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Not to hijack too much, but if you suspected an air embolism, would you consider helicopter flight to be contraindicated? What about subcutaneous emphysema?

ITs funny that while EMS in the US is still under the Department of Transportation, the Department of Transportation says little to nothing about what is required for transportation.

Criminey! Just curious, were you at a dead or near stop when it happened? Was it like a traffic tie up and he didn't see you stopped and hit you at 80 MPH? This almost happened to me once. I wasn't doing anywhere near 80, but I was once tooling along on the highway and was looking to my right with confusion at the mass of cars exiting off the highway, when I look up and see traffic stopped dead in front of me. I was very lucky and was able to stop in time, with like just a few feet to spare, and ended up staring straight at a load of rebar in the back of a flatbed that was aimed directly at my face. I was 19. Talk about a lesson learned.

Yeah, I think I'd need pics to really make an accurate picture. But from a purely BLS standpoint I think standard of care would say that neck wounds should be handled with an occlusive and normal airway management methods rather than what was done. But if that didn't work, sure, go for it, why not, after of course we contact medical control so we can put all the blame on the physician for what we did.

Okay, I've got the scenario fully now. I think your EMTs actions were understandable, but not the appropriate course action. The only time you should be putting oxygen in through a hole in the neck is if you or a physician made said hole. I think the appropriate thing to do would have been to seal it with an occlusive, and then try assist breathing with a BVM. If he continued to deoxygenate, then you could try an NRB over the wound site, similar to someone who breathes through a stoma. If that worked, then I would investigate the possibility of managing the wound and introducing a true stoma, and then do BVM to stoma ventilation. I think though the best thing for this patient would be to effectively seal the wound, which would be a challenge in itself, and then securing the airway with a King airway. The trick would be to use just enough pressure to assure oxygenation at the alveoli, without disturbing the occlusive site. On that note, depending on the patient's mental state and ability to follow commands, the best thing might be CPAP. A relatively gentle inspiratory pressure pared with some PEEP might be just what this patient needs.

Not to hard. Seal laceration with an occlusive dressing. This guy is going to probably buying a tube in the near future, so doing it now rather than waiting for complications involving laryngoedema or secretions is probably a good idea. Full precautions should be taken with the airway, in the back of the ambulance, with the bright lights on, using a bougie with an rescue airway device nearby, done by the most senior and skilled provider in the area. I'm not sure I agree with denying air transport based on suicidal ideation, with the physical and chemical restraints available to the average ALS provider, the patient's physical state should be able to be well-managed. What I was thinking about instead was the chance of an air embolism due to the deep neck laceration, and whether a change in altitude could possibly aggravate that. That would be a good reason to go by ground.

You know what the most dangerous flaw young drivers have? Overconfidence. Glad to see that you missed that one.

That would be me. I'm not working quite yet though, and there is the ever present possibility that I'm going to end up working as the most qualified Arby's sandwich maker around.

There are no red or green bars. They are all a neutral grey. Anybody who sees them as red or green needs to see their optometrist immediately.

I think mental status is extremely important, but it can't just be shoehorned into "alert" "confused" or "unresponsive." A little more finesse in assessing the mental status is required. Irritability is a good sign, but you have to rule out the fact that they are not irritated by the attention they are getting. This where it comes in handy to quiet everyone down and defuse the scene. On the other hand, asking a bystander to compare their mental state to their normal state is extremely helpful. If a usually alert person is just having trouble remembering things, that can be an early warning sign. If you think about compensated shock, your body is compensating, that is, your body is engaged in a strenuous activity. Its like bugging someone who is on the treadmill, they generally take a second to snap out of their zone, and even then, they'll have trouble with even simple questions, and they probably are going to be fairly annoyed with you. Lethargy is also a matter of relativity. If you have an in shape 20 something year old, and they're having trouble holding their head up, that's a big sign of shock. If they get up to walk a few steps and then have trouble catching their breath, that's another big warning sign. Like assessing someone with dementia, it all comes down to what's different relative to their normal state. That's why numbers aren't really reliable. If you had vitals of BP of 108/64, HR 110, RR 18, with normal skin condition, but had someone who was hanging their head, irritable, and weak, versus someone with the same set who was chipper and ready to be on their way, then you could have someone who is compensating and someone who is fine. The other big factor is how quickly the symptoms came on. If I was examining a bicyclist who had gone up and over handlebars 10 minutes prior to our arrival, and was showing the beginning signs of shock, I would be much more concerned with rapid transport to the hospital than someone who say had been having nausea and diarrhea for the past 3 days and now had a BP in the crapper and pale, moist skin. Sure, the second one is definitely sick, definitely needs to have a full assessment done and other causalities ruled out, but the first one, if his symptoms are being caused by internal bleeding, he is much more of a priority, because if you've reached Stage I hemmorhagic shock in 10 minutes, you do not have a lot of time to play around.

