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Richard B. recently posted this topic. http://www.emtcity.com/index.php/topic/16362-h1n1-update-from-new-york-state/page__hl__H1N1__fromsearch__1 This subject is now a heated discussion on many other forums for many other health care professions. NY has made it mandatory and there is now big controversey in that state amongst the health care workers. Health Care Workers Protest Mandatory H1N1 Vaccination http://www.cbsnews.com/blogs/2009/09/29/taking_liberties/entry5349581.shtml September 29, 2009 11:28 AM Health care workers are planning to take to the streets Tuesday at a rally in front of the Albany, N.Y. state capitol to protest mandatory vaccination. The rally is intended to call for "freedom of choice in vaccination and health care" and to protest mandatory vaccination for influenza and the H1N1 swine flu. "This vaccine has not been clinically tested to the same degree as the regular flu vaccine," Tara Accavallo, a registered nurse on Long Island, told Newsday. "If something happens to me, if I get seriously injured from this vaccine, who's going to help me?" While physicians, nurses, and medical technicians may not be known for their willingness to march on state capitols, a recent New York Department of Health requirement has sparked an unusually intense response. The August 13 regulations say that all health care workers who "could potentially expose patients" must be vaccinated for influenza by November 30 unless it would be "detrimental" to the recipient's health. (Any reprieve would be temporary and last only until injection with the vaccine would "no longer be detrimental.") This raises an obvious and important question: Under what circumstances can government officials order mandatory vaccination? And could the general public be ordered to roll up their sleeves for injections, even if there might be side effects beyond a sore arm or mild fever? The concern in New York also comes as skepticism of vaccination in general seems to be on the rise. First, some stipulations. Let us stipulate that that routine vaccination has virtually wiped out, at least in developed countries, once-rampant diseases like mumps and whooping cough. The horrors of smallpox -- variola major, which slays about a third of its victims, and the less deadly variola minor -- have vanished, thanks to a successful worldwide vaccination campaign. Even where mandatory vaccination can cause complications, the overall side effects in a population of millions will almost certainly not be as harmful as the infectious disease itself. On the other hand, let us stipulate that not all vaccines are created equal; some may be safer than others. Out of lack of knowledge or fear, officials may order mandatory vaccinations when the vaccine has not been proven completely safe. And we should remember that the history of our own government when it comes to vaccines is not without its low points (more on this below). Perhaps the best overview of the legality of mandatory vaccination lies in a 2005 report prepared for the U.S. Congress by the Congressional Research Service. It notes that while the federal government does have the power to order quarantines, public health has historically been the states' responsibility. The CRS report adds: "Generally, federal regulations authorizing the apprehension, detention, examination, or conditional release of individuals are applicable only to individuals coming into a State or possession from a foreign country... Any federal mandatory vaccination program applicable to the general public would likely incorporate similar jurisdictional limitations." Much more to read at: http://www.cbsnews.com/blogs/2009/09/29/taking_liberties/entry5349581.shtml

In the age of practicing Evidence Based Medicine, I am curious how everyone guages if CPR is being performed effectively? I would also like you to document your answers with evidence and NOT anecdotal stories. For example, Do you check Femoral Pulse? Do you use EtCo2? Do you use an Art Line? Do you just make sure proper rate and depth are being performed? I will start the discussion with saying my practice is to use Proper Rate and Depth along with Waveform EtCo2. Femoral Pulse Checks are useless and should not be done. I have the studies to back this up, and will post them when we get some responses. Thanks in advance. JW

I figure we may as well have a thread to express our disgust for this new show in before it is cancelled. Video Link: http://www.emtcity.com/index.php?app=videos&do=view&id=10 - Admin http://connect.jems.com/forum/topics/no-heroes-as-nbcs-trauma-fails No Heroes as NBC's 'Trauma' Fails to Deliver - a JEMS Review Posted by JEMS Web Chief on September 27, 2009 at 8:47pm A.J. Heightman Editor-in-Chief, JEMS The new series Trauma premiering Monday night is being billed by NBC as "the first high-octane medical drama series to live exclusively in the field." The show's Website says it's "like an adrenaline shot to the heart, an intense, action-packed look at one of the most dangerous medical professions in the world: first responder paramedics." Unfortunately having had the opportunity to view the pilot in advance of its September 28 premiere, I think the series is ripe for "Do Not Resuscitate Orders". I realize that, having been raised watching the epic Emergency! TV series, I have a bias for shows that portray emergency personnel as professional in appearance and attitude, disciplined and ethical and compassionate to their patients. I also realize that it's 2009 and writers and producers like to inject sex into every episode, and have characters with cocky, rebellious 90210ish cast members who bring a host of personal problems to work, but this series bubbles over with a cast that should be stationed on Wisteria Lane, not the streets of San Francisco. The premiere of Trauma doesn't begin with a well-dressed crew checking their drugs and equipment before their first run. It starts with the sights and sounds of the boyfriend/girlfriend crew having sex in the patient compartment of their rig. Then, before you can get the words "I can't believe it" out of your lips, you hear the dispatcher (who obviously knows the way the crew starts their shift), tell "Naughty Nancy" Carnahan to button her blouse and respond to an emergency call. You're next brought to the rooftop resuscitation of an electrocuted patient who gets a helicopter response in the middle of the city. It's here you're introduced to the wacko of the show, helicopter paramedic Reuben "Rabbit" Palchuk, a raucous dude with an attitude as big as his helicopter. The show's promotional hype says Reuben "oozes bravado to match his talent, but there's a hint of vulnerability in there too... which charms the panties off all the girls. They don't call him "Rabbit" for nothing." Hold on, it gets worse. Turns out, "Rabbit" is also a sexist who personally selects the male member of the sex crew to accompany the patient because he doesn't want a female medic in "his" helicopter. Don't be mad, be sad, because, when the chopper lifts off the roof, instead of departing and gaining altitude like every well-trained aeromedical pilot in the nation does, the pilot of "Angel Rescue 2" swoops down between the skyscrapers and collides with a sightseeing helicopter that's also flying between the buildings. Everybody on board the choppers dies except for (you guessed it) "Rabbit". Reuben the rebel lives to fly another day. The show flashes forward a year and "Rabbit" returns to work cockier than ever and equipped with a new, post-traumatic "I can't die" attitude. He takes his new, young, petite, ex-Iraq war chopper pilot on a high-speed, reckless ride down the hills of San Francisco, telling her it's like the scene in Steve McQueen's movie "Bullitt". "Bullitt"? "Bullitt" was released 1968, 41 years ago. Even I don't remember Bullitt! If Rabbit's law-breaking ride doesn't ruin our image enough, he proceeds to rip the door off a drunk's car as the man attempts to get in his parked car. Then he cons the inebriant into believing the incident was his fault. Don't fret though, because Reuben, ever the gentleman, strolls into the nearby bar to retrieve a pitcher full of ice for the man to put his amputated fingers in. Just when you think this show can't get any worse, you're taken to a corny multi-vehicle car-versus-gasoline truck MCI (caused by a text-messaging jerk), and forced to watch some of the most unethical EMS behavior you'll ever see. First, "Rabbit" lands in his chopper and waltzes up the highway and hears the text-messaging patient whining that "he wants to go in the helicopter". Without skipping a beat, Reuben injects him with Versed and walks away. Then, stoic Cameron Boone, a black paramedic who carries emotional baggage (and a strained marriage) after witnessing his friends die in the aeromedical crash, encounters a pretty blonde patient with a minor arm injury and "re-triages" her so she can get a ride in the helicopter with him. While "Rabbit" gets set to ride shotgun and leave Cameron alone in the back of the chopper with the target of his affection, his rookie helicopter pilot, Marisa Benez, welcomes him to "Booty Airlines". There is a happy ending to this magical series premier though. Despite detesting "Rabbit" for his bad attitude and for surviving the crash that killed her boyfriend, she closes out the show by hopping in bed with him. Johnny and Roy, please don't watch this show. Stop by my house and we'll do shots of Ipecac instead. A.J. Heightman is Editor-in-Chief of JEMS

I bring this up because I see so many Parmedics and especially basics that do not at least move clothes to do lung and heart sounds. Surprisingly I see many that just feel over the clothes for trauma. If you do not put your stethoscope on skin you fail as a provider. If you do not at least expose the area of complaint for a trauma patient you need to get out this profession now or get your money back from the school that failed to give you any training or education.

If you are not watching this documentary on PBS, you are really missing something good (for those nature-lovers among us).

