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Everything posted by zmedic

  1. Hi, figured I'd pop back in and say howdy. Hope y'all are doing well, it's been a few years. I'm now an emergency doc and EMS medical director, but between residency and fellowship haven't been on. Hope to check in more in the future.
  2. I agree that you have to sort out what you want your full time job to be. I'm not in tactical medicine but have a lot of EMS experience, and my sense is that the vast majority of of people who do tactical medicine don't do it as a full time job. They are either full time medics who respond to call out with their SWAT teams, or they are full time police officers who have additional medical training. The big police departments have full time SWAT teams but most people who do SWAT are not in NYC or LA. The best place to start would be to figure out a few cities you would think about living in and search online for info on SWAT, the then contact the departments directly. They usually have someone in charge of recruiting. LAPD: http://www.lapdonline.org/join_the_team/content_basic_view/9125 LA Sheriff: http://www.lasdhq.org/recruitment/index-DST-POST.html You might also want to contact groups that do civilian tactical medical training and ask them for ideas how to get into SWAT: http://www.ccems.com/basic-tactical-operational-medical-support-course Hope that helps.
  3. The most important part of treating a snake bite is to bite the snake back. Otherwise, they never learn how it feels and will keep biting people. (To the idiots of the world, don't do this)
  4. It's worth noting that there are plenty of people who get killed by people they think they "know." Like psychiatrists who get killed by their patients, you'd think they would know how to read them and figure out that its a dangerous situation. Sure I've gone into situations that maybe others would wait for the cops, and there are times that I've waited. It's worth keeping in mind that you can run 5 calls on someone who is "just a drunk," and the sixth time they show up with a gun in their hands. What I was taught was that about 40% of suicidal patients are also homicidal. So if you want to go in go in, but I would keep it in mind when you are approaching the house, where you park the rig, where you stand when you knock, where you stand when you are talking to the patient.
  5. Couple of thoughts: 1: Trauma cardiac arrests don't cost the system much. Most of these people aren't transported, the system isn't build for these people because even if they were shot in the head or hit by a bus physically in the operating room, most of them would still die. 2: Part of the issue with having a perfectly efficent system is fire departments. I have big problems with a huge fire truck showing up to all these calls, but I understand that you have to give fire departments something to do if you want to be able to call up 50 guys for those structure fires. 3: Sure I've run on plenty of people who should have had someone drive themselves to the hospital. But I also think about the cases where the patient isn't that serious, but the family is freaking out. I wouldn't want those people driving like crazy people through the street. Safer for us to show up and transport. Also you get the advantage of those people being brought in with their meds, directly to a bed. It's pretty disruptive to the ER when people are brought POV and people have to run outside with a stretcher or wheelchair to bring them in. 4. Is the only point of EMS to get the patient to the hospital alive? Or is it to safely transport people and make them feel better enroute? I'd say that it's less than 10% of my calls where I go "this is total crap, this person is using me as a taxi." There are a lot of things we do like give albuterol to asthmatics, pain control to fractures etc that may not save lives but make people feel better. I don't think you have to go change the whole EMS system. You have to come up with a good system, backed by evidence, where the medics can show up, do an assessment, and say "this is crap, we're calling a taxi." Denver actually used to have something similar (not sure if they still do) where there was a drunk truck staffed by one EMT, who when the medics found someone who was just an intox they would call the X car and they would take all the drunks to the hospital.
  6. I haven't taken the class. But I would add that people should be aware of the burns that may not look bad, but have high morbidity and mortality, and generally should cause you to think about taking someone to a burn center. Off the top of me head: Facial/airway Children Elderly Circumferential Hands Genitals Those are classic indications. I would also be very worried about electrical burns (ie lightning) where there may be hidden internal injuries.
  7. There are two things the jump out at me from the report. 1: I've never heard of starting transport with a living patient,having them die enroute, and returning to the scene of the accident and leaving the patient there. Everywhere i've worked either the patient is pronounced on scene or you complete the transport to the hospital. 2: It strikes me as a little sketchy having someone not from the responding ambulance department drive the ambulance. Is that person covered by insurance? Do they have EVOC? It would be very messy if there was an accident on the way to the hospital and some random ski patroller or cop was driving the ambulance. These two issues may have been okay under state rules and ambulance company rules. But they seem strange to me.
