Ridryder 911

Again, if you look at most of the post, we recognize frontier and very rural communities. The concern is some communities with 25-150,000 or >; people that claim they cannot establish a paid service. This is hogwash.. R/R 911

I would still like to see state(s) requiring a financial disclosure of these communities and if there are surrounding communities that offer professional ALS services. Communities should be required to offer the best for their public. I am sure if there were attachments to federal or state grants, requiring EMS with full capabilities you might see more. Yes, there are poor economic developed areas, no doubt. What some communities do not realize, poor EMS, LEO, Fire agencies and even hospital (s) will even cause more. Many communities have community requirements to relocate or develop new industries. I know EMS is one of the avenues major companies explore. In a small community I worked at companies reviewed the EMS system, and did not even explore the local hospital. Their reason was that all there staff & families would be transported to a nearby metro area about 15 - 20 miles from the local town, so EMS as more influential in obtaining the company. R/R 911

True 3-4 minutes is valuable , but if you don't arrive alive .. will it matter ? Again, speeding and endangering at double the speed in a residential or even high volume traffic .. how many lives are you jeopardizing other than your own ? R/R 911

Great post Doczilla .Akroeze you might want to consider an ALS rendezvous, or support (unsure of your local EMS community) if such an event does occur. I have seen very few protocols as this (reason I posted) the main point is to know the physiology, and why we are treating it. Even without protocol, if you can contact local medical control and do some consultations of the case. Be safe, R/R 911

actually most protocols follow ECC guidelines and suggestions for tx of CHF (left side). I agree, CPAP is a wonderful tool when you have a patient that is not severely distressed. It only buys you time for the diuretics & nitrates to work, re-absorbing the fluid back into the alveoli. However; there are many patients that still need to intubated and with the use of PEEP as well. Exacerbation of CHF, and when the patient is "worn out" one should protect the airway, and continue with pharmacological agents. Be safe. R/R 911

Yes, actually it has been proven not save very much time if you do drive safe. Do simple mathematics... you would have to double your speed to cut it in half... Again, if your kid/ loved one was in a Regional Level I Trauma Center, do you really think the extra 15 minutes would matter.. remember you have to allow for "scrub in" time ... etc.. Of course, I am not worried, I really doubt physicians & especially surgeons would become wackers.. they have more professional attitudes. Very seldom you see any markings on that Porsche or Mercedes that identifies them as medical. Strange you don't see stickers, bumper stickers, vanity plates, etc... R/R 911

Hey Dust, ironically U.K. is here in OKC visiting and observing how EMSA is set up. I will attach a link as soon as the news story airs. Wonder what b.s. was given.... R/R 911

I can understand your opinion, but you have to admit it is a lot better than it used to be. One can actually make a living in it. Actually, some of the medics I know do quite well for 10 days a month. Majority of the ones I work with make = or if not better than my RN counter parts per yearly basis. Middle income for approximate 120 shifts is not really bad, it could be worse. Especially, considering the required education level. Amazing, I see plenty leave and many return after they find out, that is not any easier in another profession. It is definitely better than some... and yes, I am sure not as good as many, like any other job. But as long as we have only part-timers or volunteers, it will never get better. The same is true in nursing.. my professor calls them appliance nurses.. ones that only work when they have to make a big purchase. It discourages administration from ever taking F.T.E. seriously, when you have easy replacements. Yes, I agree, we have a LONG way to go.... but, until we raise the bar of education level, and those only serious enough to make it a true profession, it will never grow. Sorry, you are burned out.. yes, I do understand after 29 years full time in EMS I can emphasize. Yes, it is not definitely not an easy profession and yes, we have a LONG way to go before it is a great profession. But, if most only took it serious (not wackers) and tried to really change things at legislative and professional level, we could improve it faster. Be safe, R/R 911

