croaker260

Agreed, are you taqlking about fractile analysis? We track this both through our charting software (ESO) and through Physio's Lifenet system.

WOW, this thread has deteriorated faster than a bacterial meningitis patient on immunosuppressants. Lots og good information available here, and a lots of chest thumping and name calling and childish dialog too. Such a shame. Anyway, I think my solution (below) is adequate for this very common situation, and it doesn't involve the SCOTUS to determine constitutionality.

****** SPOILER ******** I think that it falls closer to a prequel than a different story line in the same universe......., Its pretty obvious that the ship the Prometheus finds is the same ship that is a "derelict wreck" on LV-426 in Alien and Aliens . I am thinking that we will get a glimpse at the origin of the Alien species as well as some new horrors for all mankind.

The LEO isnt dealing with it because he knows what you are learning....that legal or not, right or not, this is a PR and a consitutional minefield..if you get into a confrontation there is no real winner here. So, consider this: 1- Stable or not? If stable...do your exposing in the rig. If unstable, your not going to be on scene long enough anyway to give the camera-douche much opportunity. And you can always put your plumbers crack between him and the patient while you take care of her. 2- No place to move her? Have a couple of FF, LEO's, or what ever hold up a sheet or yellow blanket while you do your deal, then cover her up when your not actively assessing her. Afterall , covering her up is indeed treating for shock. And in either situation you havent directly confronted the douche, just deprived/limited his the opportunity to add to his spank - bank.

One mans tasteful tattoo is another mans obscenity. Who decides? How can you decide? Keep them hidden, and ink up all you want. If you dont want to wear a long sleeve shirt to cover your sleeves..then dont get sleeves. Period.

Every culture is different social views on tatoos.... But since we are providing service accross multi-cutural barriers, we must be cognizent of the effect of our appearance. If our appearance impedes on our professionalism and our ability to build trust withthe patient..then the answer is Yes. And Yes I have tatoos, yes I served in the military, I actually am VERY pro tat and body modification. Just not visible in the uniform for reasons previously stated. If you want to be a health care professional, then look the part. And this is not specific just to tatoos.

OK, I am very pro TAT... for a variety of reasons. BUT I am opposed to TATS visible in uniform. Now this was discussed heavily in a previous thread... link to said thread here: http://www.emtcity.c...os-miami-metro/ This is a qoute from that discussion, and my opinion hasnt changed. This is my personal philosophy....keeep in mind I LOVE body art, and have some (non-visible) myself. But I realized that this is not at all about freedom of expression. It is only part about getting accepted as a professional. Our appearance is a TOOL to do our job, just like our hygiene, and the cleanliness of our ambulance, and our demeanor when we interact with patients. Just like our monitors, our drugs, and our knowledge base. Cover up the tattoos, you present a better appearance. Dont like it? Go be a garbage man, a carpenter, or a bus driver, or some other profession where public trust and public image isnt an issue, or chose a profession is so arrogant that they think it doesnt matter ( can think of a few....). Because trust me... with what we do... it does matter. Steve.

Heard of it, Seen the videos. Never seen it used. Would be interested in hearing more input. Then again, we intubate here during CPR with a bougie and dont have a huge need to them We have Kings for our rescue airway.

Well, I certainly dont disagree agree with you... The risk benefit equation for me doesn't equal out with ketamine as it does with say good ol fashioned diazepam or Ativan.. (I dont like haldol, but that is a different discussion)

Pretty much what I would have suggested. Specific gravity combined with a "Log" of reported bathroom breaks. I dont know if you can do volume assessment on that large of a population with limited resources...but a self reporting mechanism would be helpful.

Uhm, perhaps I am way off, but who would use Ketamine for sedation of a combative patient if they were not going to take more advanced airway intervention in the first place, especially with the dissascociation effects . I am missing the logic here. Seems like using the hammer on the wrong type of nail....