  8. Couple of things 1: You have any data that patients have better outcomes in countries with a 6 year residency versus 4 years? You can assume more time is better, but why not just have a 10 year residency? I'm glad I'm not spending 6 months doing anesthesia, you don't need that much time to learn how to intubate. And most of the other stuff you do during those months don't really apply to emergency medicine (I don't whip out much isolflurane in the ER) 2: I think it's a bit insulting to call an emergency residency "vocational training." Therefore a pedatrics residency is just vocational training for treating kids, surgical residency is vocational training for surgery etc. You are also putting too much stock into what someone can do after just an internship, sure you can write perscriptions but you aren't going to get hired anywhere. 3: Sure medicine is tough, but I think if you can't learn to safely treat patients in 7 years of training (med school plus residency) you are doing something wrong. There is always more to learn, which is why many people spend another 1-2 years in fellowship. I would also remind you how expensive medical education is in the US. When you are $200,000 in debt, a system where you don't start making real money until you are 40 doesn't sound so good. 4: None of this really has to do with what's being discussed. The fact that a paramedic didn't know hypotonic doesn't have much to do with how doctors are trained in our two countries. I agree there is a big gap in the education between paramedics in the US and other countries. But I don't think how doctors are trained really comes into that.
  9. Most NYC EMS ambulances spend the day posted out on the street. So bringing ground coffee doesn't help much as the guys are spending 98% of the time out on the road. Better to just bring cups of coffee, or buy some when you are out on the street.
  10. Too much coffee and you miss a rush on the bus for a confirmed pin job. Then they send you a boss. Never want a boss for the bus.
  11. I think it depends on what your expectations are for the interventions. I don't think it takes that much training to show up and say "i know you aren't having an emergency today, but I want to go over: 1: What medications you are taking? Do you have a list of them? 2: What hospital are you followed at? 3: What is the name of your doctor? 4: When is your next appointment? 5: Are you in the process of getting home health help? No? How can we work on that? 6: Do you have a recording of your fingersticks? Pretty simple. Now it's a very different skill set to have someone show up and say "I know you called 911 because you think you are having an emergency, but I'm going to decide that you aren't having an emergency and leave you here." In the first case you are mainly providing social support to the patient and ensure that they know what they are supposed to be doing, that their medical information is gathered in a readable way. In the second case you are making diagnosis. Now the question of if that second case is doable in the US is a different issue from the first case. The big problem in the first case is funding. If you target high system users it is cost effective. But maybe not expanding it beyond that. I'd also point out that I don't think it's much cheaper to have a medic go around and do this than having an RN or social worker do it. Maybe it makes sense in places with low volumes where you could do some of this while in service.
  12. There are those of use who have worked both paid and as volunteer. This isn't a volly v paid discussion. This is a "what is the role of volunteers within an established 911 system.
  13. My issue isn't that people volunteer, it's that they are volunteering by trying to jump calls rather than being part of a 911 system. I understand that a lot of volunteer groups were there before FDNY came in, but if the community isn't saying "we need more coverage, lets have a volunteer service" then something has to change. And I think it is. Look up what is going on with FDNY and Aviation Fire Department. It seems like there are groups that are volunteer and have a decent system in NYC. Columbia EMS for the university, Central Park Medical, Hatzola. People call them directly, bypassing 911. Which I think is fine. But I don't think I'd work for a service that's operational plan was "let's listen to a scanner and try to get there first." As a side note, I would think there would be legal issues to jumping calls. I could see a lawyer argue if something went wrong on a call "this person called 911, they expected an ambulance to show up. You arrived from your volunteer ambulance, that patient assumed that you were sent and thats why they agreed to treatment from you." Not saying that the vollys are more likely to do something wrong. But from a legal stand point one could argue that you as protected as an agency that was requested by the caller. I feel the frustration for the people who are volunteering. I looked into it years ago and was annoyed I couldn't just work on an ambulance in the summers during college in NYC, that I had to either go full time with FDNY or try to get on with a hospital that wanted more previous 911 experience.