Allergic reaction(s) is caused by an histamine response. The usual urticaria (rash) and maybe angioneurotic edema (swelling of tongue, throat, upper airway) and of wheezes & stridor. The patient on top of rash may develop hives or welts (not whelps as most mis-pronounce.. which is baby puppies). The more common allergic reaction occurs within 30 minutes after ingestion, can occur later but some studies shown it is least likely to. More common allergies are peanuts, and seafood (iodine). I would recommend assessing the skin for the rash, see if she is itching, any welt formation ?.. Check upper airway for tongue swelling or tightness in throat or is the palate itching?.. Some people can be very anxious so it is hard to determine, but reassurance and monitoring will calm them down to be able to examine. Again, if there is not a reaction usually within the first 15 minutes chances are it might not be an reaction. The patient still needs to be monitored in case of delay response. The usual tx. of ananphylaxis if the patient is truly developing. Dependent on your local protocol (i.e Epipen..oxygen, notify ALS , etc) ALS may administer H[sub:76cb1f67c5]2[/sub:76cb1f67c5] blockers such as Benadryl, Pepcid, Zantac, or even steroid such as Solu-Medrol, Decadron, or Kenalog. Be safe, R/R 911

Sorry, I don't see any difference in injury and syndrome if you are really talking about traumatic rhabdomyolysis. Also the D50W is used to treat the K+, not the hypoglycemia, when you are adminstering the Insulin, Ca+, etc.. the cellular shifts causing hyperkalemia. R/R 911

I agree... no P.O.V should be running "hot".. look at the MVC involving EMS units and LEO units that are even marked. Why increase the number & then what have we saved ? R/R 911

Welcome to the City Brocktalk.I guess the amazement of the studies (either misplaced tube or even dislodged) is there is no reason for such. Since you have either clormetric or capnography for formal documetation and lung sounds for clinical judgement. Our new policy is runn a strip with EtCo2 wave form upon arrival at the ER before meovement and if possible after movement to ER bed. This is to show confirmation of ETT upon arrival. We decided this after reading an article were medics was acused of an esophageal intubations occuring. They had the capnograpy wave form and was able to prove their placement was valid. saving their butts, but also showing that tube displacement occured after arrival to the ER. I highly suggest some form of documentation of confirmation upon arrival to ER's. As the old story goes they are going to blame someone... I am amazed that Houston does not have that many required intubations. Although that is a lot of medics. Again, no contriol of the system and flooding the market, I now also wonder with that many, how difficult can the program be? R/R 911

I had heard rumors that LA was "far behind".. and medics has to "jump through hoops" to perform routine EMS care. Shame, that still occurs. R/R 911

Thats all fine to tx the patient... but, you do have to have an ECG interpertation. That is the discussion. R/R 911

Apparently, you don't have the roads I have. If the patient is stable, and time is allowable, I start prior to leaving and maybe in the home I rather be sure I have a line that is patent. If time is an issue (and the travel is smooth enough) then establish one enroute. It is all about using common sense and what is right for the patient not for you. Be safe, R/R 911