KIwi, The ALS/BLS is based on the level of the call and evaluation provided, not who who did the call, though if the call is ALS, but you only have a BLS provider, you cant charge above your level. This has been exploited in the past. I k ow of several services that tried to mandate a paramedic in the back on every call to try to bill for an ALS-I billing..... it worked for a while but in the end they got hit...HARD....with penalties. I think one private service CEO was faced with fraud charges. Ironically it was their own employees who turned this in. There is a somewhat controversial exception to all of this too: Apparently in 911 systems with formal validated EMD systems, if a call comes across as an ALS type response, you can bill at the ALS base even though it may end up as a BLS B.S. call when you get there, the idea is that the complaint warranted an ALS evaluation. I am not sure if this "rule" is still in place, but it was two years ago when we looked at it in my agency. I also know that there were several agencies that took advantage of this too and also got slammed. Thats the problem with our insurance driven reimbursement model...its 99% based on transport to the most expensive place in health care (The ER), does not allow for alternative destinations, and is so complex that even common sense solutions become mucked up. I am not sure if "performance based" reimbursement would be better than our current "Transport /procedure" based reimbursement, but its pretty stupid as it currently is.

Grady has been around for a long long time, and hale from the "glory days" of Balls to the wall, duct-tape and a prayer EMS. In general they have a good name, though they are a private and all that entails. A great high volume place to start, but I have know idea how long your longtivity would be. Now as to your comment on fire department first responder medics dictating EMS...it happens far more often than you would think, particularly where there is an FD based first responder and a private transport agency ..and the contract for the transport agency is dependant on the FD's good will. These systems tend to be the poster childs for the IAFF Bully-thug stereo-type that we are all familier with. There are a lot of these type of systems in California, Vegas area, and a few other places. One that comes to mind is in Prtland as well, though this information is third hand. In general, these are dysfunctional systems that benifit the FD far more than they do the patient.

We are carrying it too, also because of the Etomidate shortage. We also carry dilaudid, Morphine, Fentanyl, Versed, and (when we can get it) Valium.

Uhm, could you be more specific? We have a generic crush injury protocol....

What he said! Seriously, anesthetic doses for Versed only intubation approach 30 mg or more. We dont even carry that much on a rig. Far better to use the right drugs for the job, than to use a crappy one in large doses. Of course, if all you have is a hammer in your tool box...then everything is a nail...

Uhm, not that I am taking credit for this, but did anyone bother to really look at my links? If I understand the original post, it wasnt as much about predicting poor outcomes as it was about honoring wishes. Anyway, I was very impressed with the KCM1 Compelling Reasons Approach... comments?

You know what they say, there is no such thing as an original thought.... This was discussed in detail at my agency before. It may be time to discuss it again... I am qouting the KCM1 systems policy to with-holding rescusitation... It is this LAST LINE that is the most interesting... A single sentance that may (eventually ) improve how we with-hold care and provide dignity.... The Compelling reasons part of this process : I think you may get some interesting reading off of the "compelling Reasons" protocol that the KCM1 system has had in place since about 1998. It takes the concept of DNR/DNI past the protocol level into the common sense and humane thinking level. http://www.annals.or.../9/634.full.pdf If you can find the associated article in a 2006 issue of JEMS, it is a very good overview of the program itself too.

Well, completely different use, but one of my (many) FTO books has a list of hand signals for "non-verbal" prompts for the FTO to help his rookie through the call when needed without taking over the call and keeping the learning going.

Dwayne had the most mature and reasonable answer on here. Considering that I have dated more than my share of strippers, psychos, and fellow medics/nurses/cops/soldiers... (and my sister has dated more strippers than I have...but that is a different story.... ) I can spot crazy have a mile away...and this story has Jerry Springer Crazy written allover it. If you continue to associate with this dude, then you will have only yourself to blame for the drama. If your GF continues to associate with this dure, then that is not your fault, but if you continue to date her after the drama starts..and It will.... then that IS your fault. Give her the benifit of the doubt andallow her to make a mature adult descision..because she is legally (if not in practice) an adult. Then let her descisions dictate your response. And above all else, conduct yourself with class and dignity. If the situation drops to the level of the nearest trailer park...go find a better situation. There is always one waiting. Trust me.