  14. My advice is to say out loud what you are doing and seeing. This is helpful for a few reasons 1: It calms you down 2: It reminds you what you are doing (by saying what you are supposed to be doing at that point in the intubation it reminds you to do it. 3: You get more time to try the intubation if the person supervising hears that you know what you are doing, and if things are going well, they know what you are doing to correct the situation and are not just staring and the esophagus. Example: "I'm opening the mouth wide, inserting the blade to the right and sweeping the tongue. I'm clearing the lips, I'm lifting to the opposite corner of the room. I see the epiglottis, I'm advancing into the valecula and pulling up. I see the cords, tube please. I have a grade 1 view (if you do), I see the tube passing through the cords. (hook up bag) I see chest rise, I have tube fogging, I have good C02 capnography. Equal breath sounds over the lungs and nothing over the belly." Sounds dumb but that's what I was doing in anesthesia and I wasn't having people bump me out of the way after 5 seconds like some were.
  15. Like I said. Are there other places in the US where there is a volunteer service that is scanning the radio and trying to beat the official 911 system to calls? In most areas of the country if you were jumping calls based on scanning the radio you'd get arrested. (Not saying NYC vollys should get arrested, just that it's a weird way to run a railroad.) It seems like it would make more sense for FDNY to say "hey, you guys have this 10 block area, you have the same computer system in the your bus as we do, you guys are 15 Victor, and we'll dispatch you from FDNY coms." That would allow them to move a FDNY truck somewhere else that it was needed.
  16. I still don't really understand volly EMS in NYC. It seems like a lot of them are in places that are covered by FDNY, where they either monitor the radio and try to "jump calls," or else they are called directly by people because they don't want to deal with the city EMS. Anywhere that you are trying to beat the 911 ambulance to a call is sketchy.
  17. I think EMS research is valuable, but it's worth remembering that the that big thing in research is having enough of whatever event you are studying to be able to detect a difference between the study group and the control group. Take cardiac arrest as an example. If you want to know if a certain drug has an effect of cardiac arrest survival it is much easier to study in a hospital than in the field. For one thing it is easier to train one or two people who sit in the hospital all day and go to every cardiac arrest than it is to train 50 paramedics in a study protocol knowing that most of them will not have a cardiac arrest in a given shift. It is also easier to record data in a hospital because there are so many people there (ie it is hard to have a medic record information for a study while also providing patient care). Finally, in a hospital there are less variables. Again take cardiac arrest. When someone arrests in a witnessed setting there is often immediate CPR, and rapid ALS. In the field you have more variables (dispatch time, arrival time, ALS v BLS v first responder first on scene, transport time to ER etc). Furthermore, since so many prehospital patients aren't going to survive their cardiac arrest no matter what because of no bystander CPR, no early defib etc, it is harder to see the difference in outcomes between say two drugs. I guess as far as ACLS goes I feel like "if it doesn't work in the hospital, where the patient has the best chance of getting lots of help from highly trained people, there is no way it is going to work in the field." I think show that something works in the hospital, then test it to see if it makes sense to have in the field. If it doesn't work in the hospital, don't even bother studying it in the ambulance. I'd also mention that one reason it is so hard to change things in EMS is that once something becomes standard of care, it is very very hard to test, because it could be considered unethical to withhold standard treatment from a patient. I'd love to randomize people who have been in low speed MVCs to backboard or no backboard, but I don't see that happening any time soon.
  18. In this case the issue with methadone wasn't so much the side effects. It's that (and this is my understanding, don't quote me) since the methedone is still stimulating some of the opioid receptors the patent still has those receptors active, so they still have high tolerance to opioid medications. (More receptors=you need more receptors activated to have the same effect). That and/or the methadone may be competing with the morphine for the receptors, reducing the morphines effect. Not sure exactly but the issue were were having was reduced response to the morphine rather than side effects. It's like when a cancer patient who is getting 10mg of morphine an hour for their pain comes in with a broken hip. You better not be staring with a 2mg of morphine dose in the ER.
