expected that you will cause some discomfort. It is important to palpate the abdomen to feel for abnormalities with the organs. Distention, hot, pulsating, masses, etc are all things you can feel.

I have never heard of visualizing a AAA. I would assume if a AAA is bad enough that you can visually see the pulsating then it is close to rupture, or the patient is extremely thin. I have yet to see a AAA in the field though so I don't know. I was always told to palpate for a pulsating mass in the epigastric region and patient complaining of tearing feeling in their abdomen.

And what would you do differently if they had RUQ pain versus LUQ pain? All you'll be doing in the field is increasing the pain/anxiety of the patient with an exam that will be conducted in the ER as soon as the doc walks into the patients room. If they're complaining of lower abdominal pain and female, we consider it an ectopic until proven otherwise...no palpation necessary in the field for that... if it's RLQ pain then we will consider appendix until proven otherwise also, again, no palpation necessary in the field.

The patient, if they are reliable can point to where it hurts and you'll have a good idea of where the pain is and what could be involved.

In the field, there shouldn't be a clinical need to deep palpate the abdomen...if you suspect an abdominal aortic aneurism then you definitely shouldn't be palpating the abdomen as the pressure could cause a big problem.

Abdominal pain is tough even for the doctors, you have visceral pain and somatic pain, just too many variables to allow for a reliable exam in the field.

As to the OP, the idea might be that in the process of assessing the abdomen you could rock the patients lower thoracic and lumbar regions causing problems. While I doubt on the average patient that palpation could directly cause trauma to the spine, the rocking and shifting that can happen during an exam could displace a fracture. Just a thought, no way of telling what the author was getting at in your CE.

Our hospitals want us to give them a general idea as to what is going on. We don't just drop off patients and if we told them we didn't palpate we would be scolded. Were not expected to diagnose but we are expected to know more than RLQ = Appendicitis. Hence the indepth CE we were required to take.

I was taking my CE online course through our required website and the topic was abdominal pain. They were talking about palpating the 4 quadrants of the abdomen to determine pain and feel for abnormalities. However, they said to not palpate the abdomen if spinal trauma is suspected.

My question is why not? I understand C-spine precautions but I have never palpated an abdomen hard enough to effect the spine. Couldn't a trauma patient have an abdominal problem too that can only be discovered through palpation i.e AAA?

Anyone have any idea why not to palpate an abdomen on a spinal injury patient?

Rales (Crackles) is caused by the "popping open" of the airways when collapsed due to fluid. I would lean towards Pulmonary Edema. History of CHF? How long has patient been in bed? Patient is obese so CHF (even undiagnosed) can be a possibility.

The inverted T-waves can be an indicator to Ischaemic Heart Disease (I've been studying up on my EKG's).

Rales can also be cause by atelectasis so I am going to agree with Kate on this one.

Now I have reached the limit of my education and will sit back and see what else I can learn.

However, if the OTC meds are for personal use only as stated in the post, then who cares if you are the one deciding to use outdated medications for your self?

You would use outdated meds? I don't mind people carrying OTC meds, many people forget to check the expiration date.

I did an audit for a local company of their first aid kits and other safety equipment a few months ago. The first aid kits - which were standard office kits and were in active use - had OTC meds that expired in 1997.

My point is not whether to carry OTC meds for yourself or family - its if you choose to do so remember to check the expiration.