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Triple Canopy is a top notch business! As far as 'taking over' contracts, I am not too sure that is the case. It is not common that contracts are 'taken over. I am sure Triple Canopy submitted competitive bids for the contracts you reference and subsequently were awarded based on the presentation. Triple Canopy along with the other commercial contractors will pay what 'the going rate' with respect to government guidelines, area of operation and specific job description/assignment. Allow me to caution you on the 'tax free' issue. There are very specific guidelines that one must follow so as to take advantage of the 'tax free' status. For example, one must be out of the continental US (CONUS) 330 days [of 365] to even qualify. Additionally, only the first $83K is 'tax free.' If you are looking to get into contracting, I highly recommend that you research 'everything.' Although I am sure that you have gained a great deal of experience in the 'Level 2 Trauma Center' you referenced, you need to appreciate and understand that there is an incredible difference between 'conventional' medicine, which you are experienced in and 'unconventional, out-of-hospital' medicine that is an absolutely 180 degree difference. I highly recommend that you obtain a significant amount of training in Tactical Combat Casualty Care [based] courses and test yourself to see if you can perform to standard. Should you find this to be your nitch, then build on it with passion. Do not let it be a flash-in-the-pan per se. Contractors such as Triple canopy are only going to tap into those medics with operational experience and a significant training dosier. Good luck to you! DC

So I used more pain meds on my patients last month than any of our other Paramedics. But as primary job is within 10 minutes to the hospital the director of nurses and me had a not so polite discussion about me interfering with doctors assessments of patients because I do pain management. The nurse said unless more than 15 minutes out I should not give pain meds. I told her my patients health and comfort come first not the doctors convenience and that any doctor that knows their job can still properly assess a patient that has been given pain meds. Plus if it seems to be hindering they can reverse the affects. So was I wrong? Would you withhold pain management? Also I am fully in compliance with my medical directors pain management guidelines, so this is not me being a rogue medic.

This nurse obviously has no idea what she is talking about. The literature shows that giving pain medication does not interfere with the exam, in fact it has been shown to improve the accuracy of the exam. Even if you are in the hospital bay, give pain meds. In the time it takes for the pt to get into the hospital, onto the hospital strecher, triaged, wallet biopsied, etc, more meds will have had time to work. I'd recommend keeping a file of studies on the ambulance to show to hospital staff that have no idea what they are talking about. Here are a few to get you started. http://www.ncbi.nlm.nih.gov/pubmed/17636812?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedreviews&logdbfrom=pubmed http://www.ncbi.nlm.nih.gov/pubmed/17032990?ordinalpos=11&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1070812 That should be enough to get you started. Spenac, I'd make it a point to make sure this nurse got copies of these (as well as the doctor if he/she did in fact complain).

Unfortunately, anyone who's been in the field awhile knows the ugly truth; you don't have to do anything wrong to get shafted. And if nurses, doctors, or other medics start talking shyte about you, you're likely to be labelled unfairly, potentially resulting in problems. It is extremely important to keep your documentation ducks in a row, as well as communicating concerns with your medical director. If someone complains to you, relay that to your MD for his input. Anytime a concern about you gets to him, it should come from you first, not through the rumour mill. He who gets his story in first wins. Just assure that you are indeed fully within your protocols, communicate effectively with your MD, and put your patient's first. That's the best way to hedge your bets and stay out of controversy.

Ditto to the above responses. I too have administered analgesics upon arriving at the ER and have also given them while waiting for a bed while extended at the ER. Most local facilities around here do not complain as they are aware their personal perceptual opinions are irrelevant to our treatment and that we will stand behind our argument that any competent physician can appropriately assess a patient with analgesia on board. Most of the decent agencies around Houston have very liberal (i.e. unlimited) pain protocols. My current guidelines allow for analgesia prn for as long as the patient can maintain consciousness and their own airway. If your patient reports pain, it needs to be addressed in the appropriate fashion. Personally, I wouldn't concern myself with comparison statistics to other medics nor the impulsive concerns from a receiving RN. Beneficence can and should go a long way!

Anyone in a position to precept students should have a very clear understanding of what both the preparations and expectations of the preceptorship are. Different programmes have different set-ups. Some schools integrate students into the field early to get them early exposure and allow them to integrate education with training and observation. Others do it step by step, not sending them to the field until they have all of their didactic done. Both students will be at different levels of preparation. However, neither should be expected to be competent practitioners of ANYTHING. Expect nothing. Teach them everything. That's your job. If they knew it all, they wouldn't need you.