I'm EMTinNEPA. I, like many others, have one foot out the door at a certain other EMS forum, so I came here on the recommendation of some e-friends. Anyhoo, I'm 21 years old. I've been an EMT for a year and a half and I'm a paramedic student. Upon completion of the program, I will have a certificate of specialty in advanced life support. After that, I plan to take the CCEMT-P course and complete an associate's in EMS. I work for a private service and I am proud to say that, even if 46Young and I will probably bump heads about it (wouldn't be the first time and won't be the last). I also serve as an adjunct instructor for my alma mater's EMT program. Blah blah blah, listing credentials, look how good at EMS I am, blah blah. I'm single with no children and live by myself. I'd like to have a family one day, but I don't realistically see that happening. I'm cynical, misanthropic, and a relentlessly sarcastic observer. I'm also a former Mass Comm major and a former Music Ed major. So that's me. If my posts do nothing else I hope they make you think.

Greetings from the wild, wild west. I finished a 24 hour shift a couple of days ago. This is an easy day in the life of an AMR medic because it was not a 48. As you will read, sometimes it’s not about the length of the shift. The shift began badly. I confronted an acting supervisor about an incident on the previous shift. I tore him a new one. The good thing is 20 minutes later, he followed me out to where I was doing my rig check to explain himself. I took it as a win for two reasons. First, he cared enough about my opinion of him to actually try to make it right, and secondly, I had made my point. The first call of the day was a minor MVA. My patient was the restrained passenger of a car that had been rear-ended. He was complaining of neck pain – C1-C2. Routine. Stable patient, full immobilization and to the hospital. Second was a “non-emergent” transfer from regional hospital to big city hospital. The transfer was ICU to ICU. I get to bedside and my patient has no eye-opening, responds to voice with moans, is on a 20 mcg/min NTG drip, contracture of the left upper extremity, spasms of left upper and lower extremities. BP is 146/90, HR of 101, respirations of 27 per minute. History of multiple sclerosis and hip fracture. Patient has three peripheral IVs including an EJ. This is a “stable” patient going by ground? The nurse explains that the diagnosis is baclofen withdrawal secondary to possible pump malfunction and the patient is going to neurological ICU. She had started the patient on 40 mcg/min NTG to control BP and HR. Patient had gone down too much, rate had been adjusted to 20 mcg/min and symptoms were being controlled with Ativan. The last time I had questioned the stability of a patient for non-emergent transfer, I had been told by the Dr. that if he didn’t think the patient was stable enough, he would have called for air. My supervisor had told me to shut up, document my concerns, and transport the patient. I told the RN that I did not carry Ativan, and the only benzo options I have are Valium and Versed. She said that would work. I don’t have an infusion pump and told her I would have to take hers. She was upset about that. I told her that I would not take the patient without the pump (thank you St. V’s clinicals for making sure I am comfortable with the operation of the Alaris). She goes to confer with the higher ups and comes back with some ad-hoc paperwork pulled out of someone’s butt and it’s all good. I still have a hinky feeling about the whole thing, but it isn’t till well after the transport when I do some research that I find that if the Dx was on the money, the patient would be HYPO- not HYPER- tensive. Be that as it may, I load the patient and we head 100 miles across the desert. To make a long story short, the details of which include delays across the dam, bleeding air out of the pump lines several times (it’s bumpy and at one point, the NTG bottle flew off the stand), emptying my drug box of benzos, considering upping the nitro, being misdirected by staff at the destination hospital not once but 3 times, assisting the RN at the destination hospital switch out incompatible tubing and no food for 6 hours, we finally arrive back at the station (after returning the pump to 2nd floor ICU and replenishing my drug box) at 8:00pm to find the crews had had their butts kicked, running about 20 calls in the time we were away and that we were up for the call. This is two crews mind you, with a couple of the calls being handled by a move-up crew from the sub-station. Usually, when a transfer crew comes back, they drop to the bottom of the rotation. My EMT partner objects to us being up, but I silence her, telling her that rough as our transfer was, we had still had an easier time of it then the crews in the city. I get to sleep about 10:30pm to get toned out at midnight for a difficulty breathing out of town, part of our coverage area, about 20 minutes out running code. Female patient, 73 years, history of CHF, COPD, oxygen dependent. Patient has cellulites bilateral lower extremities extending to the knees. I feel the heat radiate off her legs, treated 2 ½ weeks ago for an unspecified infection. Pneumonia or pulmonary edema? Quiet in both lowers, sounds like snot in the right upper. I’m thinking diminished because of the COPD and snot because of pneumonia? Fire first responders had started A & A via SVN – I hate that. It’s routine around here – they think any difficulty breathing needs A and A. Until we get her in the ambulance, it’s their patient. We load up the patient and as we are lifting her (she’s a hefty one – blue bloater) and there is a gurney “incident”. My partner is about 5 feet tall, weights 100 lbs soaking wet and she was the leading contender in the station “who goes out with a career ending injury” pool. She had been back at work for about 4 months after 6 months light duty from her last back injury. All I know at the time is that we are lifting and suddenly the gurney drops. I am at the dumb end (cause I’m a moose) and she is operating the legs. I control the descent of the gurney; patient barely realizes there was a problem. The patient was sitting straight up and blocking my view of my partner. I don’t know what happened. I peer around the patient, make eye contact with my partner, she nods and we lift again. This time she goes up without incident. Gurney is not as high as I like it but my partner does not want to try again. I lift the dumb end into the rig, go around to lift the other end (cause I’m a moose) and the fire medic is already lifting. Totally against company policy, but I raise the legs and off we go. We are busy in the rig. I am treating pneumonia, the fire medic is treating CHF. She got about 250 mL, I checked lung sounds, shut off the fluids and we continued the CHF route. Fire medic was right, I was wrong. (This is only my 4th or 5th CHF patient in a year. It’s not the problem here in AZ like it is in WI. I guess that’s why we don’t have CPAP on the rigs.) PS.. sure makes that A & A treatment look good huh? We get to the hospital and my supervisor opens the ambulance doors. WTF? Fire medic has disappeared. Supervisor and I transfer care, I take care of the paperwork and return to the rig. It’s at this point that I become aware that my partner was taken to ED room 7 in a wheelchair. She had called the supervisor while driving and told him she was hurt. I am trying to make this really long story short. Bottom line – she is in CT scan, pumped full of dilaudid and muscle relaxers and telling the supervisor I dropped the gurney. I wind up waiting at the hospital until 3:30 in the morning while he does paperwork because we can’t get an EMT to man the rig and he is now my partner. When he is ready, we return to the station. I write out incident reports and try and figure out what happened. Opinion at the station is about 80% that the girl is looking for the injury and throwing me under a bus. I’m not so sure. I am filling out the paperwork to request evaluation and remediation if required of my lifting technique. I am more upset about this incident than anything else that has happened – or will happen – this shift. (yes there is more – I am so grateful to those of you still with me on this.) I don’t make it to sleep when we get toned out to a MVA on the highway. It is about 5:00 am. No idea what type of MVA or injuries if any. I ask my supervisor, who’s driving and is the senior medic if he wants patient care. He says no. I do the standard calculations of enroute times vs. launch times on a rotor and decide against a rotor. (20 minutes there – 20 minutes back vs. 35 minute ETA plus 15 to ED for rotor unless they are lying, which has happened.) On scene, I see the rear axle of a vehicle in the northbound lane. The rest of the SUV in on its roof about 100 yards south in the ditch. First responders are log rolling a patient. The fire medic is palpating the back. The fire medic is relatively new, excellent with medical, tends to freeze up on trauma. He’s the guy that was puking his guts out on the scene a few months back when we ran on the guy tortured with the box cutter. No O2 on the patient. EMTs directed to put a hi-flow NRB on the teenage female. She is messed up. In and out of consciousness, 4% partial thickness burn on right thigh, major lacs, abrasions, etc. etc. Scene time 9 minutes then running code to the hospital. Initial BP 128/70, HR 80. 8 minutes later BP is 103/58 and HR is 113. I got a BP cuff compressing the bag running NS into the I/O and a second line in the right AC. Bottom line – 2 16 year old members of the swim team going to practice. Both moms in the car following. SUV hits left guard rail, over-corrects and rolls. Both occupants ejected. Driver lying partially under the SUV, dead on the scene. My patient has basilar skull fracture and other injuries, flown out to trauma. I get back to the station at 7:30am. (no sleep except for 2 ½ hours and up since midnight.) Last but not least – I was supposed to be off at 8:00 am. One of my co-workers is doing FTO testing this am and was informed it would be from 8:00 am till 10:00 am and had asked me to hold over for him. He is a great guy and I am a big fan of improved education in the field. If you remember how I was thrown to the wolves when I started this job you will understand why. I surrender my rig to the on-coming medic and take over the rig my friend was in. In the minds of some of the pea brains that work here, this puts me up for the next call. I refused. It didn’t do me any good tho… the FTO testing started at 9:00 am and my friend was not done until 1:00pm. I ran calls. Thank you so much for reading this. It is an important part of my debriefing and I appreciate any comments you may have on any of this. Call me crazy, but I still love my job.

Welcome! Your first post gives much hope to your time here being very valuable, to you and us. Thanks for sharing your thoughts. Dwayne

*Gets his 'reputation finger' limbered up*

Ah, I didn't realise it was changed. I thought it was always that way. Good idea.

