Dragoon

I applied a few in the military. The injuries there were significant. At the same time I also applied several compression dressings to limbs with major injury where a tourniquet would've been applied if not for the compression dressings. (Note: I wasn’t a corpsman aka medic, just a grunt with good training.) Since going to the civilian side I've applied three. The first patient was to an elderly female who was knocked down by a flatbed tractor-trailer that was backing up. Her legs were run over by the rear wheels of the trailer. Both legs were crushed. They looked like raw chicken legs that had been pulverized with a sledgehammer and felt like a tube sock full of marbles. Both legs were dressed with trauma dressings, splinted and elevated. There was no spurting blood; just continuous bleeding where skin was avulsed or at open fractures. She had begun to bleed through the dressings and I decided to apply a tourniquet to each leg. One was placed two inches distal knee and the other was about three inches proximal to the knee because her knee was twisted medially. Both tourniquets were improvised with cravats. I wrapped the cravats wide, twice around the leg and used a pen to twist and tighten. The intent was to stem the flow of bleeding. The second time was for a bicycle deliveryman who was struck by a garbage truck and still underneath it. After the vehicle was secured, my partner and I crawled underneath the garbage truck to remove him. My partner immobilized his head as I assessed the patient. A rapid trauma exam revealed a conscious, Chinese speaking male with an amputation of the right leg distal to the knee. The leg was still attached by some muscle and skin. I decided that because of the amount of blood that was on the pavement and the location (under a truck) he was getting a tourniquet right then and there. It met 2c4's criteria for application. I wasn't going to play around under a truck with limited space trying to apply a direct pressure dressing and bandage. I'm sure if I did attempt it that the quality would have been sub-par. So I applied the tourniquet above the knee because the amputation was just distal to the knee. Again two inches above. This time I had a commercial tourniquet, the C.A.T. Application was extremely easy and I twisted again until I believed the bleeding had stopped. After the patent was extricated and in the back of the ambulance we were able to properly dress and bandage both stumps and perform a more detailed physical exam. Each time was a different situation where a tourniquet was applied. After they were applied to the first patient, we did apply another trauma dressing to the ones already in place. On arrival at the hospital the injuries had not bleed through the additional dressings. The second patient never bleed through his dressings. On follow up with him the surgeon told me the tourniquet was left in place and the patient was taken to the OR with it. Application of tourniquet is flexible but you need to be educated on how to use it in addition to when.

I think for the most part that everyone agrees that scene time should be minimized. I'm all for advancing the prehospital care that we provide but part of that is knowing where to stop and when to get the wheels turning for more definitive care as mentioned previously. The "golden hour" is nothing more than a cookie cutter applied to kinematics of trauma. It's BS. Each patient is unique and your scene size-up combined with rapid patient assessment should be indicators of how long you can stay onscene. Now what do we do with all the texts that mention the "golden hour": burn 'em, use them to build cabins like lincoln logs?

Hearing "load and go" makes me want to vomit. Practitioners get that in their head and it's what they focus on. I see it a lot from EMTs to paramedics, from the green newbie to the crusty old guy or gal. They make patient contact, throw them on the stretcher, get some v/s and go. Maybe an assessment is completed and they are then off. What have they done for the patient other than drive? During my EMT course we learned how to conduct a rapid trauma assessment. I think we all remember that and how to do it. You practice it enough times until it becomes muscle memory ("Slow is smooth, smooth is fast.") and when you get onscene it's not going to take more than 2 to 3 minutes to do it. Knowing what you can do for a critical patient is the key. ABCs as mentioned and discussed. I hate to use numbers but 10-12 minutes as Kiwi mentioned is ideal. You can complete a good assessment and start critical interventions in that time. The big thing is not to keep screwing around with things: i.e repeated tube attempts or failed lines. That also doesn't mean splinting every broken finger and bandaging all the moderate and minor lacerations. On the way to the hospital reassess and maybe if you have the time splint that broken bone and bandage that laceration. Some of the best traumas I've worked have resulted in me yelling "STOP!" and kicking people out of my bus or off the immediate scene so that my partner and I can do an assessment. Usually they are the ones yelling "LET'S GO! HURRY UP!". One of us starts at the head, the other at the feet and we meet at some point. Never have I ever been onscene for more than 15 minutes with a critical trauma patient. And you know what? We get to the hospital with a fully assessed patient and can give a good report to the staff. Now is that a matter of education or experience? And how do we teach that way of thinking?