There is an expression in EMS: "Once you have seen oneEMS system.... You have seen ONE EMS system". Put another way, every system,company, agency are all dramatically different in their approach to almost everything. This includes hiring. Your best answers come from current employees, or better yet the person in charge of hiring. Thats said, I personally know many female medics (we are about 40% female at my service) including at least 3 who have been in this job for decades...yes decades... in realtively busy 911 systems....and weigh UNDER/about 100 pounds and barely push 5'2 in height. Of course they work out regularly, dont smoke, etc. And yes, they do their own lifting, etc. If you pass or fail, it wont be about your sex or stature...but about your attitude, preperation, and planning. Just my thoughts...your milage may vary.

http://www.adaweb.ne...ZAc0=&tabid=798 What are your services SOP or Protocols on declaring Clinical Death? Who is allowed to declare death? All EMS providers in the system, BLS or ALS. Transport or non-transport. Do you obtain EKG tracing? Not on obvious deaths. If so, is it on all Patients, no matter the apparent cause of the death? N/A

Your asking the wrong question...Can they managege a breech or placenta previa better than you? In our area..the answer is yes. Your area may be different. Our local ERs can (and have) done emergent and peri-mortum C-sections. I didnt say they like it. But they can.

Well , our system is a bit different. The local hospitals are large enough that they have their respective areas covered 24/7. Back when one hospital didnt have 24/7 cardiac or neuro coverage, then we simply didn’t take them there for those emergencies (IE STEMI or STROKE). If the patient insisted, well then you can see what our polcy states. It has worked well in our system. Most patients listen to us when we explain things. Our admin doesn’t play the musical hospital game. If a hospital wants to receive specialty patients, they do so 4 / 7 or not at all. Not every system does this and your own mileage in your system may vary depending on your situation. Regarding the other comments regarding imminent Birth: The only time you can tell if a delivery is complicated or if a baby is compromised is AFTER shit begins to hit the fan. Remember that 10% of newborns needing meds and intubation had none of the classic warning signs prior to delivery. It is perfectly appropriate to take a imminent delivery to the closest emergency from staffed with a board certified ER doc in this situation. if the baby delivers in the process, great. If problems develop, then you are ahead of the eight ball. YES, an EMT-B can deliver a baby in a pinch. Just like they should be able to manage an airway. Until you get into a failure to progress, or a breech baby who has the cervix spasming around its neck, or shoulder distocia? How about uterine rupture in an unintended VBAC? This may surprise you but both ER docs and family practice docs both train to deal with this, not just OB docs. And for good reason. But even paramedic programs do not touch on most of this, much less EMT courses. The list goes on and on and on and on why the plan should be to get the mom/baby to the closest ER to stabilize and then transport after stabilization/birth. We just had a local pair of midwives.. (people with over 1500 live births each) lose their liscenses for being too cavalier with these situations (some deaths resulted) , thinking they could handle this. And this was with pre-screening and lots more experiance that 99% of the people n this forum would have. And things still went wrong for them. Why do we think we should attempt this when we have other options? Its all fun and games until you get over your head and you realize that you just passed two other hospitals because you “thought I could handle it”. It is this exact situation that prompted the creation of the EMTLA laws 30 years ago. THIS EXACT SITUATION. If you feel that strongly about it….You can always wait and do the transfer to the hospital of choice after the situation is stabilized.

There is a general guideline for two minutes of uninnturuped CPR for 2 minutes that is dependant on a couple fctors: 1- Its a recommendation for EMS providrs, not in hospital. Thereforee in-hospital PALS instructors may not be familier with it. 2- It is indicated for estimated down times in excess of the 1.5-4 minute mark. for down times LESS than that, the immediate defib is indicated. This is from the PALS section of the guidlines and is secifically pesented as a consideration in pedaitric arrest. Copy of all the circulation "science behind the changes" issue is available here: http://circ.ahajourn.../18_suppl_3.toc So my opinion as a PALS instructor, without being there to observe the performance, is that its not a critical fail at all.