It only lets you give one negative in any 24 hour period, so it shouldn't be easily abused.

I found some interesting stuff while googling asthma, thought I would share. Sorry if this is a repeat, tried to search and got 200+ results. Stress Cardiomyopathy Can Occur with Routine Procedures Full Article: http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/13429

I recently transported someone with tako-tsubo syndrome. I obviously did not know what it was at the time. The call came in as a life-line (fallen and can't get up buttons) activation, that my dispatchers treat as BLS response criteria. Luckily the patient had a print out about what it is, because she couldn't explain it. She was c/o nausea/vomiting... no acute distress upon our arrival. It was my partner's tech and he went about the business of interviewing the patient and getting vitals and all that. I was reading the material and getting medical history and the med lists... Based on his assessment, my partner was treating it very BLS... He got her on the stretcher as I started reading the handout. We got half way out of the building as I got far enough into the pamphlet that I started to worry. This could go bad, and it could got bad fast. While the majority of people with this syndrome live a long, uncomplicated life after the first attack, and rarely have another one... when they do... they don't do so well. By the time I realized how bad this could go, we were far closer to the hospital than our ALS counterparts. And the last thing I wanted to do was increase the anxiety on this lady. Based on what my partner gave for a report to the hospital, they were going to put us in an over-flow room (I do not blame my partner... how was he to know? I had the info, and I didn't want to raise the warning bells because of the possible anxiety). I quickly corrected this so that we could deposit into an acute telemetry room. Within 15 minutes of putting our perfectly normal looking, non distressed patient on the ER bed, she was unresponsive on the bed with her eyes rolled back, body rigid as a board. I got another call right after that and did not get a chance to follow up on her. Scary...

At the same time you need to start thinking outside the box, yes other professions have been depicted in an unkind or unfair light as well, there is no doubt about that, however when they have protested it just may not have caught your eye. Not all computer technicians wear short sleeved shirts, clip on ties, ill fitting black pants with white socks (some wear logo’d polo shirts…) and even lawyers have complained about their inaccurate caricatures, not all bankers are crooks (last one probably hard to prove). The point being, yes TV is just TV, but this show has obviously touched a sensitive spot in most first responders for the very reason that WE ARE ALREADY so widely misunderstood by the public. Is that exclusively our fault, I think salient arguments could be made for both positions, however shows like this certainly don’t help the fight to correct these misperceptions. I do believe a difference can be found on the positive side and not the negative, in that most of the other groups portrayed on TV have some type of PR spokesmen (women) who puts out in the public view a positive spin of the profession which acts somewhat to counter negative stories or images. Unfortunately I can’t think of any such group that has run a successful campaign for EMS. Always IMHO Be Safe, WANTYNU

Did you miss the part where I referred to the person posting who is claiming to be in EMS and believes it is acceptable to drink and have sex in an ambulance? That is not about a TV show. I would hope most do not get into this profession just because of "these fun things" as well as all the whacker accessories or the lights and sirens. As a professional, I would rather move past the stereotypes that have been prevalent in EMS. It are those in EMS and not the public that continue to hold on to this skewed concept of what an EMT(P) is. As Dust mentioned earlier, the public knows the difference between a real doctor and some fictious version on TV because they have real doctor role models in their real lives. What does EMS have if those in the profession believe they are like the characters portrayed in these crappy shows?

Hi all! I hope I'm posting this in the right forum. I'm in my mid-40s and, after 20 years in a completely non-health-related field, I am back at school in the Orlando area and enrolled in an EMT course that starts next semester. After that, I can enroll in a one year paramedic program (or I could enroll in an LPN program that starts next August, and then do the LPN to RN online thing once I get my LPN, and be an RN instead. Still debating.) I know I want to be in the emergency medical field. However, I have some questions. I am in Orlando - most LOCAL paramedic jobs are being taken over by the fire department right now. I can relocate once I become a paramedic. I don't have a really good feel for what the paramedic field is like outside of central Florida. I'd love to hear from people in other parts of Florida and other parts of the country - especially if you live somewhere where job demand is decent and where there are opportunities for paramedics who aren't firefighters. I know there's this myth that if you are a nurse you can ALWAYS find a job - but if you go on allnurses.com, you will see new grad nurses in every state saying they've been unemployed for months, even a year, and sending out hundreds of resumes and networking like mad. So this recession has, at least for the next few years most likely, taken away THAT safety net. I do want to be a paramedic but I also want to be able to get a job when I graduate, so I'd love to know what the paramedic job market is like out there. Like I said - I can relocate anywhere - especially for a few years to get experience.

This is not a simple issue. Here are my thoughts, in no particular order: 1. The influenza vaccine does not afford a high degree of known protection against influenza infection, as Vent so concisely pointed out earlier in this thread. It is impossible to predict which strains will be dominant and the most virulent. Therefore, mandating vaccination really can't be proven to reduce the risk of transmission to the point where those who are opposed to vaccination for various reasons will be convinced of its merit. Also, many people have had personal or anecdotal bad experiences with the flu vaccine- my husband being one of them. Since people are already leery of the traditional influenza vaccine, they are that much more so about the H1N1 vaccine due to its speedy production. 2. Some protection is better than no protection, especially when you take into account the dynamics of population immunity. If you have 30 folks and only 10 of them get vaccinated, any given individual in the population doesn't really have his or her likelihood of infection reduced. If you have 28 of them get vaccinated, the remaining 2 un-vaccinated folks are much less likely to become infected, simply because the other folks are less likely to become infected and the risk of exposure is decreased. This is much more certain with something like polio, where there is a good idea of the effectiveness of the vaccine... the flu vaccine is such a crap shoot in all reality that it's harder to determine whether population immunity would come into play here in any significant form. If you assume that there is something like 40% protection (just for giggles), then population immunity would be significant enough to push for higher vaccination rates. If the effectiveness is only 10%, then it's really not worth the time and effort. 3. The issue of personal choice vs. public safety is ALWAYS a matter of contention. ERDoc raises some very valid questions that I think we shouldn't ignore. I personally feel that the choice to refuse vaccines is one that should be safeguarded, but those who choose to forego mandatory vaccination should also be able to accept that there will be consequences if there is a serious, community threatening outbreak. There is a reason that parents who don't vaccinate their children have to sign legal waivers acknowledging that their children will be barred from attending school during disease outbreaks. If you don't get vaccinated, be prepared to be isolated when the caca hits the fan... (this applies more to say, MMR than it does influenza, because you can titer immunity levels with MMR...) 4. The issue of personal choice is much more difficult where we as healthcare workers are concerned. We work with the populations that are the most vulnerable- the immunocompromised, economically disadvantaged, those who suffer from chronic disease, the very elderly and very young... Is it worth it to insist on your own personal preference at the potential expense of your patients' well-being? You might not get a very bad case of the flu (A, B or H1N1) but that grandma you transported for CHF might die from it if you give it to them. How many of us have come to work sick, knowing full well that we could pass on what we have, because we don't have sick time or have employers who are unsympathetic to illness due to short-staffing issues? Even if the vaccine only buys you 40% protection (again, hypothetical number), it is still statistically better than playing the odds with no protection. I really don't have an issue with employers mandating vaccination- they can tell you how to wear your hair, what treatments you can perform, and what your physical fitness level must be... if they deem mandatory vaccination to be in the best interest of the company and the patients the company serves, that is their prerogative. It is also your prerogative to choose to work for an employer who doesn't institute said policies. Most employers know that it is far better to strongly encourage (and provide incentives for) voluntary immunization, and mine has already developed and implemented a policy regarding flu exposure and infection. 5. Anyone who is more concerned about a WMD pathogen than a natural epidemic is really not looking at things clearly. We're much more threatened by something along the lines of an influenza epidemic than we are by an artificial pathogen release... looking at it solely from the perspective of statistics. Also, the quibbling over "personal rights" would not really be a factor in a WMD attack, as martial law and mandatory quarantine (at the expense of all civil liberties and probably enforceable with deadly force) would be implemented fairly rapidly. I am going to go think about this a little bit more and see if I have some other things to add. I know that I will probably get the regular seasonal influenza vaccine, as I am asthmatic and work in an assisted living for the elderly. I have not yet decided if I will get the H1N1 vaccine, as I would rather wait to see if there are any statistically adverse reactions, and as the protection I would get wouldn't really kick in until after the peak risk time at this point anyway. If my employer offers it for free, and I don't see bad reactions, I will probably get it. Wendy CO EMT-B

Also note that a two year PA program is different from other two year degrees. PA students are typically in class most days of the week, have very limited breaks, and do not have summer vacation like other college degrees. The typical PA program is in the neighborhood of 27 straight months long. Also remember, virtually all PA programs in the United States are graduate level programs. (Master Degree programs.) There are a couple of BS programs still around; however, this is rapidly changing. In fact, UNM in New Mexico had one of the few BS PA programs; however, as of this year it is now a MS program requiring an undergraduate (Four Year) degree prior to entry. Take care, chbare. Edit: "the"

There are still a few PA programs in the country that will allow you to be one after just 2 years. However, for many programs it is a 2 year program after you have obtained a 4 year degree. Also, there are now post grad school programs for internships in some speciality for the PA. In FL, if you want the ability to write scripts, you need the Masters. U of F does have a great program. The experience is not always necessary as they state it is good to have a CNA or EMT cert if you do not hold a license in healthcare profession to earn some mone during school. You are correct in that it is very selective.