Well, most shock that we deal with is either hypovolemic or cardiogenic. The early warning signs of hypovolemic shock are subtle, but I think fairly regular. Almost everybody has probably been mildly to moderately hypovolemic at some point, be it after a long flu, or out exercising with inadequate fluid intake. What do you usually feel like? Like crap, to put it bluntly. A pounding headache, weakness, maybe a little dizziness, irritability, dry mouth, a racing heart, in a person who is sick or mildly dehydrated, these signs are not particularly troublesome, they can usually be alleviated with some fluids. But in a person who you've ruled out vomiting, nausea, or dehydration, particularly someone who is at risk for internal bleeding, these signs are extremely relevant.

Great, now I have to change my login.

It's funny, as per their friends, young women with abdominal pain, GI distress or emotional crisis couldn't possibly be pregnant, and people under 30 who are AMS never do drugs or only have one or two drinks at the max.

I really think the best approach in EMT class is to teach the early, warning signs of shock, the later signs, and what the appropriate course of action is. EMTs should be like scouts, IMHO. They should be the first line who gets there, and make a general assessment, and then either call in or cancel more intensive resources. I think the best approach is clear, simple concepts, that can be remembered by the newest of EMTs, in the dark, in the rain, etc. I think the best skill an EMT can have is when to call for the calvary and when not to.

I can only reiterate what has been said before. The decision if the scene is safe or not is ultimately yours. The presence or absence of law enforcement isn't necessarily the deciding factor of scene safety or not. In class, we say, call for law enforcement, but of course life is more complicated than that. I've had times law enforcement has been present and said the scene was safe, while I disagreed. This usually came down to "there was a bad guy here, but he's definitely not in the apartment, but he might still be in the building." That might be safe for them, but not necessarily for us. I would say that if you are told via radio to stage and wait for law enforcement, there had better be a pretty good reason to disobey clear, direct orders, and you need to have a good grasp of what the consequences are of your actions. But again, the decision is ultimately yours.

What I like: Good new hire orientation and mentoring program Unified area service Lack of fire service intrusion Free boots!

Putting in my own vital signs from my physical, HR = 90, BP = 105/72, gives me a shock index of 0.86. My heart rate was a little higher that morning, and my BP on the lower side. I had exercised strenuously the night before and skipped breakfast. I was probably a little dehydrated, but according to the shock index, I should have been in bad shape, right? MAP, of course, is a far better indicator of perfusion, particularly the central perfusion pressure, rather than systolic, diastolic, or heart rate. For my own vitals, my MAP would have been 81.7, well within the normal range, so in this case the shock index is not reflective of perfusion. I'd rather EMT-B's not worry so much about the number, and more about when to push the panic button and engage in rapid transport or meet up with ALS. It drives me up the wall that some EMT and first aid textbooks still list loss of radial pulses and diaphoresis as a "warning sign of shock." Nuh, uh, homey, if you've lost your radial pulses you're actually headed in to Stage 3 hypovolemic shock and you are in bad shape. Reinforce the subtle warning signs of shock, the tachycardia, the restlessness, the air hunger, etc. I think that would be more beneficial.

All right, score one for rock and roll. I can't say I can remember any patient that was confirmed to be under the influence of ecstasy. I had a few GHBers, and like Happiness said, they also presented with symptoms consistent with a CNS depressant. The only big difference on presentation was that the patients were markedly diaphoretic. I'm not sure if this was an effect of the drug or an effect of being in crowded clubs surrounded by sweaty people. Ecstasy on the other hand increases cytoplasmic concentrations of dopamine, epinephrine, and norepinephrine, which produces stimulant effects. I'm not sure what the pathophysiology is with stimulants and hyperthermia, my index here says that tachydysrhythmias are the leading cause of cocaine related non-traumatic deaths, and then lists a couple of others, including hyperthermia. Young people don't have strokes much, nor are they usually insulin dependent diabetics, particularly if they do roofing, they might be able to throw their electrolytes off, but statistically speaking they're probably doing drugs if they didn't whack their noggin. Who does ecstasy and then goes to work on the roof is beyond me though. Maybe it was a small town, no clubs to go to. Did his coworkers remark that during the day he did say several times "Wow, those hammers... sound.... awesome!" or something? My book here says that benzodiazepines, nitro, ASA, an NS 0.9% are the first line treatments for cocaine related chest pain. It also says that calcium channel blockers can be used for stubborn hypertension, and beta-blockers are contraindicated because of possible exacerbation of the alpha-adrenergic effects of the cocaine.