This was discussed on Firehouse forum. One of the responses (from Croaker) I thought was very interesting. More detailed than I usually see in EMS for "crushing injuries".. I believe he is from Idaho. Here is copy of the protocol. http://forums.firehouse.com/showthread.php?t=77821 PROTOCOL TITLE: Crush Injuries REVISED: GENERAL COMMENTS: This protocol covers isolated extremity crush injury with entrapment. Extrication of the victim from the means of entrapment should not be performed until medical care can be provided. BLS SPECIFIC CARE: See General Trauma Care Protocol T-1 - Assess for the “Six P’s: - Place (but do not tighten) tourniquet on the entrapped extremity. If this is not possible, have the tourniquet standing by.  Tighten only if precipitous hemorrhage occurs.  May use tourniquet as prophylaxis on Medical Control or ALS instruction. - Be prepared for significant bleeding and sudden cardiac arrest when patient is freed, especially in prolonged incidents. ILS SPECIFIC CARE: See General Trauma Care Protocol T-1 Prior to being freed from object: - IV access (to a max of three attempts) with TWO LARGE BORE LINES.  IV: 200-500 cc crystalloid solution. Repeat PRN.  If the patient has been entrapped for more than 1 hour, fluid therapy 20 ml/kg rapid IV bolus (1 to 2 liters) using normal saline PRIOR TO RELEASE FROM ENTRAPMENT.  Use with caution in patients with Hx of CHF. After being freed from object: Fluid therapy 5 ml/kg/hr (300 to 500 ml/hr). Increase as needed for hypotension. ALS SPECIFIC CARE: See General Trauma Care Protocol T-1 - Place a tourniquet, consider its use as prophylaxis . - Strongly consider sedation and pain management. For Crush Injuries with active entrapment greater than 1 hour: - Sodium Bicarbinate.  IV: 1 meq/kg IV (minimum 50 meq for adults) given IMMEDIATELY PRIOR TO RELEASE FROM ENTRAPMENT.  OPTIONAL INFUSION: 50-100 meq/1000 cc, run at 150 cc/hr, titrated for effect. - Calcium Chloride (for crush injuries with hyperkalemia changes on EKG)  IV (Slow): 2-4 mg/kg  DO NOT GIVE IN SAME LINE AS BICARB INFUSION. PHYSICIAN PEARLS: Victims entrapped and crushed due to heavy objects, (e.g. fallen debris from a structural collapse) present a unique challenge. These crushing objects place prolonged and continuous pressure on the extremities resulting in skeletal muscle death (rhabdomyolysis) with release of its cellular contents (myoglobin) into the plasma. These adverse effects are known as Acute Crush Syndrome. After the skeletal muscle injury occurs and the crushing object is removed, the accumulated cellular toxins (myoglobin) and electrolytes (potassium) are released into circulation and may cause lethal cardiac arrhythmias, acute renal failure and sudden death. The systemic effects of Acute Crush Syndrome only occur after the object is removed and the injured extremity is re-perfused. Removal of the object causes a massive fluid shift into the injured muscle, resulting in acute hypovolemia and hypotension. Large volumes of NS (avoid LR) must be given to the patient intravenously both before and after the patient is released. The addition of a buffering agent, such as sodium bicarbonate, to the IV solution can help prevent the myoglobin deposition in the renal tubules and may counteract hyperkalemia as well. A tourniquet may slow the spread of toxins from the injured extremity, and result in improved outcomes as well as preventing catastrophic blood loss. - Sodium bicarbonate should not be used in crush injuries of short duration (less than 30 minutes). Its use is indicated when evidence of distal ischemia is present. These signs are commonly known as the six “Ps.”  Pain  Pallor  Pulselessness  Paralysis  Paresthesia  Poikilothermia (cool to touch) - Trauma patients are very susceptible to heat losses and preservation of body heat is paramount. - While ACEMS typically uses normal saline exclusively, in MCI’s multiple IV fluid types may be available. It is important to note that Lactated Ringers should be avoided as it contains potassium and lactate From what I read it is a very good general protocol. R/R 911

If the ER Doc or services can't stabilize the patient long enough for the surgeon to respond in safe and timely manner, then the patient outcome is probably so low surgical services will not matter. Trauma Alert system (prehospital) will buy enough time to notify a heads up.. There is enough idiots out there, without any more ego's running with lights on their vehicles. Sorry, they already usually have an attitude enough, and have enough special services without additional. I can see the surgeons now responding in their Porsche's ...pegged out. R/R 911

ACLS is so watered down...(still awaiting new instruction material for the 2005 course) our janitor passed it .. and technically (dependent on the course coordinator) you can re-test until you pass, I even know of some that don't administer a test at all. So having the card really means nothing any more except you attended an AHA recommended guideline course on ACLS .. that's it & that's all.. it & and $1.50 usually will buy you a Coke. The only reason most Paramedics still take ACLS, is because the NREMT still requires it for re-registering. It is a shame that level & respect has disappeared. Now it is considered a joke. Yes, it is geared at ACLS providers level, so not knowing or not being able to perform those skills discussed or described in sitting in a class, is really wasting money. If you spent that amount towards your advanced or even a PHTLS course to advance your knowledge on something you can utilize & use. To take the PHTLS Advanced level you must be certified at the advanced level.. licensed or certified to intubate or establish IV's ... The reason is it has surgical airway and I/O etc.. in which is an advanced level. There are many other CEU's courses that are at your current level that you gain insight & education on. Good luck, R/R 911

I highly recommend talking to your program coordinator and seeing if they would allow a class of anatomy and then a separate class of physiology. The combination (which most colleges require) very seldom transfer to upper level )medical school etc) as separate courses, rather count as 1 anatomy class. The separate classes as well gives more in-sight in physiology, which is very essential. Most programs will allow the substitution. Reviewing an anatomy book is good, but can be difficult without structure, but yes it can be done. Some colleges allow one to "accelerate" if they have prior knowledge. I also recommend a medical terminology class if possible, proper pronunciation and spelling is essential in medicine. Knowing what the word means, one can tell many things about a disease process, or surgical procedure, without knowing much more. Other classes than might enhance is math for pharmacology, and any biological, general education level classes as well. Good luck in your studies, R/R 911

