NREMT-Basic

The only thing I have personally seen that smelled as bad as that must have was gas gangrene of the leg. The surgeon himself almost passed out. And is it just me or does everything below the incision look completely necrotic. Could this be diabetic gangrene?

Calling patients customers comes out of the corporate medicine mentality. In EMS, we treat patients. Leave the customers for the coding and billing departments.

Im not really sure of your point here. Im just saying that I have a problem with those that assume because someone is a volunteer, that they provide inferior care. As for the poster that makes the generalization that volunteer providers run 3 or 4 calls a month, its just that, a generalization. In the town just north of me, the volly rescue squad runs 5-6 calls a day on average and alot of them would put so called "professionals" to shame. If the number of calls is the defining parameter, then does a "professional" provider lose their skills when they only run 4 calls in a given shift. The idea that all vollys are worthless and inferior to their paid counterparts is ridiculous and without statistical back up. Almost every time this is brought up, I ask for someone to show me the numbers, and they never do.

I personally hate so called professional colleagues in our field who belittle the concerns of our fellow professionals. She said he finds it difficult to work with psych patients, someone else said they hate going into nursing homes. I personally dont mind working with psych patients and thought its not my favorite thing I dont mind nursing homes except those completely staffed by utter incompetents. By saying you work with your hands AND your brain, you werent being bold, you were being insulting. Theres a difference.

I agree. Right now we have one hospital out of three in my city offering paramedic training and out of the 30 spots in the class, the first 25 automatically go to the city's fire fighters because they have one year from their date of hire to become EMT-Ps and that hospital (being the corporate megalith that it is) has a contract with the FD that their FFs will only be trained by this hospital. And while I agree that its a good thing for FFs to have a general concept of first aide when they roll up, I dont know why EMS and fire are inextricably linked as one anymore than EMS and LE are. Especially when it seems like many fire departments do not do their own transporting and have to wait for transporting EMS to arrive anyway

Dust- I really am curious so please leave the guns in the holsters. On what do you base the generalizations you make about volly services? Is there some study out there that shows that volunteers are inadequately trained, poor quality providers? Does it show that they dont follow the same protocols as their paid counterparts? I know I hear you and a lot of other anti-volunteer folks (and everyone has a right to their opinion) constantly bashing volunteers and the agencies for which they work (which was supposed to be stopping on this site) and I am truly interested on what that constant bashing is based. Because someone shows up in the ER or at a scene wearing their agency's t-shirt and ball cap and blue jeans does not make them a poor EMS provider any more than the military special operators we see in AFGN with ragged beards who look as though they have never seen a shower. Im sure, in fact I know, that there are a lot of people out there who are alive and kicking because there was a volunteer service available to assist them. I just dont understand where the wholesale hatred of all things volunteer comes from. I was in an ER the other night and saw a volly crew come in, the volly paramedic up on the cot pumping the patients chest giving text book CPR. In what way was he failing his patient because he was wearing a real-tree camo baseball cap and if that patient lived, do you suppose they cared who took care of them. The strange thing was, once he handed over care to the "professional" hospital staff, it took a room full of people and 35 minutes to try to get a tube in (and I literally mean that every paid provider in that ER flocked into the room whether they needed too be there or not just to try to get in on the action. What bad habits are learned by volunteers that would automatically be straightened out by a paramedic making $8.50 an hour. All Im really saying is that I would like to see the numbers that say volunteer services give less than standard care. And is that just in the US or would you also say that Israel's MDR is also less than good at what they do because they are largely volunteer? Perhaps you are right, but I like facts and figures and Ive yet to see any pertaining to this particular argument.