Well, since mobey mentioned SSRI's, that got me thinking about tricyclics, so we could whack him with some bicarb as well. The only caution there is that if he continues to desat, in the presence of excess CO2 in the blood stream the NaHCO3 molecule can actually actually dissociate twice, going from NaHCO3 to something like Na+ HCO3- to Na+ H+ + CO3-2 and add another hydrogen ion, making things worse. But if we're at the point of trying anything and everything, I still think we should focus on managing on cooling (if he is hyperthermic) and possible substance abuse. Check his nasal septum. Is it ulcered, suggesting insufflation of cocaine? Are there burn marks around the mouth, suggestive of freebasing? Are his pupils dilated? Are there any reports of him hanging out with Lindsey Lohan? Does he smell of cannabis and is there any possibility that cannabis may have been laced with PCP? What's the capital of North Dakota? Who was the only President to have been elected to two non-consecutive terms? Bismarck, and Grover Cleveland

Stimulant related hyperpyrexia and/or cocaine washout. Board and collar to be sure, strip down to skivvies, turn on air conditioning in the back. Rapid transport. Begin large bore infusion 0.9%, recheck vital signs after 250 cc bolus. Depending on temperature, distance to hospital, etc., more aggressive cooling methods may be necessary. Look for signs of electrolyte imbalance in EKG, peaked or flattened T's, etc. I helped the ER on a case similar to this, a man had passed out after cocaine usage at a construction site, was not discovered for over three hours in 90 F heat with high humidity, his temp was over 107 degrees F. I got to do the 100 yard dash down to the cafeteria for bags of ice as the ER set up the collapsible tub. I didn't even know such a thing existed until then. I don't think adenosine or cardioversion is going to help, but you can always try. What might help is if you give him the benzos, you'd have to convince medical control, but i know benzos are used to mitigate stimulant related tachycardias. But really this guy needs access to more differentials than we can provide, a tox screen, for one. I'm willing to bet it would come back positive for cocaine or methamphetamine, usage of which can be higher among people who work menial level construction jobs.

Yeah, I would have loved to have been a fly on the wall when the back room phone calls started getting made to the state. "Aw, come on Mitch, why do you have to be like that? Just let this one go. Its no big deal. We're heroes! It's okay!"

If I narrowed it down to the absolute essentials, I would say: 2 good pens. Get a good gel pen that doesn't skip or run. Trauma shears. Get a back up pair, they often go to the same place that your socks in the dryer go to. My definition for a call that ended well is based very much on whether I lost my trauma shears or not. Stethoscope. Do not go with the two tube "I just got out of EMT class" model. Get a Littman. I suggest the kind with a sealed back because the kind that has two bells can get muck in it. Write your name on it in big letters somewhere so when someone tries to hork yours you can spot it. That's all you really need to carry on your person. Everything else can be gotten out of a bag or off the truck.

It's not a run around. There is always a third option to a "Yes/No" query, that third option is "That's a stupid question." This dilemma is only applicable to a very small population in a smaller socioeconomic bracket. The issue effects such a small portion of people as to be, in a practical sense, irrelevant. Is it morally ethical to destroy a termite mound in Botswana? Maybe it is, maybe it isn't, but with the world has some really major issues right now, maybe we could worry about that. I grumble a little bit when I hear about the super-privileged complaining about something they can't have. Waahhhh!

All else being equal, I'd rather the Westernized world reach out and help the millions of women around the world who have no rights or worse, and then, afterwards, worry about who gets admitted to the country club. I'm a worldview type of guy, and so long as their is female circumcision, forced prostitution, pouring acid on women because they want to go to school, honor killings, war rape, gender preference abortion, and a hundred other crimes against women that happen each and everyday, who gets let into the golf club and who doesn't is of little consequence for me.

Your gear bag should be a matter of personal preference: See what type of calls you should be running, and take it from there. Don't be that guy with 50 occlusive dressings and no BP cuff. If you are running on a volunteer "drop and go" squad, I recommend a one piece jumpsuit with reflective markings and an EMS logo in big dumb letters on it. Get a good pair of boots, the kind that you won't have a problem scrubbing with chemicals in case you get God-knows-what on it. If they are not provided, get a good pair of goggles, and a helmet. On your person, I would recommend: 1 quality stethoscope. 2 good quality black gel pens 1 black Sharpie marker 1 pocket sized Mead notepad 1 pen light. I recommend the kind that you can swap out an AAA battery with rather than the disposable kind 1 pair durable sunglasses or clip ons if you wear corrective lenses. Getting a durable, pocket sized protective case is also recommended 1 pack chewing gum 1 durable belt that can be quickly attached or removed from person. On belt: 1 glove pouch 1 flashlight holder 1 good quality flashlight. Mini Mags or High-intensity LED flashlight is good. 1 pair trauma shears 1 tape holder. You can use a cotter pin to a trailer hitch or a saline lock made into a loop. 1 roll 2 inch tape 1 radio case. You can get radio case combos. Make sure it stays put when you change positions. I also highly recommend a complete physical before you start working. Going from being sedentary to a quick burst of high intensity lifting or cardio is a real shock to the system. Get scoped out for high blood pressure, cardiac dysrhythmias, or respiratory disorders. Best of luck.