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I remember saying this a few years back, but I like to appear out of nowhere and say "Please state the nature of the medical emergency."

Wendy, i can understand your viewpoint, but here is mine. When it comes to someone who is terminally ill, it is NOT ethical to allow them to succumb to malnutrition or dehydration or even suffocation in the case of a ventilator when there are other options available. It is not ethical to put any living thing in unnecessary pain or discomfort if the ability to alleviate that pain is available.

I understand your reservations regarding 'slippery slope' when it comes to assisted suicide, but I can tell you that after the Nuremberg trials after World War II and the extent of the Nazis practices of euthanizing social undesirables, there very, very strict rules and laws in place governing that sort of thing. Do not buy into the Sarah Palin 'death panels' concept, you can easily institute a program that provides for end-of-life care without the fear of the afflicted being removed from the gene pool.

Your belief in the sanctity of human life is not misplaced, I happen to agree with you. But even more important than the mere presence or absence of life is the quality of life.

I think that EMS could benefit from klcking up the levels a notch. What the United States needs is a national mandate. There needs to be a mandate that every population of a certain size needs to have advanced level providers able to respond in a timely fashion. And before anyone gives me this socialism-states-rights-the-south-will-rise-again bullshit, I have three replies for you, Medicare, Medicaid, and Highway funds. You don't want the federal government telling you what to do, give back your federal money.

New Jersey is my example of what EMS looks like under local control. Backwards, over-funded, sometimes outright corrupt little fiefdoms where blowjob politics* rules the roost. If you put things like heath care out there under the span of local control, it will turn into a nightmare. People with a high-school education and 120 hours of first aid training will be in charge of multi-million dollar organizations and I cannot begin to tell you what that opens up.

My ideal system would be this. You have three levels. Transport-technician, Paramedic 1 and Paramedic 2.

Transport-technician would be responsible for attending to simple IFT's and dialysis runs. It would be the very basics you need to know to be reasonably successful doing simple IFT's, discharges to home or rehab, or dialysis runs. Think of what we could do if we didn't use EMT-B's for this role, rather, we had an actual course dedicated to transport. We could do things lessons like reading charts, geography lessons, who to call if the patient stops breathing. It could be customer service driven and just make for such a more enjoyable experience than two EMT-B's who hate doing it.

Paramedic 1 would be the equivalent of EMT-I, plus some sciency stuff. You would need English, A&P, basic math, and some sort of elective as prerequisites. It would be a year long, not necessarily paramilitary, but regimented like a good private school is, with regular physical activity and have clinical and field time interwoven with didactics. You would still be a moron when you graduate but hopefully you're a little better prepared for the field.

Paramedic 2 would build on paramedic one, and add advanced airway, cardiology, neonatology (like the NNRP, not like one chapter in the book and five questions on the cumulative exam), pharmacology, pathophysiology, and in depth learning of the respiratory system, PEEP, I:E ratios, hypoxic hypoxemia, hypercapnia, all that fun stuff. The entrance would be open, and based on previous academic and physical scores coupled with MMI style interviews.

Plus any 911 receiving ER that did not have a cath lab or CAT scan on premises would be mandated to have a fully operation CCTU truck on premises, ready to transport, with a paid 24/7 crew to standby. I think you could get away with having an ER nurse with special training who works the floor until it's ready to go coupled with a paramedic who operates as an ER tech if you were worried about people sitting on their keisters.

That would be my system, and it would be great. It would also piss off, in order, the IAFF, the NAEMT, every volunteer squad in the nation, probably the nurses unions, and some good ol' boys who do things thar way round 'thar parts. Which is why it will never happen.

*blowjob politics is my neologism for the petty interpersonal goings on that run EMS systems to a large degree. Many times it comes down to who received, did not receive, procured for, or failed to procure, oral sex upon or from another person. Contracts, promotions, hirings, firings, write-ups and test scores many times fall into blowjob politics land. When I come up with a less crude way of saying it, I will be sure to post it.

I believe in bringing the patient to the equipment when possible; think about a cardiac arrest that you know is a confirmed arrest: Bring all that equipment to the patient, or take 5 minutes to bring the patient to the equipment --- much easier. I agree with the policy of using the stretcher, if they can walk to the bus and sit upright, why do they need an ambulance ride ?

And you're a manager. That figures.

I consider myself a pretty intelligent individual. I also think that my 2 year associate's degree program, coupled with many, many clinical and field preceptorships left me with just barely enough knowledge to adequately care for the critically ill or injured. Maybe I'm just neurotic. I remember after my first field delivery going and enrolling in an NNRP course on my own time with my own money because I realized there was a gap in my education. I mean, if you feel comfortable being the highest medical authority in ever changing, less than ideal circumstances dealing with things that would make an ER doctor start phoning some friends, then fine, good on you. I guess the fire service is just that much superior than I am. At least that's what they keep telling me.