We can all agree that surgical/intubations is the best or "Gold Standard of intubation education and clinical studies. I assisted in one Paramedic class that we intubated cadavers.. when Oral Roberts had their medical school. There were so many donated bodies each student had their own to practice surgical airway and any other dissection they wanted to etc.. It was not as nice as surgical theater, but; definitely was better than mannequin and the surgical airway and chest etc.. was nice to be able to perform and demonstrate. Has anyone else used cadavers before? The other item is what is your satisfaction percentage for QI % for intubation ratios ? .. and how much performance is acceptable before re-education .. and procedures? One of newer Paramedics is modifying QI and our Medical Directors is supporting it. I also question distance education programs, and some technical programs... do they routinely schedule O.R. rotations ? Our technical program allows observation, & if the physician feels comfortable or allows them too, that is great. Most are only getting exposed to very few ETI, an increase of LMA is now being used for short surgical procedures. I am attempting to find out if NAMSE has a policy statement or accredit ion requires such.. R/R 911

According to American Academy of Surgeons (ACS) Level I criteria is to have surgeons in house and have the ability to respond in a timely manner. By not having such they could be in violation of the criteria of the Level I rating. With several other criteria, and response of other surgical teams.. i.e anesthesia, scrub teams, lab, & radiology. Some states do deviate from ACS and have local policies. Most require the surgeon to have a response within 15 minutes of notification. Usually the ER physician or attending is responsible until arrival and the work up is usually began. The lights and sirens on P.O.V. is never a good idea, especially on private vehicles ( hard to imagine a light bar on a Lexus or Jaguar) I still have a hard time with us even having such sometimes. They already have a "MD Deity" complex, this would encourage this more... R/R 911

Ditto, what AK said. Most of the air flight programs are not what medics & even nurses expect. Usually as what AK stated it primary used for long distance ICU or even nursing home to nursing home transports. Kinda knocks the wind out huh...? All of the flight services I have seen and worked for required the Paramedic to have at the minimum of 5-6 years at at the Paramedics level and preferred CCEMT/P with multiple experience (ER/ICU etc...) the nurse the same with 3-5 yrs ICU experience and maybe ER experience in lieu.. Study hard .. pay your dues.. it is a very competitive position. R/R 911

Noahmedic have you heard any rumors on the trial study of the "Advanced EMT/I" as of yet ?.. I agree, there is a lot of problems with PUM. Then I have seen very few services without any "major" problems, and when you finally do .. they go and screw things up later on ... You know EMS is not really that complicated of a profession, usually people make it more that it really should be. I did work at an EMS once that was total medic units, and we finally developed into a great EMS. We did not have any turnover rate for 10 years... oh, an occasional squabble but it was very minor and resolved itself in a day or so. Unfortunately, most of crews either got tired or older or both... probably the best times in EMS & we knew it ... If most medics did their full job and people left most their attitudes at home, then management treated employees as adults & expected them to behave and perform as such, things would be better. Finding all those combinations is the hard part. Be safe, R/R 911

Allright you two... don't make me pull this thread over .! :wink: The vents we have on the EMS rigs are pretty simplistic since most are <30 minute travels, we do have a Burdick portable vent with all the lights & whistles, sighs, etc.. that is a bitch to set up and clean-up afterwards so nobody will use it very often. We used VAR quite a bit, in post fresh hearts and also when I worked in the ICU Burn Unit, some would start after a day or so on the vent (especially if they looked like they would be hard to wean off) & others would start on some soon as possible.. all depending on the mood of the pulmonologist. I perosnally like it and most of the R.T.'s seem to describe they have a decreased ARD's number and increased some saves. I know it was not that long ago, if you got ARD's it was a automatic death sentance, with the surivial rate near zero.. still not good at all but better than it was 10-15 years ago. R/R 911

Wow !.. now that surprises me.. you can buy AED's now at Sam's (a division of Wal-Mart) for $2500, locally here. R/R 911