I understand hospital ERs getting full and things getting backed up but there is a disturbing trend in my area lately. First, crews will bring someone on the ambulance bay, be told there is no room right now, take the patient off the cot and wheel them to the waiting room without ever being triaged or even being checked in. Every couple of hours (maybe) a nurse or most likely a clerk will stick her head out the door and say "who doesnt have an arm band yet?" whereupon half the occupants surge toward the triage window where she feverishly prints out their arm bands and tells them to take a seat. Now we all know that there are patients who will do ANYTHING to get seen for a multitude of reasons, but when I last had to take a relative to the ER, there was a gentleman sitting across from us, holding a shop towel on his arm which was completely soaked in blood which was now beginning to run down and pool on the floor around his feet. He'd been there for 4 hours. Of course I dont know why the heck he was complaining because the elderly woman sitting two seats down and coughing her head off and just about passing out every time she did showed me her wrist band and she had been in that waiting room with coughing and SOB for a little shy of 16 hours. The first couple of times I saw this scene, I thought well, its one of those nights. But then when you do get you actually back into the ER (getting a wheelchair in the hall is considered a step up from sitting in the waiting room) you can be screaming bloody murder in pain and nurses walk right by you as do Docs, techs, etc to go back to their conversation about pizza and who they slept with last night. And honestly, alot of it could be cleared up if they, as my EMT instructor said, "put some snap into it" and moved at a speed that indicated they realize they work in a trauma center and are not spending a sunny sunday at the flea market. And it could even be a little more tolerable if they would/could put the ER on diversion, but they cant because the other three hospitals in the city are also the same way so there is no where to send diverted patients. Except for people realizing that they are working in a hospital and moving at the appropriate pace, Im really not sure what the answer to all of this is. Perhaps if we went back to MDs being paid by the patient instead of a salary independent of patient care each year because they are working for XYZ Healthcare in BFE, Nebraska which is really nothing but a glorified call center, things might improve. And maybe if ER staff had to turn their photo IDs around so they could actually be seen instead of hiding them in their pocket or in some other way obscuring them, there might be a little more accountability. Perhaps we need to get a few of the more "efficiency minded" folks from here at the City to assist hospital staff in moving like they gave a &^%*. I know Im gonna get flamed by Docs and Nurses, but if you arent behaving as mentioned above, Im not saying YOU are the problem

To be fair, you havent made comments about the value of tacmed in THIS thread. Not in THIS one. But you have been known on occasion to essentially compare them with "fire monkies, vollys" and other "whackers."

redacted because it somehow posted twice.

Dust...arent you a little old to be caving to peer pressure, brother. You and I have gotten along quite well and I value you for your analytical thinking. I was not the first to assert that DMATs are tactical. I was extrapolating on our friend from Missouri whose paramedic friend says they are. I said in certain cases they might be, and in certain cases not. But what I said about the cult of the gun stands true. If hostile environment is what we are talking about, lets talk about Katrina where the literal environment itself was hostile. Lets talk about medical personnel with no defensive resources getting shot at. Lets talk about the fact that street EMS doesnt usually pack in their rations, water and supplies to be self sufficient for AT LEAST 72 hours. I dont see many paramedics from AMR or Acadian doing that. When IMERT was in the Gulf Coast in 2005, they lived off what they could carry in for more than 72 hours because the response of the Red Cross, FEMA and the National Guard was slowed. What you and that others are doing is equating "hostile environment" with getting shot at and slinging and MP-5 over your shoulder along with, what was it...ah yes "my bad ass combat medical pack. For the TacMed folks with the limited scope of vision dictated to them by the cult of the gun, its all about performing medical interventions while trying not to get shot. For DMATs (in which group I classify IMERT) its about working in situations where we are given drugs to counteract nerve gas, among other things. I dont particularly care if I am ever called a tacmed operator. I know what my job is, train on it regularly and may soon be coming to a disaster near you (well not you, but near someone). It seems to me that tactical doesnt need to involve bullets and tactical black stethscopes. To me, tactical can also include a group that can be wheels up four hours after being requested and within 10-12 hours have a field hospital set up and be complete sufficient up and including providing their own drinking water, electricity, mass producing medical O2 from ambient air (now thats cool, I dont care who y'are) and bringing along a few hundred respirators that need no electricity and nothing but an O2 tank to function. Its not just about the weapons kids. If it were, would the $200 Benchmade I carry make me a tactical medical operator? What interests me most is that I havent heard Dust ever do anything other than bash tacmed as a foolish and dangerous folly and now you seem to be defending it.

Nope. Sorry. I misread what you said. My bad. Its just my thinking that tactical EMS does not necessarily involve being armed. I would certainly think military medics of days gone by would be considered tactical, but there was also a period where, under the Geneva Conventions, medics/corpsmen could not be armed. Of course this isnt the case now. I have known some combat medics and hospital corpsmen that are some of the most heavily armed individuals in their squad, but again...I dont think simply carrying a firearm AND being an EMS provider makes you a tactical medical provider. Under some of the information and definitions that have been given, a doctor who goes along for the ride with a SWAT team and carries a sidearm for defensive purposed is not tactical, whereas as SWAT officer trained as a paramedic is. Hmmm..is it really all just about the cult of the gun? Dont get me wrong, I have firearms and enjoy using them and appreciate the fact that I am allowed to own them. But if it is just the fact that the provider is armed, then DMATs certainly are not tactical. When I think tactical, I think intended to provide a specific purpose and the case of medicine I think pre-hospital, austere, field medicine, guns or not. Under that definition, DMATs would be tactical. I also tend to think of tactical more as equipment and gear than I do a person or group. Standard medical equipment that has been modified or invented for use in the field: drag stretchers, VorTran ventilators, etc. Im sorry I misunderstood what was said up there, its just something I am trying to sort through as I look at different types of pre-hospital providers during my Masters work.