Before I saw who posted this, I had only seen some of the top of the picture and I thought the inside of that bus looked familiar. You would have gotten extra points for inverting the stretcher with the equipment strapped to it. Though that is right up there with silly stringing the cab of certain crew in the "Boogie Down" some time ago.

If the city were to go to a true third service you'd eliminate a few hundred of employees who are on the "promotional" list to go to the suppression side. Not a bad thing. There are still quite a few around to include Richard who wore the old green pants. I think they'd love to go back. I'd be more inclined to join if they became third service instead of the bastard child.

Already being discussed. http://www.emtcity.com/index.php/topic/17449-news-feed-suspension-ends-for-nyc-emts-in-bagel-shop-incident-jemscom/

Opportunity only knocks once. Temptation leans on the doorbell. USMC Recruiting Station Berkley: We piss off more hippies by 9am than you do all day. (If hippies were up before noon.) I♣Hippies

Here are two videos that compare the standard and alternate issue boots with what was originally issued and an individual off the shelf purchase. This video compares the weight. This video compares the flexibility.

Universal call taker or UCT - where PD takes the call and info and then forwards it to the "appropriate" agency. No more specialized call receiving operators. PD operators will do it all: first aid instructions, complaints, etc. The same system that suppression is currently using that they are having so many problems with: no info, bad addresses. A conditions boss I spoke with said that it was supposed to make its way to EMS this summer but so far it hasn't. Though I have noticed a delay in being dispatched from the time the call is entered to when we are dispatched. About 2-4 minutes and its not because of no unit available or units being preempted.

Chief Sickles (sp?) I believe is gone from Queens, not sure where he is though. He is still a miserable boss making life difficult for the crews who are trying to do the right by picking up jobs that are close to them. I saw him a few months ago on a midnight tour at a simple fire in mid-town. He buffed it. My partner was so upset when he found out Sickles was there that he said he would have slashed the tires and gone out of service mechanical rather than do the standby. And Sickles made everything hard too: changed vehicle staging twice, had us relocate where we were setup twice, trumped the division captain a few times. I really think he was f'ing with us. The best thing to happen was when the conditions boss sat down on the stair chair and said "He wants to do it all, he can. No need for me." As far as the statistics go I've heard that all of the breakdowns that Richard mentioned are available but FDNY won't release it. Apparently the numbers without skewing and manipulating are quite scary and show considerable holes and flaws in the system. I do believe that on the slowest of days we are doing somewhere of around 3,000 patient contacts. Richard, you might know the answer to this; do they still plan on implementing the universal call taker into EMS? If they do the chaos that will ensue is going to be wild.

The missile MVA was about two years ago on the Bruckner expressway late at night. I don't remember all the details but it was a fender bender. Officer asked the tractor trailer driver for the paperwork and what he was hauling; answer, tomahawk missiles. I think it was two or four. The missiles were inert (no warheads or propellent). Bomb squad, ESU and fire were called. I think the Bruckner was shut down for about an hour till everyone had a warm and fuzzy that there were not going to be any big booms. That night at least.

Heck NO! That place is way to upscale for EMS hooligans. The Subway Inn or Port 41 is where it is going to happen. That or the last car of the F train to Coney Island with an oversized boom box (must have dual tape decks) and concealed beverages . Any other place is unacceptable.

Now just say it as one word.

It sucks that FDNY EMS has such a bad rap. I've never had a problem with Dr. Freese. He has done more to advance and progress NYC*EMS in the last two years than any of the other physicians at the office of medical affairs. About every six months there are revisions and advancements to the protocols that benefit us and it is a result of Dr. Freese. We all know that NYC is not great but is has gotten better in part because of him. We have some real pompus a**hole physicians that treat us like crap (80249 for anyone in NYC) when we call for orders or consults that we have to deal with but I've never had a problem with him. He is also an attending emergency room physician at St. Vincent's Medical Center in Manhattan which has it's own EMS department that handles 911 in the city. I hope that A/TC EMS gets the best doc but try not to knock the guy just because he has FDNY in resume.