PS.. right after I got home, I found out that Alyssa had died.

Hi All, My Paramedic Prep course at Daniel Freeman (UCLA) begins in a few days. Over the past year I've been working as an EMT and have taken several classes to raise my "points" average for the Paramedic School selection process. These included becoming Phlebotomy licensed in California. The class will mostly be fire guys, but they do set aside a half dozen slots for non-sponsored civilians like me. But the competition for those are high. After the Prep course (if I'm successful) I'll also need to sit the Hobet exam. And like a lot of people say, the math is an issue. I've been out of high school close to 35 years. My Julia is helping me out. But I find the problems confusing so we found tailoring the practice questions to my limited understanding really helps out a lot. For instance: If Dust can drink a case of beer in 4 hours, and Nick can drink a case of beer in 6 hours, how long will it take for both of them to drink a case of beer together? Easypeasy - 2.4 hours and it's time to get more beer . . . The below is a bit I wrote up for a skydiving forum I frequent to explain why I wouldn't be around for a while. Please excuse the small over-explanations as this was written for non-EMS types. NickD Wish Me Luck . . . I probably won't be around here much for awhile as I'm starting Paramedic Prep classes in October, and hopefully shortly after that I'll be accepted to Paramedic School. I officially left my job as an EMT here in a So Cal coastal city and I've been thinking over my time there and things I've learned, things I'll miss, and things I won't miss. When I started as an EMT I was lucky to get on with a private ambulance company that ran 911 calls in support of the local fire department. We did some interfacilty transfers but it was mostly fire calls. I started by working 12 hour day shifts and then went to nights. My very first partner was a jovial Mexican fellow assigned to break me in. On my first morning out we stage the ambulance in our assigned sector of the city. And his first lesson to me is, "Hey man, ya know what EMS really means, right?" "No what?" I say. "Earning Money Sleeping!" And he goes into the back of the ambulance and curls up on the bench, "listen for our call number on the radio," he says and promptly starts snoring. We have three radios in the rig. One is tuned to our dispatch. Another is on fire's frequency, and the last is a hand held we take with us on scene. But it all sounds like noise to me. I pick out words here and there but I'm absolutely terrified they are going to call us and I'll miss it. The city has five different fire stations and they are numbered. I study the plastic covered street map we have trying to figure out where we are in relation to what fire station. If I can pick out the fire station we are covering, and then hear them being called out, I'll know to expect a call from our own dispatch on the other radio. Problem is I'd never been in this city in my life, the map is printed for 20, not 54 year old eyes, and I haven't even figured out what microphone is connected to what radio. I don't want to make it sound like I didn't get any training or orientation from the ambulance company when I started. But I'll just leave it like this. If their instructors taught skydiving we'd all have been shut down by the FAA long before now. I'm anxious for my first real call, of course, I feel more than ready to make the jump from school to the real world. But at the same time I'm like the kid in right field who's just praying the ball isn't hit towards him. This goes on for about a half hour and I gotta pee. They never covered that in my training. I hear fire stations being called out and I hear the corresponding ambulance being called out too. I pay particular attention to how they answer as that part is my job. I knew I wouldn't have mic fright. I've talked down thousands of skydiving students, took flying lessons and talked to ATC, and BASE jumped a lot talking to my ground crew all via radio. The last one being mostly about how's the wind and is the coast clear. Suddenly I hear, "Engine 24, Rescue 24, difficult breather, 123 E. 3rd street." And just as suddenly the snoring in the back stops and my partner says, "That's going to be us." Things are happening fast now. I'm frantically scribbling down the address on my pad when our dispatch radio calls us. "54, non-emergency." I pick up the mic hoping to god it's the right one and say, "54," in my best fighter pilot voice. "54, non-emergency," they come back, "respond with Engine 24, Rescue 24, 123 E. 3rd street, 123 E. 3rd street, Code 2." "Tell 'em two to four minutes," my partner says while he's still in the back yawing and putting his boots on. I click the mic and say, "54 copies 123 E. 3rd street, with Engine 24, Rescue 24, give us two to four minutes." I thought it went well. So far so good. But my partner got behind the wheel and laughed. "You sounded a little squeaky there." I found out he could be sound asleep and still hear the radio just fine. This was my first call. The one they say you never forget. I thought how the tables were turned now. I was the excited and scared first jump student, and next to me was my non-nonchalant, even bored looking, first jump instructor. We rolled out onto the Blvd as I fumbled with the map trying to find the address. "Don't worry," my partner said, "I know where it is." But I kept looking just for the practice. Code 2 isn't lights and sirens but you still have to make time getting there. My partner, I'll start calling him Ricky, so I don't have to keep writing "my partner," skillfully and efficiently weaves us around the morning traffic. "Put your seat belt on," Ricky says. Man, in all the excitement I totally forgot. Ricky reaches into the plastic bin that sits between us and grabs a pair of rubber gloves and puts them on. I do the same. "You can start the paperwork now if you want," he says. I reach again into the bin and pull out the metal case with our run sheets in them. I start filling in what I know, the date, our unit number, the address we are dispatched to. I realize it's hard to write in a moving vehicle. The traffic is bad, and even though Ricky knows the best streets to use, they are all clogged with people still driving to work. "In another minute," Ricky says, "you'll have to call fire and tell them we need an additional two minutes." And just as I'm figuring out how I'm going to do that, they call us. "54, what's your ETA?" "Tell' em two more minutes" Ricky advises and I do so. And fire comes back with, "54, bump it up to Code 3." "Copy," I say, "bump to Code 3." "Rock and roll!" Ricky says as he puts up the windows and hits the switches on the emergency lights and sirens. The traffic ahead magically parts as I call out, "Clear right," at every intersection. I don't want to sound like a whacker. A whacker is someone in EMS, usually a newbie, that wears too much equipment on their belt, and gets off way too much on the lights and sirens bit. But damn! This is very exciting! While I'm watching the road ahead I'm trying to run through my protocals for SOB (shortness of breath) but I'm drawing a big fat blank. We turn another corner and I see a fire engine and the smaller paramedic vehicle in the middle of the block. We park in front of them and I go around the back and pull the gurney out. "Got the hand held?" Ricky asks. No, I forgot that, so I walk around and grab it out of the cab. And I grab the metal case with the run sheets too. Calm down I tell myself, you're not thinking. "Critical thinking!" It's my EMT school instructor. I can hear his booming voice in my head right now. "No, no, no," he'd scream. "Your patient is presenting with this, this, and that, but not this. What does that tell you!" I loved that guy. We roll the gurney up to the front steps of a nice, but modest house. "Go inside," Ricky says, "see what's going on." I thought to ask if he was coming with me, but instead I just went. The door was ajar and I opened it. There was no one in the living room, but I could hear voices further back in the house. I walked down a short hallway and looked into the first bedroom I came to. She was in her eighties and laying supine (face up) on her bed. She was talking with the two fire paramedics. It was obvious she was having trouble breathing, and she seemed confused. They had her on O2 and also hooked up to their portable heart monitor. One paramedic looked up at me and said, "Bring in the gurney, if you can't fit, bring in the stair chair." I went out and relayed the info to Ricky. "We'll get the gurney in there," he said, "I've been here before." I came to learn Ricky would say that a lot on the calls we ran. As I stood in the woman's bedroom again I took a minute to look around. There was a picture of her on the wall. In the photo she's about twenty and beautiful in that way all woman were back in the 1940s. On the table next to her bed was a photo of a man in a WWII military uniform. He was also about twenty. Put him in a jumpsuit and he'd look like any other young dude on the drop zone. It was the beginning of my realizing these were real people. People with lives full of hopes and dreams. "Her husband died about ten years ago," Ricky mentions in my ear. But there's his photo, I notice, still on the night stand, right by the bed they spent a lifetime in. The paramedics stood back while Ricky and I placed the woman on the gurney. We were the grunts after all. There are very specific techniques for lifting and moving patients but it went well and we buckled her in and covered her with a blanket. Ricky got my attention with a look and motioned to the O2 tank on the end of the gurney. I didn't get it at first, but then caught on he wanted me to switch out the O2 hose from the paramedic's tank to that one. We rolled the woman out and lifted her down the stairs. I was concentrating hard as the worst thing is dropping a patient. We put her into the ambulance and one of the paramedics got into the back with me. This was an ALS (advanced life saving) call. What made it that was the woman was altered. Her level of consciousness wasn't normal for her. Some other things that make some calls ALS are trauma, strokes, heart attacks, etc. For the lessor things we'd have taken her in alone. Those are BLS (basic life saving) calls. And a paramedic doesn't need be aboard to transport. I sat on the left side and the fire paramedic was on the right side of the gurney. I saw he was preparing to run an IV line. "Get me a blood pressure." He directed. I grabbed the blood pressure cuff off the shelf and the stethoscope out of my pocket. I'd done this a hundred times in school and another hundred times on my poor Julia at home. The paramedic told Ricky up front to, "Go easy three." He meant use the lights and sirens on the way to hospital but don't kill us getting there. I put the cuff on upside down the first time, but quickly fixed it. I found her brachial pulse in the crook of her arm and pumped up the cuff. But then we started moving and I couldn't hear a thing under the siren. I kept trying but it just wasn't there. The paramedic noticed I having trouble and said, "over palp," is good enough." I knew he was telling me to get her pulse at the wrist and do it by feel. "110 over palp." I told him. "Okay, strip out this bag for me." He tossed me a bag filled with saline that he was going to hook into the IV. I'd done this few times but he noticed me fumble dicking around with it. "First day?" He said. "First call," I replied. He smiled at me and said, "Okay, look, here's the easy way to do it." He was a cool guy. He let me do the blood sugar stick on her finger and he explained everything he was doing to me. I got lucky again. I later found not all the fire paramedics were as easy going. In fact some of them were down right pricks. "Your a bit older than most of the new EMTs I see." he added. But instead of giving him my life story, I just shot him a "that's the way it is" look. "Change that O2 hose over to your house tank." He told me. "Those small gurney tanks don't last long." We rolled into the emergency bay at the hospital and wheeled her into the ER. The paramedic gave his report to the nurse while I listened. I'd have to do this myself on the BLS runs. We were given a room after a bit of a wait and transferred the woman to the hospital bed. I removed the EKG leads from her chest while trying not to notice her bare breasts. You do, I found out later, get very used to that sort of thing. When I came out of the room the paramedic was already gone. Ricky was off getting some new sheets and blankets. Then he would make up the gurney and clean up the back of the ambulance. In the meantime my job now was to get the woman's medical insurance information and finish up the run and billing sheets. Besides the basic info the run sheet must include a full narrative of the entire call. Every intervention we made, and the outcome, must be included. I think of myself as a fairly good writer, but it's hard to be too creative using all those medical abbreviations and terminologies. "Are you still working on that," It's Ricky. "What are you doing, writing a book?" Back in the ambulance Ricky told me to clear us on the radio and I did. "That's ice cream," he said. What's ice cream," I asked. "Any first," he explained to me, "like your first run, your first cardiac arrest, it means you gotta buy ice cream!" I couldn't help laughing out loud. After a lifetime of "beer firsts" on the drop zone now it was ice cream. "Whata ya laughing at, I'm serious, man." "Nothing, Ricky," I said, "I ain't laughing at nothing. So the time passed. Almost a year's worth of calls, some routine, some not. Overdoses, gun shot wounds, stabbings, beatings, drunks, car accidents, and just plain sick people. Sometimes only lonely people and often those who simply abused the system. But we took care of them all. The best part? I found I have a soft spot for elderly people. Rolling them into a nursing home, sometimes knowing they'd never roll out again, I'd stop outside and watch a sunset with them. Or grab a flower off a bush on the way in and lay it on their bed stand. Sometimes I'd just sit and listen to their stories of how no one comes to see them anymore. Other times I'd just let them hold my hand for a little while. When ever I got back into the ambulance Ricky was always going, "What took so long, what the heck were you doing in there?" "Nothing," I'd say, trying hard not to let him see the tears in my eyes, "I wasn't doing nothing, man." Wish me luck, everyone, with my Paramedic ambitions! NickD