I think there is sort of a contradiction coming out of Missouri: You and your medic friend seem to say tactical involves SWAT type medicine. DMATs dont perform this kind of work, but you seem to consider them tactical. I tend to agree with the idea that they (and IMERT...which is essentially after all, a DMAT) are operational, not tactical. By the dictionary defintion, DMATs would be tactical, but by those who operate with LE, etc they would not be. This also brings up another question: Im not deminishing what SWAT does at all, but how often do they need on scene medical care, I mean statistically. If its often, then it would seem to make sense to uptrain a member or two of the team as medics and not put doctors with sidearms out there to get tripped over. After all, a doctor isnt going to do much more out there on the lawn or behind the APC than a paramedic can do.

We have subteams within IMERT that are trained to provide medical care in WMD hotzones (ie hot, warm, cold). They are trained to provide BLS/ALS in full hazmat gear. Granted they arent likely to face being shot at, but would this be considered tactical?

Which is no longer called BTLS. It is now ITLS or "International Trauma Life Support" Basic and Advanced.

Tactical seems to be the favorite word in EMS these days. I have always wondered what make an EMS provider a tactical EMT, Paramedic, etc. Is it necessary to be armed and wear armor, is it purely based on job description. Im on a state/"federalizable" disaster med team. We bring in all of our own gear and each "operator" packs in his own food, water and gear to be self sufficient for the first 72 hours. We maintain a tactical operations center (TOC) and work hand in hand with armed elements of the NG and ANG. We ourselves do not carry weapons (unless you count my Benchmade) or wear ballisic vests. Basically we come in my plane, set up a field hospital/casualty collection point, triage, treat and evac. Would we (or the other DMATs around the country) be considered tactical or is that a term reserved for armed medical teams? Would the more appropriate term be "operational?" I really am curious because tactical is applied to everything from the medical operators themselves to stethoscopes. We wear BDUs and comat boots. We are trained to respond to CBRNE events. What exactly makers a provider or team "tactical?" Thanks.

I thought I remembered reading on this site about your course that participants need to bring x amount of frangible ammunition and all tactical gear including duty weapon. Since I dont own a vest, etc, would these be provided an if so are they prohibitively expensive? And though it is not my duty sidearm, is an XD .40 allowed for use?

I think I have found the fatal flaw in the "if you dont transport, you arent EMS" argument. I also think it can be summarized in the following scenario: Im sitting in the post with my paramedic partner. We get toned out for a motor vehicle collision. We arrive and are the only medical unit on scene except for the firefighters who got there about two minutes before we did. I dont know how they do it but they always do. Anyway. We assume care of the sole occupant of the vehicle as the fire department works feverishly at disentanglement. The patient is pulled from the vehicle and placed onto the long board from my rig. My paramedic partner starts an IV, I do my assessment, and report my findings to my partner. By this time, the patient is screaming "oh my god, my leg, my leg" which corresponds with the fact that I told my partner that her femur was fx mid-shaft. Being the compassionate soul that he is, he gives our patient 5mg of MS. Oh I forgot to mention that extrication time was in excess of 20 minutes. The head fire fighter on the scene has called for med-evac helo which we can here making its approach over our heads. By this time, I have packaged our patient, a patent line is established in the left a/c, c-spine is controlled and per my partners instructions I have pillow splinted our patients leg. A fire fighter has gone to assist in landing the helo and it is now on the ground. As I pick our gear up off the roadway, my partner goes to the helo with the flight crew and gives them his report on our patient. She is placed on the helo which promptly takes off, circles over our heads and disappears into the distance. As I am finished putting our equipment back on the truck, my partner walks up to me and as he is stripping off his gloves says "Boy. Im sure glad we arent EMS or we would have had to transport her ourselves." Have I encapsulated your argument. If not, here is the short version:" No Transport=No EMS." Do I understand your position correctly? As for sitting or standing by at a sporting event: In the process of sliding into homeplate, little Tommy gets a face full of gravel, because his coach didnt teach him the proper way to slide. His eyes are unaffected because his over achieving parents have bought him a $200 pair of Oakley shades to wear while he sits on the bench most of the time, however he has abrasions and some minor cuts to his cheeks and chins and has split his lip. He is brought to you by the coach and you clean his wounds, many of which exhibit only capillary oozing. You clean him up, establish that no foreign matter is in the wounds, staunch the bleeding on his lip and tell his parents that he can probably get back into the game if he wants to or you can transport him to be examined. They refuse transport, you have them sign a refusal and little Tommy resumes his rightful place on the bench where he sits with a bag of frozen peas on his lip for the remainder of the game. Do you turn to your partner and say "Boy, I am sure glad that kid didnt want transport...we would have had to call EMS?" Whether a patient is transported to a hospital or not makes no difference in whether you are EMS or not. I think it was a faulty argument when it was made in the last thread, and it still is. The medical control physician on duty does not transport, but I think we can agree that while he is on duty he is part of the EMS system. The medical director does not transport, but...well you get the idea.