Hyperoxygenation of head injury patients is beneficial

Doing fracture management without analgesia is appropriate

OPAs and King tubes can be inserted on responsive patients without pharmacological intervention

An NPA inserted on a head injured patient creates a high risk of the NPA entering the brain

You can 'tell' by looking who is having a heart attack and who isn't

Response times are the gold standard marker for a system's performance

People who are unconscious yet maintaining an airway need to have advance airways placed

EMTs save paramedics

Looks nice, chbare! It gives me some ideas. I'll post a pic of it when I'm done with mine.

If a leg is only being held on by a few pieces of soft-tissue and it is preventing rapid extrication, then I think you should do what needs to be done to save this person's life. If it is mangled but still attached, then I think the best course of action would be to throw a doctor who is qualified on the chopper and have him land and perform the procedure. If your level I has a helicopter but no orders or procedures allowing a physician to perform a field amputation, then I'd say that is an issue that needs to be addressed. If you perform the amputation yourself, you have to be cognizant that you are performing out of your scope of practice, and be ready to defend your actions at an inquiry. If you honestly, truly feel that it is necessary to save the person's life, then you should do what is in the best interest of the patient.

Welcome, congratulations on your discharge. Can't wait to hear some of your input.

BP 100/70 with a heart rate of 140? That means he has a MAP 10 points above critical with a heart rate 10 points below being in SVT. That's really bad. How long prior to our arrival did the crash happen? If it was 20 minutes ago he may have a chance, if it was 10 minutes ago, not quite as much. Tell the OIC that if his men can't get him out and loaded on a chopper in 20 minutes or so he is going to die. Hopefully they can cut their extrication time down. I assume the local hospital can't do any emergency fence-post-ectomies, so we need to get him to a surgical facility ASAP. In the mean time, check for tension pneumo, relieve if it is causing a rise in intrathoracic pressure and reducing venous return. As well, see if they're is anything leaking from the leg that we can work on, make sure the pelvis is stable, fix as necessary. Start two large bore IV's, but titrate it to maintain a permissively hypotensive level. I don't think there is anything on the doctor pack that will help our driving-ability-challenged friend here. The worse case scenario for him is that he managed to transect the subclavian artery. That's one of those injuries that even if you have a trauma surgeon and OR suite sitting next to you, they may not be able to do anything before you bleed out. Reference two cases that high light this. The first is the 1986 FBI shootout in Miami. Early in the battle, one of the perps was hit with I believe buckshot which destroyed his upper thoracic vessels, however, he was still able to return fire for several minutes, killing two agents. No surgeon in the world could have repaired the damage that he sustained, he was dead, but it took him a while to realize it. Second, more poignantly, was the case of John Lennon. He was only 20 blocks away from a hospital and probably about 40 blocks away from a trauma center when he was shot, but he was dead on arrival at the ER, the bullet had also taken out his subclavian. So on that note, on top of everything else, tell the fire guys to make sure not to touch the fence post, for all we know, it's actually tamponading and even looking at it could spell the end for Uncle Jake.

I have a bag full of patches that one of these days I'm going to figure out to make a nice display with. The kicker is that with a few notable exceptions they are all patches I have worn at one time or another. Trading patches has been a tradition that has gone on for pretty much as long as people have worn them. Many stations and firehouses have a display of patches they have collected, to show how far some of their visitors have traveled or who they have met. I actually trade pins more than I do patches, and I have a pretty cool collection of those too.

While we're on the subject, can anyone offer me suggestions on how to display them? I have about 15 to 20 of the suckers and I want to arrange them chronologically. I think a large pin board would work but I'd like to have a cover over the top. Any thoughts?

Musicislife, about the medical patient, let me put it to you theoretically. In an unconscious victim, how do you come to the conclusion that it is a medical rather than traumatic etiology?

My advice on tattoos is this: Having a tattoo doesn't necessarily mean you are a hot-dogging, motorcycle riding ex-con with a meth addiction, but you will find that some employers tend to think so. Getting the job you want in EMS is no easy task. You will be up against many people who are as equally as smart and capable as you are, and your tattoos can and probably will put you at a disadvantage. So if you want to get a tattoo, go ahead, but don't go around complaining if certain doors shut for you. The parents of a preemie getting a neo-nate transport to a specialty facility to do not want to see a tattoo of a grim reaper riding a Harley with a flaming Star of Life in one hand, no matter how cool that sounds.

Me personally, I have no tattoos, I have some really cool looking scars though, and scars, unlike tattoos can only be earned, never bought.

This entire scenario rests on whether patient #1 is indeed pulseless and apneic. Detecting respirations and pulse outside, in a car, in varying weather conditions is rather difficult. Unless there is obvious signs of death, I'd prefer an assessment under controlled conditions and an EKG strip before I start throwing around the toe tags.