I can tell you that the actors themselves have put in a good deal of effort to try to get a feel for what real EMTs/Medics are like, what working EMS is like, and the hardships of their lives are like. They are of course limited by what the people on the movie staff tell them to go for and the stories they create.

What they are not telling you about the N1H1 vaccine is it is for the older strains. N1H1 is mutating, so chances are if you are exposed or have N1H1 it is not the same as the vaccine and would be susceptible anyways. In my "day job" I work in a lab with a bunch of micro geeks, not a single one of them is getting the vaccine. It hasn't been tested enough or long enough. N1H1 is the flu....wash your hands and cover your cough, simple as that.

Testing is a whole different issue. I have no problem with a screening, but mandatory INOCULATIONS is a different animal. I think we overestimate our ability to handle many things- especially viruses. We have spent BILLIONS on AIDS research and still cannot come up with a vaccine for HIV. A virus is a an insidious beast that by design constantly mutates. A virus is designed to take over a host cell's processes and replicate, which makes a one size fits all "cure" sketchy at best since we are all different. Many times, the yearly vaccines we develop turn out to be far less effective than planned because by the time we develop the vaccine, the virus has already mutated to either a more or less virulent form. I think it is foolish to think we can rush into an H1N1 vaccine without those same issues- especially since this vaccine is not fully vetted.

Unlike what happened with the Avian flu, we do have cases in the U.S. of H1N1 and it has proven itself to be deadly. However, we have always had Influenza A around at various times during the year and have taken precautions. It just happens that there are many more cases than usual this year in a younger population excluding school age where the flu is present each year. However, Influenza B is still the leader for deaths here in the U.S. For some it is a crap shoot if they get the flu with or without the shot. For others it may offer protection. Most will go on a little protection might be better than none at all. I am not convinced we know exactly what influenza virus types or subtypes will predominate and if this vaccine will offer adequate protection. I believe it was last year's seasonal flu vaccine that was stated to have misjudged what the predominant strain was going to be. Even more so, will that give some a false sense of security for maintaining the highest standards for precautions? Right now in many hospitals, everybody with flu symptoms are considered guily under proven innocent or well or dead. Those that are subsceptible are getting hit hard with what some have termed as Flu Associated ARDS. This can be deadly and requires serious intervention with the big technology and expertise of the intensive care Physicians. For testing we use rapid antigen tests, which can give results in as little as 15 minutes. These tests can usually distinguish between influenza A and influenza B, but they do not identify subtypes. Some tests are not as sensitive in adult patients as they are in children, who shed more viruses. That fact can result in false-negative results for adults. For more specific testing, the specimen goes to a CDC lab and even those results are returning sorta positive and sorta negative with nonspecific whatever type of flu. Other vaccinations I don't have a serious problem with since we can test for titers to determine one's immunity. Mandatory TB testing also doesn't bother me since that is determining presence from exposure.

I look at it this way. We are potentially exposed to all types of communicable diseases during the course of our duties. As part of our job, we use PPE and take proper precautions to minimize the risks to ourselves and to our families. I see nothing different about this. I look at the fiasco with the Avian flu and the panic we were exposed to. I refuse to take a shot for something I am not convinced is the best course of action. We now have 2 local hospitals here that are mandating H1N1 vaccines for ALL their employees. If I worked for these facilities, at this point I would probably be looking for another job. Just because we work in the health care field, it should NOT mean we should lose our rights and freedoms. Heavy handed tactics such as this mandate scare the hell out of me.

The "two-year associates in nursing" is a myth. There are at least two years of pre-requisites BEFORE you can apply, at least with all of the two year programs that I checked. And that's not necessarily a bad thing; I'd rather have a better educated nurse. I would not like it if someone with a high school diploma could go to school for two more years and become an RN. And most of the pre-req's make sense. I'm not crazy about having to take developmental psychology, but whatever. A&P I & II, biology, nutrition...not bad things to know as a nurse. It's just a drag for me, in my mid-40s, to have to take all these courses and completely reinvent myself after decades in the journalism field. But what can you do - I can sit here and cry about it while going broke, or I can go take the classes I need and get a job.

They are in too much of a hurry to get this out there. They moved the release date up before clinical trials were even over. Think HPV vaccine. They put on the full court press on this, claiming it was safe, etc. Then, even before it was released, more information came out- like it wasn't nearly as effective as we were led to believe. It did not prevent all forms of the disease. Then we find out that there were significant side effects, and girls actually died from receiving the HPV vaccine. Unfortunate, and yes, it does happen with even supposedly "safe" vaccines but why push something like this, especially when it's efficacy and safety is such an issue? I've never received a flu shot before, and I am just getting over the first cold I have had in about 5 years. Are there instances where people NEED these vaccinations-yep. My wife has asthma and before it became well controlled by Advair, even a simple cold had the potential to put her in the hospital. She still gets a flu shot every year- and has the sore arm today to prove it. I'm also of the opinion that we overmedicate ourselves today anyway- our immune systems are wasting away. Medicine is a wonderful thing, but I think we have become overly dependent on popping a pill for every ache, pain, or sniffle. If there is a valid medical reason- an underlying illness, obviously it's a good idea. Unlike the general public, we have the capability to protect ourselves and the patient should the need arise. Mandatory- no friggin way.