Dust forwarded this video. IT IS SHEER GENIUS. What a great way to vent frustration and identify an issue. I have told everybody to boycott the trauma show and A.J at JEMS is doing the same. I have emailed the link to everybody I know and they love it. I could not resist the chance to send the link to Randolph Mantooth. He'll laugh his ass off. I'll let you know what he says (he loves this kind of stuff). Again, sheer genius lurks somewhere in the confines of this list. Thanks for letting me in on it. Bryan Bledsoe, DO, FACEP P.S. There is an "E" at the end of "Bledsoe" (e.g., Drew Bledsoe). But, it's all good.

"It's the three important things about emergency medicine, which is never give up, never give up, never give up. Because there's always hope." That is cold!!!! My link I hope the link goes thru...

What a win-win that would be! Blondie's boobs and continuing education to boot! It just shows what TV could really be . . .

Fairly new evidence based thoughts out of the UK where many concepts are discussed: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2751736 Much of the immobilization hysteria in the United States boils down essentially to the following broad concepts: 1) Defensive medicine 2) Protocols 3) Ease of Movement Take care, chbare.

I don't think it is fair to expect anyone to know "everything," especially a student ride-along. Not only is it not fair, but it would sap you of obvious teaching opportunities. The best learning experiences are often the ones borne of mistakes. As a preceptor, I want my riders to make some mistakes... that is why they are there, to make mistakes under as controlled an environment that we can provide for them. Hopefully the services have chosen well and provided the preceptee with a smart and experienced preceptor. I, along with many over the years on this on-line community, have yelped for better education for EMS. I have even done my part in some small way by becoming a part of the education process. Wanting higher standards and more progressive education does not mean that you also have to expect perfection (for lack of a better term). I think it is important not to lose sight of the fact that EVERYTHING is a learning experience, and our students need to be given every opportunity to get the most out of all the different ways there are to learn. Many people learn in different ways. Some may devour the med lists and contraindications like I do buffalo wings, while others learn from going out and seeing it in the field while riding next to letmesleep. I think that this is the reason why we provide them with these various opportunities to learn... and if it isn't the reason... it should be. We aren't like bees... we are not brought into this world knowing everything we need to know. Some of us are slow learners, but once they get it... they get it. It is imperative to remain patient with our riders... even the ones that you don't think are going to make it. Just some random thoughts based on the convo.

Good on you mate, I think analgesia is probably the most important part of prehospital care.

This is one of the many reasons that i decided to pursue a career with EMS, ive spent a lot of time feeding people alcohol. Im a responsible bartender, observing the laws on over-serving customers, but of course there are many people who get behind the wheel anyway. Its a crappy feeling to know that somewhere along the way one of my customers might have been involved in an accident. So i decided to start the transition into another career direction. Im still a bartender, ive gotta earn a paycheck somehow! I have done very well for myself slinging drinks over the years so ive already got my schooling paid for, now ive just gotta do the hard part, buckle down and study.

I am very proactive in controlling patients pain and I'm sorry if that ticks off the docs a bit, but I'm going to within my ability to do so and providing the patient is stable enough to allow it. Every patient is different so that would influence how far out I gave pain meds (within the 5 minute category). I think to withold pain medication is not only cruel but compromises patient care - pain increases heart rate, anxiety, among other things. If you can reduce that don't you see positive effects from it? As to the being close to the ER, well, I'm going to go ahead and give meds if the patient warrants it because our ER's around here are almost always overcrowded and it takes the docs a bit to get around to see a patient sometimes. Sometimes it's even a bit before someone comes in to assess them (the nurses sign paperwork, ask for vitals, and leave). If they already have some pain control on board then it helps them wait out those long minutes. From a patient perspective, I can say I've appreciated the few times I've received pain meds due to a few significant injuries I've had. It was one of the kindest things they could do. It at least took it from being almost unbearable to just discomfort which I could more than live with. Old people I've found are some of the most reluctant to take pain meds as most have been raised with the "suck it up" mentality, and younger people the most willing. That's solely an observation and much of it depends on the patient's prior experience with pain. If the worst thing they've had is a stubbed toe, then obviously a broken arm is going to be unbearable and if the opposite is true, then they will have a greater pain tolerance (which varies from person to person as well). I hardly think you are overstepping appropriate patient care Spenac - you have put your patients care and comfort first, and I'm sure they thank you for it. You already knew your answer as others stated and I give you for your treatment of your patients. If a nurse fusses at you again, just calmly ask - if you were in this position wouldn't you want some analgesia? I'm pretty sure their answer would be yes. It's not cruel and it got alot of people in our area to change their mind set. Most don't want to give to due lack of convenience, it's one more thing they have to give, one more thing to chart. But when you flip the coin and get them to thinking about it being them, most will soften. Continue your compassionate care (wait did I just say that to spenac?) and always stay safe.