While we're on the subject of chemical restraints, a person I know who is one of the foremost experts in mental illness mentioned to me the dangers of using benzos as a chemical restraint. Apparently, while not common, a person who is agitated can have a paradoxical effect to a benzodiazepine and go completely out of control. 'Paradoxical effect' is kind of a misnomer, apparently what happens is the benzodiazepine has the effect of completely eliminating a person's inhibitions, and you can imagine what that does to a person who is already agitated. This is why haldol is the prefer sedative in these cases.

Bernhard, if you ever develop a plan for the incorporation of alpenhorns into MCI scenarios, I will be on board.

First thing I learned at Outward Bound, "clear and copious" in regards to urine and proper hydration. Dwayne, maybe you could make up a form with a quick questionnaire, such as average fluid intake, and then a spot for vitals, and finally a color chart to relate urine color to. If you pulled workers at random from the floor and did this testing over a month or so you should have some pretty good data.

Bernard, I think the best solution is to get him on a regular schedule of commitment and see if he sticks to it or bails as soon as it stops being fun. First I'd have a direct but firm talk with him about command structure, and how replying snarkily to your superiors ends with a sight seeing tour of your various lovely rivers without benefit of a boat. Once you're past that, set a schedule for him, say 3 days a week for an hour or so he has to come in and wash the equipment or organize supplies or mop the floor. If he is right for your squad, then he should be able to do as much, and if he can't spend three hours a week helping out, then he can find another hobby.

The OPs cited study was completed at the hospital I work at and one of my medical directors is a principle on it.

We have adjusted our protocol slightly since this study was published but contrary to what you might think from the results of the study, we are still using the KingLTS in our practice. About two years ago, we were given the mandate that the KingLTS was to be the only airway we use in cardiac arrest for the simple fact that, agree with it or not, paramedics are generally not the best at intubation based simply on the fact that we don't have the muscle memory to be great at it (we employ 135 medics and each medic sees 1300 patients yearly), we should really take the results of OPALS and numerous other studies to heart and make the airway as simple and mindless as possible and based on the emerging literature, the KingLTS was that device.

Hey Dave, thanks for the reply. Its always great when you can talk to someone who knows the intimates about the studies. Just out of curiosity, why are there so many medics in your system? 135 for the population of Minneapolis seems excessive. Also, how is Prince, and can you get me an autograph?

Here's another study that I found interesting. http://www.ncbi.nlm.nih.gov/pubmed/22465807

What with all the sturm und drang (read: hoopla) about ET tubes and such, it seems that in porcine models in V-fib arrest with CPR in progress, placing a supraglottic airway significantly decreases the amount of carotid blood flow. That is, I think, really bad. Do you think this will have any ramifications on EMS practice? I doubt it. After all we found out back in 1978 that buccal glucose doesn't work but that didn't stop anybody.

FFS. How many members have we lost on this board now? What's the count?

I don't know how feasible this is, but I'm sure Stephanie would love to have some patches or pins we could send her. That would probably mean a lot. If someone can post a physical address maybe we could send some.

I'm not sure if its computerized or not. If it's not computerized bring two #2 pencils, it's multiple choice. Follow the instructions for filling in the dots you are provided. The questions are random ones from different study areas that make up a certain percentage of the total answers, i.e. the test will be 10% Operations, 20% Pediatrics, 20% Trauma, etc. I'm sure if you Google it you'll find the exact percentages.

If you've read all the chapters and gone to class faithfully and answered the questions in the workbook, there shouldn't be any problem with taking it. A brilliant guy named Richard Feynman, a nobel prize winner, came up with a sure-fire algorithm for solving complex math problems, it had three parts. 1. Write down the problem. 2. Think very hard. 3. Write down the answer. He was tongue-in-cheek kind of guy but there is some brilliance there.

well that's a given owo' is there anything in particular they like to put more than others like scenarios or vocab or locations/functions or is it completely random with everything like the nationals are?

I wasn't being facetious. The key to doing well on tests is to study. There's no magical formula or 'tricks' to pass these exams. Read the material, recall the material, apply the material. People will tell you not to "over think" the questions, and I'll agree that expanding on the given information for a question might lead you astray, but "over thinking" is rarely a hazard. So is "over studying." There's no such thing as over studying. There is studying and finding out the exam is much easier than you thought it would be, and you reviewed the material more in depth than you needed to, but you will never get a bad grade because you "over studied."

Also, I liked the question about whether you intend to pass the test or intend to work in the field, because the gap between the two is huge. To pass the test, you need to get a 70%. To work in the field, you have to be correct pretty much 100% of the time. Even if you're right 99.99% of the time, it might mean somebody died who didn't have to.

A warm code, and you would not work it??

Its in Arizona. There was a possibility it might have been JT Ready.

Study.