It is a little more than signing off on a "skill". To give the vaccination, there should be a public health clause in your statute which also provides for additional education. When you give an IM,SL, SQ or IV med, you are acting under a certain set of protocols for a field diagnosis as signs and symptoms appear. For a vaccine, you are working off of what if and must provide the necessary education for whatever patient population presents for them. As a parent I would be hesitant to have an EMT(P) who is only going by "I can give a shot" mentality vaccinate my child. That being said, your state may already have established the legislation necessary. Here are some updates: http://www2a.cdc.gov/phlp/H1N1flu.asp One another thread here, MA had passed a very comprehensive Bill which I am surprised LA doesn't have one similiar. Many of the other states updated their statutes for Public Health and Disaster Preparedness after they saw what happened with Katrina. http://www.mass.gov/legis/bills/senate/186/st02/st02028.htm Hurricanes are just one of the reasons Florida has vaccines in its statutes for EMS. However, it has still been controversial for allowing Paramedics to administer them to children. A couple of counties (Lee and Indian River) was even trying to be active in Public Health but eventually some of the momentum was lost and projects scrapped due to a lack of interest from the Paramedics as they did not want to do "clinic work".

It seems like Hollywood has missed once again. If they would at least try and make it somewhat "real world" people might watch it. Jumping out of your helicopter with your cape on, popping someone with Versed and walking away is poor form and just down right wrong. I, like everyone else has seen the trailer for this trash. It's crap and left a funny taste in my mouth. The sad part is, the lay public might just like this show and it will stay on forever to the determent of my chosen profession. Shows like this do nothing for EMS but coddle the cowboy mentality and attract whackers. Ha! One of the comments from the JEMS crowd suggested a show like "COPS" for EMS. "Paramedics" was the closest thing to reality that we had and was a decent show but was thwarted by HIPPA. The reality is, a show showing the way things really are is boring and wouldn't sell. Can you imagine 2 out of shape EMT's complete with ballcap, "You can't force me to run into a burning building, I'm a volunteer" T-shirt sitting around eating "Cheetos" and watching Jerry Springer for hours until the tones go off? Not my idea of entertainment. Disclaimer: Before some of you go off the deep end, My description was purely fictional, I hope. God knows no of you work for a squad like that!

There used to be a very low budgeted program produced by some Hollywood person who lost their daughter because of some accident, or she was saved, or whatever. This program was all 'real calls' whether EMS, Fire, Law, or Aeromedical. It was called "Emergency on Scene". I have a few video taped segments of it, all raw footage. This is what should be shown. Real stuff, not the 'ab-lib' dung that everyone thinks they want to see.

I'll watch it for the same reason I watched the first episode of "The Listener," morbid curiousity and perhaps a bit of masochism. The show might make a good drinking game. Take a drink (or shot) every time you wonder what else is on. First person to change the channel has to chug and buys the pizza.

You should realise that (and I know its a bit rich coming from somebody down here) but whodathunkit the IAFF and Fire Departments in places like FL/CA/TX/DC are not known for thier stellar standard of Paramedics (ALS) and I would bet dollars to defibrillators many of them are terrible patch factory graduates. That said be careful where you choose to go to school; many on here like AK and Vent can offer you advice on where to avoid. As far as nursing I'd recommend you get your RN and eventually your BSN; Vent should be able to give you more detail about how that works in Florida but I think she runs a decent bunch of NICU/ICU/CC IFTs which will get you out of the hospital anyway; not sure about HEMS but may be an option. Nursing offers far-in-advance the opportunities of Paramedicine, not just in the US but most places in the world. Now this is more true in the US from what I have seen than say here or in Canada, but EMS is the bastard child of medicine that has for the last four decades managed to be a profession built upon skill without a decent foundation of medical knowledge and research. While you are waiting for your EMT class to start see if you can take college A&P, patho and pharm (might have to seek out somewhere specifically with a nursing or allied health faculty). It will give you a good foundation of knowledge far beyond the ten pages of A&P in your EMT textbook. Personally if it were you (and I've kinda found out the hard way) that it's easier to get your nursing qual's FIRST then if you want to work in the street for a bit maybe see if you can challenge your Paramedic test; Florida lets you challenge as an RN or BSN and I am sure a bunch of other states have a bridge program. As for the job market I can't specifically say in the US what its like but I know a few people who have graduated here (we only have a BN (BSN) program per the nursing council) and have found work in Canada, the US and Australia. I know some places in the US have a severe skill shortage while others generally only hire Bachelors Degree qualified nurses ... might have to go work out in Tumbleweed, Arizona but heck a jos's a job right?

I think this is a topic that plagues providers. Each state or region has different rules, and every agency has different ways of helping or not helping with obtaining needed recert. requirements. I am actually doing a live call in radio show on this topic Monday Sept 28th at 8pm EST. I would love for EMTcity members to come and join in the discussion. Here is the show link Who Is Paying For Your Continuing Education? It is scheduled for an hour so you can still watch the new show "Trauma" at 9:00.

Unfortunately, we have been giving a medication with profound alpha effects without much improvement in M&M. (Epinephrine) We are even giving a newer modality that attaches to its own receptors and supposedly acts in a very similar way to an alpha agonist. (Vasopressin and V1 & V2 receptors.) Not much in the way of improvement with vasopression either. Dwayne, from a pure physiological perspective, some of the retrograde flow studies do make sense. (At least in the larger veins that do not have valves.) Even in a person with a beating heart, it is quite easy to increase intra-thoracic pressure to the point of decreasing venous return. (A pseudo back flow if you will) This is easily accomplished with poor ventilatory strategies that lead to the development of auto PEEP and air trapping. Remember, the "normal" CVP is only 2-6 mm/Hg in a healthy adult. In fact, the mechanics of normal breathing and intra-thoracic pressure changes actually assist with venous return. Therefore, it is safe to assume (in a purely physiological sense) that the loss of a normally functioning system and the loss of a true driving pressure for the vascular network can lead to retrograde flow of the venous circulation is possible. This appears especially likely in the setting of CPR. Take care, chbare.

Herbie, I think you need a bigger rig. I will admit that I have not reviewed the original article or the sources cited in it. Lack of evidence is not the same thing as evidence against. If you don't have an ideal test you have to accept the next best thing. I agree with Mobey, maybe the OP had good intent by bringing up this thread but the way it was carried out was very condescending.

Please read your question Now this quote is one of the first lines in RED you posted. Seems like you posted this to stroke your own ego. You specifically asked how WE assess proper CPR, then after the very 1st post, you slam the guy stating there is NO proper assessment backed up by evidence. Duhhh......

Prehospital, the sign that CPR is being properly performed is indeed a palpable pulse- if you feel a femoral pulse, then clearly you are doing effective CPR. Oxygenation-o2 sats, ETCO2, color improvement, EKG changes to a viable or shockable rhythm vs an agonal rhythm, pupils constricting(before Atropine administration), etc- all indicate how things are going. As for checking the femoral pulse, in a prehospital setting, some things are also easier said than done, based on the scene, the patient's size, are you in a moving rig, the level of training and experience of the person monitoring that pulse, etc. I've had first responders and EMTB's tell me they feel a return of a pulse when a person is clearly in a confirmed asystole. If the patient "looks" better, then clearly you are doing things correctly. All the gadgets in the world are great but I think you also need to correlate them with the clinical picture. If we cannot get a ROSC, then our job is to keep the patient as viable as possible until the ER can pick up care and possibly provide an intervention or medication that we cannot. Obviously with CPR, ensuring proper compression rate and depth is useless unless the patient is being adequately oxygenated, so I guess the more ways you have to measure a patient's condition, the better idea you have of how effective your efforts are and what, if any adjustments need to be made.

Why don't you post the studies so that we can have a discussion and people can add their opinions as we go.

Starting an IO to administer D50, dear god.