Yeah, but your word's good enough for me. And I agree at that point that things might possibly be improved for a cervical spine injury. But what has come before that? In the group of patients we're talking about, look at the manipulation that's taken place. And now, not just against the weight of the head, but against the force of another person attempting to hold it still. So after all of that manipulation, unless you have a way to from combative to immobilized without movement, by the time we've immobilized are we still really doing any good? I'm not so sure... Anyone have that study that compared New Zealand, with almost no immobilization of any kind, to a New Mexico service that immobilized nearly everyone, that showed the NZ system showing significantly reduced morbidity where spinal injury is concerned? (Again, taken from my head, I could be misremembering) I was just talking to our medical director the other day about this, but I can't remember where I saw it, though he was familiar with it. Though my thoughts are not likely to change anything, I sure find the discussion interesting... Dwayne

Hello all. I’m Angie and I am a student at the UC. I’m excited to read your stories, thoughts, and opinions as well as contributing my own. Any questions, feel free to ask!

I think you guys are all up in arms for nothing. -The medicine will never be 100% accurate in a show like this, we're just going to have to get over it. For the lay public (read: the vast majority of the viewership), the medicine is just a backdrop anyways. Nobody really cares whether it was actually VF on the monitor or if you treat it with analgesics versus electricity or whatever. That stuff is esoteric detail that is only really important to a minority of viewers already in the know. -EMS workers are not so "professional and dedicated" that it is a sin to portray their moments of weakness. The NREMT is upset because the show had a scene that involved a paramedic driving under the influence. What is the assumption here, that such a thing cannot and does not happen? Get over yourselves. We're not special, we fall victim to the same mistakes everyone else does. -Say what you will about the so called profound effect television has on the hearts and minds of the viewing public, but I don't think there is any real expectation out there that the show is a perfect portrayal of EMS. Police officers on Law and Order routinely abuse suspects and break the law, House MD crosses the line on every single episode, and most car chases on TV break the laws of physics on a regular basis. Viewers don't bat an eye. Shows like this aren't about reality, more like hyper reality, and the viewers know it. - Count your lucky stars. At least the characters on this show all seem genuinely interested in their work, are compassionate towards patients and dedicated to providing (at least what the show considers) quality medical care. These providers have excellent, direct working relationships with doctors and nurses, and the profession is portrayed as an essential and necessary component of our medical system. That's a BIG step from being an "ambulance driver," guys.

I would be curious to see any evidence against a C-collar and if there is any evidence against manual stabilization... I agree there are arguments to both sides, and I can see where in some situations the collar would cause more harm either emotionally or physically, but what about the consequences of those people who are paying more attention to the hot chicks than keeping in-line stabilization? Without a collar to at least help hold them in a neutral alignment, couldn't the distracted people holding manual cause more harm if there is in fact a spinal cord injury?

I voted a -1 so I feel as though I should back it up. One sentence really: Clinicals are part of the educational program.

Hey Angie! Welcome to the City! What level certification are you currently, or trying to achieve? Remember, to really get your moneys worth here, you have to participate. The lurkers take very little from here. Express your opinion, judge other peoples opinions, share your ideas, admit when you're wrong. See? Easy! :-) Good luck. Good to have you on board. Dwayne

I was under the impression that an intelligent clinical program was designed to give students those exact skills, right? Surly I don't have to explain to you that no amount of 'pretend pt assessment' in school prepares them to do well upon entering the clinical setting? Do you mean to imply that you came out of medic school a seasoned paramedic? I have to doubt that. Or perhaps you are of the school that believes that only those that have been Basics for so many years should be allowed into paramedic school? What did you believe that clinical time was for?? Dwayne Firefly, I was under the impression that he was referring to clinical time, yet it appears you're referring to FI (Field instruction, Field Internship, etc) of a newhire. Those would be two different areas of education as well as separate conversations I think... Dwayne