I'm not going to get into a pissing match here about the education and experience issue. Maybe I could have made my opinion clearer in that you need an education to do this job. A 120 hour EMT class doesn't cut it. This is medicine, not first aid, not shuttle service to the hospital. Get some health science courses and take your paramedic course. In the 10 to 14 months that it runs you will get your field experience. If you can't put the book learning together with the practical application then your preceptor shouldn't be signing off on your ride-a-longs. You do not need three years to learn how to do proper BLS. What are you going to learn there that you won't on ride-a-longs? We've already had the thread that mentioned slamming narcan, equals poor patient care. And if the shooter returns then the scene was not safe. To borrow from Dust, FAIL. No disrespecting EMT's. I am one. I'm just believe that how we operate sucks. Most of the time we do things is because that's the way it's always been done. (I sure wish I could find the "monkey smack around" thread.) JMHO. By the way, I'm in NYC*EMS too.

I don't know why we have some who continue to think that? When I started about three years ago in my EMT class I heard the same thing. I also heard it out on the street too. "Get experience before you go to medic school." Flash forward to today and I can tell it is total BS and how wrong those that said it are. You do not need EMT experience to become a paramedic. You need an education: A&P, pharmacology, english composition, math to name a few, Use the search function here and you will see the consensus of what the members here think you need. Experience is not one of them. Hearing this nonsense again and again gets my blood boiling.

I'm not sure if the is more suited for this forum or the Non-EMS Discussion forum being that I think it straddles both. In April I will have been working for my current employer (a hospital based 911 and private provider) for two years. I have had plans to start paramedic school in the fall after completing the prerequisites to be a degree student earning an AAS in Applied Sciences. I had planned to quit working full time then and become a PRN employee so that I could focus my efforts on school. As I was doing my taxes I found out that after three years of service I am vested in my employers cash balance retirement plan where I am credited with 5% of each years pay with interest on top of it. They just changed it from 5 years to be vested. So now I not sure what to do. Do I stick around for another year for the cash retirement fund or do I pull chocks and go to school? Working full time and going to paramedic school is not an option for me. The only reason I am able to do it now is that I have been doing the eye dropper plan; taking one, sometimes two light classes at a time. Some of the things I have considered are: I'm not happy with my management and they don't appear to be unscrewing themselves; morale is down and frustration is up as I like to say. I don't see myself sticking around for the long haul with them. But, I am employed, getting a good paycheck (it beats out most of the other EMS providers in the area) and I have benefits (that I contribute to). I also enjoy the area I am working in. Not a big thing I know but it does make it more tolerable. At times. So I am not sure if I should put my plans for school on hold and gut it out at work for another year just for the money, or to leave the money behind and go to school, getting it done and coming out a year later a better provider, and ultimately better paid. I'm 29 years old too so I feel like the clock is ticking for me with thinking about retirement in addition to all the other adult responsibilities one has. I have some time before I have to make a decision and would like hear what other think.

I think that it is a combination of education, maturity and "mentorship". As stated before age is just a number, it does not guarantee anything. Look at the military. There you have 19 and 20 year olds responsible for teams and squads that may have as many as 20 troops with all there associated equipment and gear that can sometimes total several million dollars. They did not ascend to that position because they were the oldest, but because they have earned it and are mature enough to have handle it. I remember being a 22 y/o sergeant in the Marines responsible for a section of 16 Marines of varying ages with all their equipment and baggage. I worked hard to get there. I went to the appropriate schools and took the required classes (education). I spent a lot of time in new and unfamiliar situations with some one standing over my shoulder to make sure I wasn't screwing up. As I showed mastery of the skill I was given new tasks and responsibilities grooming me for more responsibility later on. My superiors before me were both great and sucked ass. I learned from all of it taking away things that worked and didn't. They were all examples (mentorship). I grew up really fast in the Marines becoming mature way faster than if I didn't enlist (maturity). We need to increase the amount of education required in EMS. Providers need to know why they are seeing something, what they are seeing and then know why they are doing an intervention. I've been working in EMS for almost three years. May partner will tell that you she has been doing this for over 12 years. We are both basics. I am a "why" driven individual always trying to learn what it is going on etc. She has been doing things the same way since she started and only knows that. Forget about trying to tell her there is another way to do something. We couldn't be more different and it drives me absolutely crazy. I'm a clinician and evolving, and she is technician. You would think that with all her time she would have the experience and maturity; I don't. She still has a grab adn go mentality. I've also learned more about what not to do from her (reverse mentorship). I agree with what Curse said, "When I first started I knew what I knew. These days I know what I don't know." To be able to recognize that in one's self is the maturity that is needed with this job. That doesn't come from age but from knowing one's self.