Im not sure this is very logical. If you are standing by at an event, someone collapses with a massive MI and you begin treatment and you are in the employ of a company that provides emergency medical services, then yes, you are, by definition, EMS. EMS is pre-hospital emergency medical care. The venue makes no difference, nor does whether those providers on standby transport or not. There are EMS agencies out there that do nothing but standby at special events, on movie sets (the one that comes to mind is Medics at the Movies) or sporting matches. As I said in the first part of this thread, this is just another my stethoscope is bigger than yours, Im a real EMS responder and youre not argument. Its no different than the discussions about volly departments, firefighter EMTs, etc. The only thing that makes the thread mildly tolerable is the intent of the person who started it. I work with a team that doesnt transport but we perform emergency, pre-hospital medical interventions. DOes that mean we are not EMS?

Well thats just bizarre! Ive never seen lemurs in a parade.

I was taught (please correct if I was taught incorrectly) that a elevated core temp is common in post-ictal patients. The two most recent that I have seen were both very hot (in the 102-103 range) with extremely dry skin. The paramedic not so PC referred to it as "shakin and bakin' " and both had O2 sats in the high 80s-low 90s on room air. Both sat and core temp improved in both with 12-17LPM via NRB. Can someone tell me for reference what causes the elevated core temp and low sats? Is it a CNS reponse and is it as common in post-ictal seizure patients as we were taught?

I had a patient earlier this year that was in full tonic-clonic when we got to him....seizing on concrete and jumpin like he was hooked to a car battery. Mind you none of the rescue personnel on scene was making any effort to do anything. In the process of packaging him he become conscious though not A/O. Someone came out of the building he had just been in (beer and phenytoin...yum) and said that he has smacked his head on fire hydrant as he fell the first time and this matching perfectly with the mongo lac on his scalp. For me, this bought his him some c-spine action with a no-neck and a long board. We transported him to the ER, basic supportive care, med starts a line in left A/C, no meds given per med control while en route. When we rolled in a signed him over, I left the room to write it up, came back and a PA had taken him off the board and out of the collar. When I questioned why this was done without clearing him when we had a known head contact with hard object plus the seizing on pavement, the PA said "I know a screwed up neck when I see it. He's fine." I asked him if I could quote him in my PCR and suddenly he was calling for assistance to re-collar and board the patient. Go figure. I did tell him though that he should use the hospital's board cause the paramedic wanted ours back. I didnt know anyone's face could turn that read without stroking out. He was also upset because the medic had assessed what he believed to be flail chest (though I wasnt so sure) and had written with a black sharpy on the patient's chest "possible right flail chest." They dont like that in the ER I gather from the way the PA questioned the parental lineage of the medic. In the trauma bay and in the box are two different matters, Ive learned. Another seizure pt had two episodes of emesis in our presence and then a third one as we rolled him in to ER. He started gagging, I hollared for some assistance, didnt get it, unstrapped him, log rolled him and let him blow chow on the wall paper. Some times you just have to smile and nod.