It is not just you. It is a profession wide weakness that unfortunately I don't see improving unless drastic steps which may hurt some are made. As far as the students - I'm wondering how they managed to successfully complete their ride time if they cannot complete basic functions of patient care. I've been left wondering the same thing a few times. I remember very well when I started and felt like I knew nothing. Everyone has a learning curve and as long as they are willing to listen and learn GREAT ! If not, please keep walking. If you are employed and ride with me, you are expected to know routine treatment for certain conditions, your common protocols, and also be familiar with your common medications you will be using. I will quiz you on the information and yes, I have been known to leave a student at the station writing drug cards during a run and told them come back when they know their drugs (granted I only go with what is on the approved list, not every drug they could possibly see - I'm not that hateful). As a student, you are expected to at least know the basics, and you certainly should by the time you are being precepted as an employee.

I also would like to emphasize that the 83K is only tax free if you spend a significant amount of time OCONUS. That means no bumping the nasty with the wife in the United States when you take leave. I learned that one the hard way. I would also emphasize the fact that the operational environment in Iraq or Afghanistan (where I worked) is significantly different from anything that you have ever encountered. Many of the medications have different names and routes, any medications are used that you would never see used in the USA ( Isosorbide and sufentanyl infusions anybody), and the operating tempo is quite different. In addition, a working knowledge of primary care, medical intelligence, epidemiology, and diagnostics is mandatory. Depending on your job, operational experience is a must as stated above. I was not an "operator;" however, we still worked in the non-permissive environment and spent much time behind the wire, therefore operational experience was still needed. Good luck and as stated research and have a good idea of what you are getting into. I learned valuable lessons the hard way. This is a money driven business, and with money comes all the various problems that accompany such a concept. Unfortunately, it's pretty tough dealing with said problems when you need to worry about planning a route of travel, kidnapping, firefights, IED's and VBIED's. EDIT:Welcome to EMT city DCHealth. Good luck and take care, chbare.

I can honestly say that I have done much more in my lifetime -- or even just the last few years -- deserving of a Nobel Peace Prize than Barack Obama. So have probably half the medics on this forum. So yes, the Nobel Prize is rendered completely irrelevant by this gesture. Ronald Reagan was not even nominated for a Nobel Peace Prize for eight years of actual significant achievements. There are damn few winners since 1980 who can match his achievements. Talk tough, achieve greatness = loser Talk nonsense, achieve nothing = winner

>> Its just TV to me<< The power of television has been debated ad nauseum since Felix the Cat first appeared in early TV demonstrations. The bottom line however is we are so overexposed to TV it might be hard for us to realize how much it does manage our perceptions. Especially in younger people. There are several young EMTs in the Paramedic Prep class I'm attending that are all ga-ga over EMS air transport. They know little to nothing about aircrew safety statistics, the over triage, especially in pediatric cases, of many patients, and the exsisting studies that show lack of improvement in patient outcomes. What they do see is the percieved glamor, and in the case of one female student, how cool she'll look in that flightsuit. And she actually said it was the show "Trauma" that peaked her interest. She's a EMT in a small IFT company and I don't think she's even seen a helicopter up close. Skepticism, in most of us, only comes with age and experience. So to say, in effect, TV is just TV is a stretch for the general population. It's more about what information we take in, and the quaility of that information, not its source. For example "Emergency" vs "Trauma" - one good - one bad - and both from the same source, television. If viewing TV was a medical procedure we'd have to call it invasive. And if we spent more of our spare time reading peer-reviewed EMS journals instead of watching TV we'd all be better off . . . NickD

Sure, its no Law and Order, but i find it slightly entertaining. There are much worse shows on television these days if you ask me. There isnt much else on the tube on Monday nights anyway. Ive been a bartender for most of my adult life, and the movie "Cocktail" with Tom Cruise is a terrible portrayal of what its like in this business. But its still worth watching. "Trauma" feels the same way to me. I agree that the character development needs some work, but people say this about almost every new show, because we have no idea who they are yet.

Wow there sure is a whole lot of hatred for the show on this site! I agree that its corny and unrealistic, but its a drama, they are all corny and unrealistic. Sure it portrays some EMS workers in a negative light, but as long as we dont attempt to emulate these characters on the job i dont see much harm in it. At the end of the day, the show is about EMS workers helping people. Of course the show isnt completely accurate, the viewing audience doesnt care about the ins and outs of this business. They want to see intense drama. I understand some of the displeasure around here, but boycotting a show? Cmon! Its just TV!