It seems that over the time I have been a consumer of this fine web-site, that there are many instances where we make judgments on people based on their posts. I have found my self doing it in the past, and after some critical thinking, I have determined it is because of natural prejudices that I have. We all have them, we all (rightly or wrongly) use them. I, for instance, tend to immediately discount posts that are incredibly hard to read and do not at least attempt to have some grammatical accuracy. Even though I know better than to equate bad posting grammar with intelligence... I still do it. I know that some on this site view me as the funny wordy guy that disappears for 8 months out of the year, while others see me as an arrogant rabble rouser who is more concerned with sounding “smart,” and less concerned with content. The truth is that I am neither of those things... this site, and my posts do not define me any more than they define the rest of you. Some naturally stereotype each other based on education, race (yes crotchity. Racism still lives, but there is no need to turn this into one of those topics), religion, political leanings, country of origin, what EMS system you work in, who you work for (paid vs. volunteer)... and so on, and so on. What I would like to accomplish here is to try and bridge the gap between some of these prejudices. I contend that we often misrepresent each other and misinterpret things simply because we have no idea what type of person you are, and we make the mistake of using our posts on an EMS message board as a barometer to judge our intrinsic value as a person and provider. To use some City veterans as examples, I've seen Dustdevil characterized as a cranky, BLS hating, Canadian disrespecting, arrogantly mean-spirited dude. He has come under attack multiple times for his stances on certain subjects (sometimes by me). I've read enough of his posts that I believe this characterization is incorrect. There is a sensitivity to many of his posts that we all usually miss. An understanding of fundamental quality on a human level, fiercely proud, loyal to those who he calls friends, and unerringly steadfast in what he believes in... education and enlightenment. Quality people equal quality providers. DwayneEMTP is the guy that pokes you in the chest when he senses weakness (in mind or in argument). Challenges you in a brusque manner, and throws haymakers until it's over. What I think is sometimes missed about him is that, at heart, he is a pragmatist. Why walk in a circle if you could get there in a straight line? A man who is eminently capable of the subtler arts of vocabulary and diplomacy, but doesn't see the point. Anything worth knowing is worth fighting for. If you back down and are unable to defend your stance (or lack thereof) than you weren't worth the educational experience to begin with. He's not being it to be mean or hurt feelings (as I only recently came to realize after getting' all up in my grill), but to cut to the chase and provide a learning experience for us all. It's a harsh tactic to some, but one that makes sense if you look at it from their perspective. Some even view VentMedic as a sanctimonious unicorn... (sorry, was too funny to leave out). So what I request is... tell us a story. Tell us something that has happened to you that was important to your values, tell us about an event that shaped who you are, tell us something about your family that you are particularly proud of (or not proud of, if it is applicable), tell us something that will give us some insight into who you are. Give us some context, some reference point, some humanizing detail that allows us to more accurately view you as a person, and not some EMS robot. Not only can doing some internal assessment be something that will allow readers to understand you more, but I sometimes find it cathartic to unleash a little bit of your own experiences on others... makes you remember how you got where you are, and sometimes surprisingly tells you where you should go. These stories do not need to be about EMS, or your place in EMS, but it is okay by me if it is. Those of you brave enough to participate... one simple ground rule. No replying to these posts. Allow them to stand alone. Any discussion should take place in PM if desired. Just tell us a story, and enjoy everyone else's. If you don't use proper grammar, then I will surely judge you.

Newfoundland declares war on the U.S.A. President Obama was in the Oval Office wondering what he would do next, when his telephone rang. "Hallo, President Obama" a heavily accented voice said. "This is Archie, up ere at the Harp Seal Pub in Badger's Cove, Newfoundland , Canada , eh? I am callin' to tells ya dat we are officially declaring war on ya!" "Well Archie," the President replied, "This is indeed important news! How big is your army ?" "Right now," said Archie, after a moments calculation "there is myself, me cousin Harold , me next-door-neighbor Mick, and the whole dart team from the pub. That makes eight!" Obama paused. "I must tell you Archie that I have one million men in my army waiting to move on my command." "Holy jeez," said Archie. "I'll have ta call ya back!" Sure enough, the next day, Archie called again. " Mr. Obama , the war is still on! We have managed to acquire some infantry equipment!" "And what equipment would that be Archie?" Obama asked. "Well sir, we have two combines, a bulldozer, and Harry 's farm tractor." President Obama sighed. "I must tell you Archie, that I have 16,000 tanks and 14,000 armored personnel carriers. Also I've increased my army to one and a half million since we last spoke." "Lard t'underin' bye", said Archie, "I'll be getting back to ya." Sure enough, Archie rang again the next day.. " President Obama , the war is still on! We have managed to git ourselves airborne! We up an' modified Harrigan's ultra-light wit a couple of shotguns in the cockpit, and four byes from the Legion have joined us as well!" Obama was silent for a minute then cleared his throat. "I must tell you Archie that I have 10,000 bombers and 20,000 fighter planes. My military complex is surrounded by laser-guided, surface-to-air missile sites. And since we last spoke, I've increased my army to TWO MILLION!" "Jumpins," said Archie, "l'll have ta call youse back." Sure enough, Archie called again the next day. " President Obama ! I am sorry to have to tell you dat we have had to call off dis 'ere war." "I'm sorry to hear that" said the president . "Why the sudden change of heart?" Well, sir," said Archie, "we've all sat ourselves down and had a long chat over a bunch of pints, and come to realize dat dere's no way we can feed two million prisoners." CANADIAN CONFIDENCE CANNOT BE SHAKEN! :lol: :lol:

Similarly... In the 1967 Arab/Israeli "7 Day" War, an Egyptian Army division was advised that a lone Israeli soldier had been spotted in the desert near them. They sent out a 2 man team. Neither returned. They sent out a 6 man squad. None returned. Then, they sent out a 50 man detail. One returned. When He reported to his general, he said Same time period, an Israeli recruit, after 3 days in basic training, requested a 3 day pass, which was, of course, denied. The next morning, the lookouts reported a lone Syrian tank, flying a white flag, approaching. It stopped just outside the gates to the camp, and when the hatch was opened, it was the recruit! He got a 3 day pass! 3 days after his return, he asked for another 3 day pass, which was, again, denied. The next morning, the recruit showed up in an Egyptian Armored Personnel Carrier! He got another 3 day pass! On his return, other recruits surrounded him, and asked how he was able to do what he had been doing. He said

I have a pretty open mind and I enjoy learning from others (even if it is that albertan squint) I became a emt because on the day my brother in law died in my lap there was no ambulance in our community. In hind site he still would have died reguardless but it was decided by my paramedic friends that I would make a good medic and then they went and made sure I have babysitting ect for the course that I had to attend and here I am. Now 14 years later I am still learning and come to this site everyday so that I can find new information, see what everyone is up to and have a quick argument if there is time. This week I need info about pallative and hospice care (thanks mother those links are great) and to those I asked thanks. One thing I do find here is not matter who you are (cranky, snotty, mean or any other bad chartactistics) if you come here for some help it will be provided to you. I think we all have good and bad in us and as I say to my boys You will never like everyone and the ones you dont you suck it up or walk away.