I never "light up." The only two vehicles in my agency with lights and sirens are command vehicles. Im on call 24/7/365 with a pager waiting to grab my ruck sack and get on a C-130 waiting for an explosion or a hurricane. We have no ambulances since we dont tranport 911 or non-911 and on the rare occasions we do its with someone else's rig...like one of the Nat'l Guards. Im an NREMT, but since all of the above is true, does that mean we arent EMS? We have all the same toys and do the same procedures (except more advanced than most Critical Care teams). Is this the new Im a paramedic and youre a stupid EMT my schmeckle is bigger than your schmeckle argument? I vote with Dust on this one. The DOPH in most of the states I know of say those NET EMTs are licensed by the same EMS division as the trauma chasers. A general big old -25 for even having this conversation.

I dont have a problem with practical jokes, as I said, and I thought that the weather report on the tac channel was quite funny and will remember it. But when it causes embarrassment or harm to someone, I just dont happen to find that funny, which is what I said. As far as the female firefighter, you're right...it did take awhile for things to normalize after that. But I can assure you, she can handle her own with the best male FFs out there and has no problem carrying her gear or dealing with the other aspects of her job. And when I say that I am not for things that embarrass someone, I mean in a really bad way. The weather thing is funny and if anyone has fallen for it, Im sure they were a little red in the face afterwards. I learned early on not to be the first one to go to sleep or to fall asleep in a recliner in the lounge while watching television. Thats just asking for it. I dont have a problem with having fun on the job, I just dont happen to agree that getting pranked is the way to see if you can handle the job. Im pretty sure thats what practical exams are for.

Hazing and initiation "rituals" are against the law in almost every state and as with most things like this it is usually up to the victim of the act to determine if it was funny or made them feel embarrassed, scared, etc. Virtually nationwide there are laws against this kind of behavior. Im not against jokes and having been the new guy on several services, Ive been on the receiving end of many myself. What you fail to see is the difference between a joke, and hazing. Hazing is illegal because it is legally defined as behavior that intimidates, embarrasses, injures or frightens the person who is the brunt of such behavior. Do those of you who advocate it feel good about causing such feelings in people? Do you somehow imagine that filling an ambulance with smoke from a smoke machine and then sending the new guy in to retrieve equipment makes him "part of the team?" Not to mention the fact that your supervisor should fire you for the damage that liquid smoke machines (which produced an oil/soap based smoke) is going to contaminate the inside of your rig. So now you not only advocate hazing but vandalism of the property of the company you work for? Im guessing these are the same people who say they will shock an unruly patient with the LifePak (which by the way, I challenge anyone to come forward and prove that they have ever done, though Im sure no one would because it is considered aggravated battery by means of a weapon). We get all the whiners here all the time griping and moaning about how EMT-Basics shouldnt be on rigs, they have no place in EMS, etc. I say the only people who dont have a place in EMS are the chuckle-heads who think its funny to embarrass or scare someone. I work for an agency that is run directly by the Illinois Department of Public Health and our regulations expressly forbid this kind of behavior and make it clear that the guilty party will be penalized (up to an including being eliminated from the agency) and reported to the DOPH EMS division. Usually on this board, when we talk about newbies, we are talking Basics. Most of the Paramedics I know on this forum would go ballistic if a Basic did this to them. I see nothing wrong with practical jokes and while the joke of the newbie being told he has to give a weather report on the tac channel and I personally think it is harmless and actually funny, there are a lot "Noobs" who wouldnt. Here's a good test: when your getting ready to play that jokes, think about whether it could potentially harm or embarrass that new employee to the extent that he feels uncomfortable coming back to work for his next shift. If so, you are probably in violation against the various state laws against hazing. On the flip side of the coin, remember what they say about paybacks. You may well end up on the down wind side of a "joke" much more intense than the one you yourself perpetrated. I know a female firefighter/EMT who was the victim of a particularly nasty little "welcome to the club" prank which all the the prankers (who happened to be men) thought was hysterically funny, until the female fire fighter/EMT who had been on the receiving end sent letters to the significant others of the men who had played the joke on her saying she was having an affair with their husbands, boyfriends, etc accompanied by polaroid photos she had taken of herself sitting on the various firefighters laps with her arm around them and herself wearing those firefighters' turn out coats with their names on them. Oops. But hey, what the heck. Its all in good fun, right?

I have not seen this particular disaster functions "matrix" organized in this way. I assume that it is not organized by level of importance or priority. If so, to me, it seems a little skewed and out of order. As for those who advocate explaining or not not using acronyms at all, I agree, though Im often guilty of it myself out of habit. This is a basic NIMS/ICS (see there I just did it :shock:) concept which falls under the category of using "common language