I'd be willing to bet that he's referring to a possible increased risk of transmission from the exhaled neb. In the future you might want to reach a little and begin by assuming that the poster is not an idiot. To imply that reuse of his disposable nebulizer was the crux of his issue is short sighted, and a little silly. Again, I don't believe he was asking for an opinion as to how 'it sounds' but for people that have experience with it and can offer an educated opinion. Not trying to bust you chops brother, but you've made a poor start... Most of us did when we were new here. Welcome, and I hope you'll stick around. Dwayne

Let me start off in saying that it doesn’t matter if your student is coming from a degree program, a fly-by-night program, or anything in between. Is anyone else out there sick and tired of MEDIC students that are getting to their clinical rotations and can’t handle simple pt care? How is this happening? Let me qualify the question a bit: A medic student is working at a department in a non-responding capacity; let’s say they are a secretary. This person decides to educate themselves by going to EMT school so they can improve their billing skills. After approx 10 years of this job choice they take further advantage of the educational bennies their department offers and they attend an accredited medic program, so they can make more money and transfer in to the field. Of course during these last 10 years they have made many friends along the way who have “helped” (and I use that word loosely) them along the way. Now they come to do a ride-a-long and can’t start a simple interview let alone run a call as expected of them. The above is a fictional story, but pretty damn close to reality. It seems to me that over the past few years numerous students are coming in to be precepted and have no clue about their meds, how to interview, perform skills, or any combination of such. Is it me? Am I getting old and crotchety? Why is it that my generation of medic is holding this generation of medic to a lower standard?

I disagree with blaming the schools for this phenomenon. The schools are there to produce an entry-level employee, not a five-year veteran. As most of you know there is a big transition from book-learning to patient care. The problem is not with the school, it is with our substandard training and orientation programs for new hires and new medics. I think new employees should have to ride third or with a preceptor until they have been checked off (actually ran) every type of arrest (adult and pediatric) and other critical calls. Until the prove their worth on the most critical of calls, they should not be the lead provider on an ambulance. In a busy service, this means they would probably have a 6 month orientation, in a slow service, maybe a year. Do you honestly believe someone who just passed the Bar exam and became a lawyer gets assigned as lead counsel on the highest profile cases 2 months after they get out of school ? There is only so much that can be taught in the classroom with manequins.

Umm... how bout using a new neb each time? What's the problem here? IV ventolin? For respiratory? Sounds less effective and more dangerous...

Here's another study with sabutamol It does help with the search when you enter the name for the drug most commonly used in countries other than the U.S. Intravenous salbutamol bolus compared with an aminophylline infusion in children with severe asthma: a randomised controlled trial Thorax 2003;58:306-310; doi:10.1136/thorax.58.4.306 http://thorax.bmj.com/cgi/content/abstract/58/4/306 Unfortunately I'm not coming up with too many recent articles. However, here is a very recent article on SARS and MDIs. There was a lot learned from SARS and most of it was what was done wrong or could have been done better especially for the respiratory isolation issues. But then other parts of the world don't always have the expertise of Respiratory Therapists. http://www.rcjournal.com/contents/07.09/07.09.0855.pdf

So, to add to this conversation. It looks like there is some good news and bad new out about H1N1. It looks like it is starting to come back (with a vengence perhaps). Total influenza hospitalization rates for laboratory-confirmed influenza are higher than expected for this time of year for adults and children. And for children 5-17 and adults 18-49 years of age, hospitalization rates from April – October 2009 exceed average flu season rates (for October through April). The proportion of deaths attributed to pneumonia and influenza (P&I) based on the 122 Cities Report has increased and now exceeds what is normally expected at this time of year. In addition, 19 flu-related pediatric deaths were reported this week; 16 of these deaths were confirmed 2009 H1N1 and 3 were unsubtyped influenza A and likely to be 2009 H1N1. A total of 76 laboratory confirmed 2009 H1N1 pediatric deaths have been reported to CDC since April. The good news is: Almost all of the influenza viruses identified so far are 2009 H1N1 influenza A viruses. These viruses remain similar to the virus chosen for the 2009 H1N1 vaccine, and remain susceptible to the antiviral drugs oseltamivir and zanamivir with rare exception. This is taken from http://cdc.gov/h1n1flu/update.htm Though I don't think the immunization should be mandatory, I will be getting mine, as will my family.