That article has got my blood boiling. I work in NYC and there is so much wrong with it that I don't know where to start. From description of how the man fell "he lurched slightly left, then fell forward, straight to the floor, crashing head first into the metal gear box under the seats." Not possible, the man would have had to somersault between his legs to make contact with any "metal gear box" that does not exist anymore. (They used to be on the old "redbird" subway cars that haven't been used for 30 years) To the first responder nurses placing a bystander's nail file in his mouth. BS!! And if this man was homeless no one would have been within 10 feet of him let alone sitting right next him. The smell is horrible. Her description of the EMT's turns my gut. NYC has its problems, but they are bureaucratic and rooted in the administration(s) and management, and can make working in the city a pain in the ass. The 3,000+ EMT's and paramedics that respond daily are professionals. Now I'm not saying that we don't have our share of bad apples and skells but her portrayal of us is insulting. Subway jobs suck. Especially real jobs. You are down three stories on average with no comms and its usually just you and your partner. Maybe you'll have the lone transit cop waiting with the aided. You make patient contact, assess, start life saving treatments and package. When you get back to your bus, you reassess and go. (Refer to Urban EMS: Why do urban EMS fear on-site treatment?) There is no hanging out on the platform joking and smoking. The last place I want to be is in the subway with an unstable or stable patient. You do feel like you are an exhibit at the zoo and commuters are coming and going in all directions. We maybe curt to bystanders if they are in the way, but my colleagues and I are always professional. This call could have easily been one that I was on. As stated by many already, a lot has to do with perception and for some perception is reality. The author gave her point of view of a medical emergency (with much dramatic license). It unfortunately paints those of us that serve NYC's citizens in a disreputable light. That article is very scary for those who read it and are unfamiliar with NYC, EMS and NYC*EMS. Please don't believe all that you read.

This was sent to me so I don't have the link. Scene Time May Not Affect Mortality in Trauma Patients Vicki Gerson Medscape Medical News 2008. © 2008 Medscape October 29, 2008 (Chicago, Illinois) — Time on the scene of an accident or assault does not predict mortality in trauma patients taken to a level 1 trauma center, according to a retrospective observational cohort study. However, the results need to be validated, the researchers say. The study was presented here at the American College of Emergency Physicians (ACEP) 2008 Scientific Assembly. Emergency medicine physicians have always believed that the "golden hour" of care was the most important factor for trauma-patient outcomes. "However, there are no real data to support this theory," lead author Michael T. Cudnik, MD, associate professor in the Department of Emergency Medicine, Ohio State University Medical Center, in Columbus, told Medscape Emergency Medicine. "The data for this study was collected from the institution's trauma registry." Dr. Cudnik and colleagues wanted to determine whether scene time had an effect on mortality in injured patients who were transported directly from the accident scene by ground or by air to a level 1 trauma center. This study took place between January 2001 and December 2006 in a large metropolitan area and included all patients aged 15 years or older who were admitted for at least 2 days or who died before 2 days. A total of 4461 patients were included in the analysis. These patients had injuries from auto accidents, penetrating injuries, falls, or assaults. They were injured in their homes or in public places. Dr. Cudnik noted that the location of the injury was not accounted for in the analysis. Furthermore, although some of these patients might have had a myocardial infarction, such information was not obtained nor included in the analysis. The researchers did not include transferred trauma patients or patients arriving by private transportation. A multivariate logistic regression analysis was developed for scene time and mortality to see if there was any association, and it adjusted for factors such as age, mode of transportation, and severity of injury. Injury severity score (ISS) and revised trauma score were obtained. Of the total patient group, 59% were transported by air. According to the study abstract, "the median ISS was 10, and overall mortality was 5.2%. Mean scene time did not differ between survivors (14.4 minutes) and nonsurvivors (15.3 minutes)." In the final analysis, scene time was the only factor that had no association with mortality (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.96 - 1.01; P = .17). This lack of association remained when patients were stratified by those who had been intubated before arriving at the hospital (OR, 0.98; 95% CI, 0.94 - 1.02) and those who had not (OR, 0.99; 95% CI, 0.95 - 1.02). Even for patients with a scene time longer than the mean, there was no "observable" increase in mortality (OR, 0.79; 95% CI, 0.51 - 1.22; P = .25). In addition, no increase in mortality was seen when patients were stratified by ground transport vs air transport, blunt vs penetrating trauma, Glasgow Coma Scale score less than 9 vs 9 or higher, and by those with an out-of-hospital systolic blood pressure of less than 90 mm Hg vs 90 mm Hg or more. The researchers also looked to see whether scene time interval (in 10-minute increments) was found to be associated with an increase in mortality; it was not. The area under the receiver operating characteristic curve was 89.4. "We can't take the study on its face value [to determine whether] scene time is a predictor or not a predictor of mortality," Brian O'Neil, MD, course director of the Research Forum at the meeting and associate chair of the Department of Emergency Medicine at Wayne State University School of Medicine in Detroit, Michigan, told Medscape Emergency Medicine. "There are many factors that go into scene time that the study did not look at," Dr. O'Neil pointed out. "Was the scene secure? Did the patient have to be extracted from the car? When it is possible to 'scoop and run' with patients, they do a little bit better." Nolan McMullin, MD, FACEP, a staff emergency physician at the Cleveland Clinic, in Ohio, who heard the presentation, said, "I find it a little surprising that scene time was not associated with a higher mortality. Throughout emergency medicine, we are taught how important it is to reach the medical center quickly." Dr. Cudnik did say that he would like to see future studies validate his findings. "It is important to identify which patients need to be transported quicker than others in order to save more lives." The study did not receive commercial support. Dr. Cudnik has disclosed no relevant financial relationships. American College of Emergency Physicians (ACEP) 2008 Scientific Assembly: Abstract 171. Presented October 27, 2008.