  19. As others have mentioned, high addiction potential. That alone makes me wary of giving it. I don't think addicts are inherently bad people, I think genetically there are many people who have genetic predispositions for addiction. Given that, I'd rather not expose people to addictive substances if I have a choice. I'm sure that there are many cocaine users, meth heads etc who wish they had never tried the stuff. That being said it seems to work very well on sickle cell pain. Also for some reason maybe some better effect than morphine in those with high morphine tolerances. Had a burn patient the other night who was on methadone at home, morphine wasn't really touching her pain but 2mg dilauded x 2 over 3 hours did well.
  20. Went to a talk from a medical lawyer the other day. They said that HIPAA only covers those who receive money from Medicare/Medicaid. Ie Hospitals, ambulance services, doctors etc. The police aren't under HIPAA. Now there may be other state laws that cover police releasing information. And if you give info you are at risk of being sued in civil court for libel/slander. As others have said, 911 calls are public record.
  21. I think that if you are working as "an EMT" you should be able to provide that level of care. Ie you should have the equipment that one would expect from a BLS service. 02, trauma dressings, oral airways, BVMs etc. Otherwise you aren't providing the level of care that your certification entails. Secondly, in many states you are certified as an EMT, but you aren't allowed to provide emergency medical services without medical oversight/medical director. As others have said, if you are signing up to work an event, you aren't covered by Good Sam. You also don't have any liability insurance. I used to be in the situations in college, when groups like the rugby team would hire an EMT to work events but it was super sketchy. No medical director, no insurance. That's why my college started an EMS service that was licensed by the state as a non transporting service.
  22. I think the reason that they have higher C02 levels is more likely due to the fact that they will have a lower respiratory rate and/or smaller tidal volumes when hypothermic rather than changes on the blood itself. If patients are producing C02 at a similar level but are not breathing it off as well, their end tidal C02 will be higher. Furthermore, one would expect that the body would have a higher metabolic rate when hypothermic in an attempt to generate heat (like shivering), which would also be expected to increase C02. Truth be told, I don't think I would spend too much time worrying about the C02. I would spend more time looking at things like shivering, mental status, heart and respiratory rate to determine severity of hypothermia.
  23. Look, my issue is that when you are treating PEA, without looking with an ultrasound you don't know if the heart isn't beating, or if it's beating and the pressure is so low that you can't feel the pulse or if there is a pulse, but the person checking just can't feel it for whatever reason (amped up, lack of experience etc) People in asystole are dead dead. And those who are in vtach/vfib have a good chance. And while those in PEA are often on their way to asytole, it makes me very uncomfortable saying "PEA has a poor prognosis, so don't work it." In the ER we generally work PEA until it turns into something else (like asystole). The reason that the ER often doesn't spend a lot of time on the Hs and Ts in those people is they tend not to still be in PEA by the time that they get there. I respect what people are saying, and we shouldn't needlessly put people's lives at risk transporting arrests that aren't coming back. But I think PEA should either be worked on scene for a few minutes, if it turns into asystole then stop. If it becomes vfib shock. And if it's stays PEA it means that something is going right enough that the person isn't going into asystole. You can't sit there all day. Transport. At the very least there is a much better chance that there will be some sort of organ donation (kidneys, corneas) if you get them to the hospital.
  24. I agree with not transporting asystole. But your patient who is in PEA, are you sure the heart isn't moving? Or could they have a pressure of 35mHg. What about those Hs and Ts that you can't easily diagnosis or deal with in the field (tampondae, hyperkalemia etc). Sure most of these patients aren't coming back, but I think PEA should generally be transported. Asystole should not be.
  25. If the ambulance is going to pull up to a hospital then you are being brought directly to a no carry zone, so I don't think it makes much sense to have a gun in the ambulance and then have to ditch the gun between the door of the ambulance and the door of the ER. And if you are carrying in the rig it is saying "I'm afraid for my safety from the EMT/paramedic," in which case, why call 911?
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