Defining moment in my life in EMS - I wasn't going to share, but I'm posting perhaps against better judgement, but I will anyway. Those that know me will instantly be aware of the story because I share it with people freely in person, and is much like AK's (by the way AK - glad you're still here with us !) But it definitely defined who I was a caregiver and gave me new eyes for my patients. There are a few things I will leave out as they are quite personal and have no place here, but this is the thing in general. Sept 11 is a day I'll never forget. It's the day I started my EMS career, the day the towers fell, and the day my life nearly came to an end. I had left that morning from my other job which was non ems related and was driving in a construction area which was very narrow as it had concrete barriers on both sides. I saw a semi coming the other way and didn't even think about it. The next thing I remember was waking up to a cop (who I've affectionately coined smokey the bear since then) and seeing how white his face was. He wasn't moving very fast and I realized I had just been involved in a wreck. My first thoughts were to see if I was stuck - I tried to pull my arms free (they were through the instrument panel of my car) and realized I was. The next thing that went through my head was "don't move your head or neck you know better". I just stayed put and as the cop walked back up to my car I can remember telling him "hey you mind getting me out of here smokey?" Usually I loved making fun of those hats, but this day, it was a site of comfort as were the sound of the sirens. It's amazing how comforting that sound can be when it's you that's in trouble. I realized I didn't hurt and kept wondering, why don't I hurt? I didn't understand why I didn't feel anything (real smart here didn't realize I was in shock eh?). The cop panicked realizing I was still alive (he seriously thought I was dead) and immediately called for a helicopter. First thing I said was "no way in hell you're flying me out, I'm fine just stuck, you can take me to the local hospital". Obviously he didn't comply - dang cops just don't listen well do they? I don't remember anything in between, but I was told I was in and out of consciousness as it took over an hour to remove me from the tangled mess of my car. They said when I was awake I kept telling them how to extricate me from my car (I didn't realize there was no front end to my car). I just knew I was pinned in there and wanted out, but I was told I never panicked, just insistent on how they should get me out. The next thing I remember was seeing a helicopter landing (dang cop) and continuing to argue with them that they weren't flying me out. I didn't win the arguement and I was loaded up. I looked into the flight medic's face and told him "just don't let me die". Evidently I became combative in flight and well we know what goes on when that happens. Evidently at some point the sedation wore off in the ER and I remember hearing them say that C5 and C6 looked funny. I can remember thinking that's why I didn't hurt and thinking through the stupid thing I learned in class about what injury correlated to what vertebrae and thinking where does that leave me? What will I still be able to do? My life is about to change. Evidently things went quite downhill after that because I was out for the next three weeks and unaware of anything. My sister later told me when she talked to my chief his first comment was "is she still alive?". My coworkers kept coming around and talking to me, telling me that everything would be okay, but I wasn't aware of it, but it was good to know they were there and cared about me. I remember the first day I was aware of anything looking around and realizing what had happened and looking down at my legs which were in casts and I willed my toes to move. I had to know if I was paralyzed or not. They moved and I thought, well at least I have function, the rest can be dealt with. The doc came in a little later and I asked him when I could go back to work and the hobbies that I loved so well. He told me it would probably never happen and I would be lucky to walk again with the damage to my legs. I had pretty much broken everything in my lower body, suffered a head injury, pulmonary embolisms, developed ARDS, and lacerated my liver and spleen. Yet somehow I had managed to live and had not damaged my spine (the cervical spine issues were just a minor abnormality in the vertebrae in my neck not a break as they originally thought). Everything hurt, but I was grateful to be alive, but I wouldn't accept not walking or returning to EMS or the other important things in my life. I loved them too much. I knew the wreck had been bad, and I needed to see the pictures for closure, so I could fully understand what had happened. Everyone except my partner at the time refused to let me see. I just kept getting the response "you don't need to see that, you don't want to". My partner went to the site where my wrecked car was and took pictures and brought them to me against everyone's advice. He was adamant though that I saw them how he showed them. The first ones looked like I expected the car would and then he showed my the side. I no longer had a front end to my car - it had literally been ripped in half. Then I saw the section of what was the driver's seat and I just couldn't take my eyes off of it. When I looked, there was no space for a person. The only reason I lived was my seat broke in the impact and when the car crumpled, I was pushed back and what was left of the front end of my car was pushed up on top of me. I went from the front seat to essentially the back seat. A few more inches and I wouldn't be here. They had to push the front end back over three feet just to get to me. To this day I look at it and wonder how anyone could survive. It took over 20 surgeries to restore my body to a functional state and I was stuck in a wheelchair unable to walk for over three months. I had to stay in a rehab facility and every day deal with extreme pain. The next obstacle was returning to work and everything I loved. My mind couldn't understand my body's limitations or accept them. I worked my butt off in therapy and a year almost to the date of the accident I got to return to work released to full duty. I have worked extremely hard since then never giving up on any of my dreams, finally completing the last phase of my recovery almost five years since the accident and celebrating it. The accident as horrible as it was made me appreciate everything I had. My friends, coworkers, family and everyone that stood by me during that time. Also, it made me appreciate what my trauma patients went through and the long road to recovery they faced. Before that I only thought of it as get them on the helicopter and to the trauma center (remember I work rural so a vast majority of severe trauma pts are flown) never once thinking of the long road to recovery they faced or the fact that their lives would be forever changed. I didn't care about that I just cared about saving their lives. Not that it was wrong, I just look at them with a different expression now, one of knowing the long road they will face ahead. I have more compassion to those in that situation and yes, it affects my work and I'm glad. If it didn't I would be concerned. For me, it took going from caregiver to the one cared for to develop that empathy for my patients, but it's made me a better person and a better caregiver. I wouldn't have it any other way. Thank you to all those that cared doesn't seem to be enough, but words will have to suffice as I don't know any other way to say it except to try to pass it on to everyone I care for. Stay safe out there.

Cosgrojo's Story In High School I used to play football. Before Freshman year started, football practice began. During the brutal heat of summer we were required to participate in Two-a-days. For those who are not crazy enough to have played football... "two-a-days" mean two full practices (in our case 3 hours each) a day, one in the morning and one in the afternoon. Having never been involved in organized sports before, I was unaware of the difficulty that lie ahead of me. My sporting life prior to High School was intramural and pick-up games. The budgets for organized sports were cut completely in my elementary and middle schools. First day, first practice, about 3/4'ths of the Freshman recruits (including me) vomited multiple times due to the unusually brutal nature of our practices (The thought of up-hill bear crawls sends shivers through my spine even today). We would have about 4 hours off between practices to rest, recover, and have some lunch, and rehydrate. I would go home and spend most of that time laying in my bath-tub with cold water running over me trying not to puke. My step-father was an asshole (I know, appears random... but I'll work it in). My step-father was quite fond of my older sister, and spent a lot of time with her and a lot of money on her. She is the classic all-American girl with good-looks, tremendous athletic talent, and exceedingly popular. She always got what she wanted. I don't resent her that, if I had those gifts, it would be hard not to use. I did, however, resent how she was favored. The two of them would come up with these odd things that they wanted to do, and once they realized they really didn't want to do it anymore, and it required more work than fun, they stopped. Often times this meant that I now had to finish what they started. My Mother around this time was going through some mental instability problems, and was not fully aware of the strange dynamic that appeared to be brewing in our household. One day after practice number 1 was completed, I limped home, covered in bruises, feeling like I have been beaten with a baseball bat, barely able to bend down to untie my shoes, I was given a task. My step-father and my sister had apparently decided while I was at practice that they wanted to paint our porch. Now we were not rich, but had a big house. Real estate in the early nineties in rural Maine was very nice, big houses for no money. We had a gigantic porch. They had maybe gotten 4-5 feet (out of 20) of porch painted, when they decided that they would rather go water-skiing with some friends. I was told in no uncertain terms that this was now my responsibility. It took me a week. If healthy and without any physical pain or defects, would have gotten first and second coat on within the first day... easy. I didn't eat lunch, I didn't shower between practice, and I didn't make a peep. If anyone cared to look I was obviously struggling to overcome the trauma my body was under, but no one looked. My best friend Dustin would come by and offer to help, but I would tell him no. I didn't complain or bitch or make a scene. I knew that if I brought this to my Mother's attention that it could end badly, she appeared to be very emotionally fragile at the time. I knew that my sister didn't care, she was having a blast, and I knew my step-father was an asshole and just didn't care. When I finished, my friend Dustin was standing there with me admiring the job, and commented that I should be proud of what I did (mind you he is being very sarcastic, and paying me back for my persecution complex). He off-handedly commented while he was on a particularly good roll comparing my struggle with those of the holocaust, that I should sign it like Michaelangelo did all of his great works. I smiled and agreed. I went and found some bright neon green paint and slapped my initials in bold font "J.C." on the concrete slab in front of the porch. We lived right off of a major road in my bumpkin town, and the slab is literally less than ten feet from the road. I was pleased with my statement, and Dustin was scared enough to go home and make me promise I didn't say it was his idea (Dustin is a sweet guy, funny, sarcastic, bright... not much of a stand & fight guy). I won't tell you what the fallout was, That's too personal.... but I don't regret it. I don't get much opportunity to go back to my home town much, nobody I care about lives there anymore. Couple years ago when my Grand-mother was in the ICU (eventually died), happened to be driving around with no particular place to go, and found myself driving toward my old town. Much has changed, much has not. The current owners of the house have repainted the house, the barn and the porch. Remodeled the fenced in yard, and improved the lawn, and generally changed a lot. Almost didn't recognize it... until I saw the initials. Not sure if that is why I started crying right then, and am tearing up right now while typing, or something else entirely... Thanks for reading.

That is the persona he likes to portray, but he's really a big soft teddybear. But, OP, you gotta roll with it. Don't let other people's adverse criticism of others bother you. The ones who do the criticizing are usually buttheads anyway who feel threatened by someone more intelligent or better spoken than they are or don't take criticism well. Not worth your anger. Glad you are still around to tell that story ak. Must have been pretty scary.

I'd hate to know what some think of me. I'm all up for a good challenge and to learn and actually like when someone forces me to expand on something or give references to it (though I certainly try to when possible). Though some have dismissed me probably as secretive and full of crap because I refuse to tell particular things at times or state if you want to know more, to PM me as opposed to having things in open forum out of respect for those that give me that nice thing that pays the bills called a paycheck. I also tend to be quite animated and say what I think and well, if you don't like it I'm sorry. I can appreciate DwayneEMTP for that - he's a straight shooter and I like it. Vent and Dust - feel free to challenge me all day long. It is people like you that make me want to learn more (so I can argue more intelligently ! ) To even a few of the mods that I initially thought to be grumpy, I've learned over time that they really aren't. You just have to be willing to listen and learn sometimes (thanks happy feet !) and I've grown to respect them. I can't say there are many on here that I would care to work with because as one is on here and what one is to work with may be two very different things, but I think in general all try to give the best care they can. I'm in agreement with us all trying to be respectful of each other whatever the location or level. The best to you and be safe to all.

From the book "SLAM: Street Level Airway Management" found this tidbit on proper exam technique: "When assessing respiratory movement, it is useful to expose both the chest and the abdomen, and then look along the line of the abdomen and chest from a position close to the patients feet. From there it is often possible to spot small differences in the degree of expansion of the two sides of the chest which may be invisible from directly above the patient."

really? ! I agree, this is the least to do when using the stethoscope or looking for trauma or injury... well, this is concerning!!!