I'm an EMT almost three years in NYC working for a hospital who provides 911 service to the city. Before that I did the opposite and was in the Marine Corps for six years. Like I said in the title of this post, I've been a member of the site for a little while and have learned a good amount here. I've become a firm believer in evidence based medicine and knowing why you are doing something instead of the cook book crap that I see running around. I love doing my job, correctly and I get ticked off when I see laziness on the part of the provider. I'm a human resources nightmare as I don't have a problem telling my coworkers they suck if that is the case. But I've been muzzled if I want to keep my job. I'm chomping at the bit to go paramedic school but am trying to hold off till I take some core classes: the A&P's, pharmacology so I can understand what it is I am doing and why. Also school isn't cheap. Looking forward to contributing and learning some more.

New York state does allow BLS units to carry epi-pens. The following is taken from the New York state protocols for Anaphylactic Reactions With Respiratory Distress or Hypoperfusion If either cardiac or respiratory status are abnormal, proceed as follows: A. If the patient is having severe respiratory distress or hypoperfusion and has been prescribed an epinephrine auto injector, assist the patient in administering the epinephrine. If the patient’s auto injector is not available or is expired, and the EMS agency carries an epinephrine auto injector, administer the epinephrine as authorized by the agency’s medical director. B. If the patient has not been prescribed an epinephrine auto injector, begin transport and contact Medical Control for authorization to administer epinephrine if available. VI. Contact Medical Control for authorization for a second administration of the epinephrine auto injector, if needed. The REMSCO (NYC region) protocol, #410 for Anaphylactic Reaction is nearly identical to the state's with the assisting and use of the epinephrine auto injector being left up to the agency's medical director. i. If the patient is having severe respiratory distress or shock and has been prescribed an Epinephrine auto-injector, assist the patient in administering the Epinephrine (0.3 mg via an auto-injector). If the patient’s auto-injector is not available or expired, and the EMS agency carries an Epinephrine auto-injector, administer the Epinephrine (0.3 mg via an auto-injector) as authorized by the agency’s Medical Director. ii. If the patient has not been prescribed an Epinephrine auto-injector, begin transport and contact On-Line Medical Control for authorization to administer 0.3 mg Epinephrine via an auto-injector, if available. NOTE: IN THE EVENT THAT YOU ARE UNABLE TO MAKE CONTACT WITH ON-LINE MEDICAL CONTROL (RADIO FAILURE, NO COMMUNICATIONS) AND THE PATIENT IS UNDER 35 YEARS OF AGE, YOU MAY ADMINISTER 0.3 mg EPINEPHRINE (ONE DOSE ONLY) VIA AN AUTO-INJECTOR IF INDICATED. THE INCIDENT MUST BE REPORTED TO ON-LINE MEDICAL CONTROL AND YOUR AGENCY’S MEDICAL DIRECTOR AS SOON AS POSSIBLE iii. Contact On-Line Medical Control for authorization to administer a second administration of 0.3 mg Epinephrine via an auto-injector, if needed. I am only aware of one agency in NYC who's BLS units carry epi pens, New York-Presbyterian. FDNY EMS' medical director has decided that their BLS units will not carry them.