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Sorry bro, but I am compelled to point this out because many people fail to make the proper determination. While it is possible to have a concomitant dissection and aneurism. It is not generally proper to say "dissecting AAA" IMHO. The pathology of a dissection versus aneurysm is different: In a dissection, there is somewhat of a tear of the intima within the vessel. This leads to dissection of the layers and the creation of a false passage between the layers. With time, this dissection continues until the false passage communicates with the external environment of the vessel. This is generally not good. The location of your bad dissections are commonly around areas of a vessel where you have high pressures and a turn of the vessel. Many originate in or around the aortic arch in the thoracic aorta. You can research the late Dr. DeBakey as he actually created a classification system for dissections and survived a dissection himself. An aneurism, however, is in essence a weak ballooning of a section of the vessel. Of course, many histological and pathological changes occur, but we can agree the basic mechanism differs from a dissection to an aneurism. Take care, chbare.

Here is my personal veiw on the matter, each member that rides in an ambulance must me the minimum of EMT-Basic if they are providing any medical care. If the purpose is for an Explorer Program then CPR and First Aid should do. I have heard and still hear to this day that "children" (Individuals under the age of 18 or still in High School) should not be allowed to take an EMT course or allowed to work / volunteer for a service. I believe that there is more too it than just an age, some people are more mature than others at an earlier age and are capable of handling the situations. For me it just made sense for me to take my EMT-Basic course during my summer vacation between my JR and SR year in High School. My class had five high school students in it with me being the oldest at 18 and the youngest being 16 (she was 17 by the time it was time to test). We all completed the EMT-Basic course and we all passed it on the first attempt (both the written and practical). Four of us obtained National with the youngest just obtaining State due to her age. Three of us joined our local EMS Service and attended to patients by ourselves, after being signed off on by our service. What was the outcome? I became a Paramedic, three are in Medical School and the fifth is in Law School. I firmly believe that if the individual is mature enough and has completed the training that is required to become an EMT-Basic then they deserve to be on a service. I am sure that some people will disagree with me, but hey it is a free world.

http://www.ems1.com/ems-news/735601-nd-ambulance-crews-rely-on-young-volunteers/

I was an EMT at 16, in this podunk, backwoods area. Lots of things aren't agreeable in words, or on paper. But rural America works with what it has, as does urban America. I'd go on, if this said rural ambulance sent live victim to the morgue.. But really, I don't see any problems, if that's what works for them, so be it.

I finished my EMT-B class about a month ago, currently I am 17 and a senior in high school. In this area they normally require you to be 18 however, I got into a special program that started up so my class was all high school students. I feel that if you are mature enough and smart enough then why should age matter? The only thing that I regret about so young is the fact that around here you have to be 21 to be employed by an ambo service, so I am going to be looking for jobs as an ER Tech once I get NREMT certified when I turn 18.

I agree with you in theory, however the american EMT student is poorly educated* and the (only) one or two ride alongs they do are often in the middle of the 4 month program, so they are not even ready to do the few basic skills that they are taught. *Individuals should not get offended. EMTs as a whole under educated. That includes me.

To those stating that you can poke an abdomen without fear of rupturing an AAA, and referring articles to cite this, you may want to review some pathology of aortic aneurysm. Many people have asymptomatic AAAs that may require surgical repair in the future, but are for the present, stable. It seems reasonable based on the posted citations that abdominal exams may be preformed without fear in these patients, when it is justified. However, in a patient with a dissecting AAA (different ballgame), I find it unreasonable to preform unnecessary palpation of the abdomen for teaching purposes. -daed

Hey Lisa. I'm not sure how old you are, but the only time I hear how valuable 'time in cert' as a basic is is when I'm talking to the part time firemen/medics and basics, at my service. They love the whole, 'whoever last that longest wins' concept. Most of the rest of us think it's utter bullshit. I like to believe that I am considered a competent medic where I work/have worked, both here and in Afghanistan, yet I've never worked a paid day as a basic. I truly believe that the most valuable things I use in paramedicine I brought with me. Kindness, attention to detail, a solid work ethic, a half decent ability to problem solve, a hunger to be a better medic tomorrow than I am today, the maturity necessary to talk with patients, make mature decisions, and the life experience to understand the pain of my patients and those that love them. Oh yeah, and an almost unlimited ability to haul the same drunks/drug addicts/psych patients over and over week after week without choking anyone. :-) In fact it's been my experience that the vast majority of the terribly difficult decisions I've made have been moral/ethical, not medical. I chose to go straight to medic school from basic based on the opinions mainly of Dust, chbare and akflightmedic, though many others were influential as well. I earned my AAS in Emergency Medicine and have never, ever regretted it. As chbare mentioned, EMS is the only medical field where many believe it is best to gain experience before knowledge. All others do it the other, and seemingly more logical, way around. If you choose to go straight to medic you WILL catch some shit from those that don't have a significant education (which is why they need the 'experience' scaffold to support their self esteem)...but f*ck em...this is about you, not them, right? Best of luck to you in whatever you decide. Dwayne

This is really two separate questions: 1. How long until your unit is available for the next run. 2. How long until you actually clear the hospital. It should rarely take any more than fifteen minutes to make your unit available for the next run. It is the driver's job to IMMEDIATELY take the cot back to the ambulance, clean it and the ambulance, replace linen, restock supplies, and notify dispatch that we are available, but still out at the ER pending paperwork. The driver shouldn't be dicking around in the ER, flirting with nurses, gawking at patients, eating and drinking snacks, smoking fags, or just generally being useless until AFTER the unit is ready for the next run. In my experience, the problem is usually that the driver fiddle-farts around forever before returning to the truck to ready it. As for actually returning to the street, it takes as long as it takes. If there is opportunity to do so without neglecting my patient, I will do some basic charting enroute. Mostly, I only get demographic info during the trip, as well as charting vitals and other immediate concerns. The narrative will all be done at the hospital when I can concentrate solely upon it, with all information finally available. That usually takes no more than thirty minutes max, and unless a priority run comes in, will always be completed before leaving the hospital. Of course, if you're using the lame-arse charting system (whether electronic or hardcopy) that is a simple system of box-checking and drop down answers, then this should all be happening in about half the time of a narrative. In that case, the medic should be ready at about the same time as the driver, unless there are unusual complications.

Wow. Just.... wow. It seems that there are at least three different questions here: Should abdominal palpation be done on this patient? Should it be done by an EMT or EMT student? Should it be taught to EMTs at all? Was the situation handled correctly by the OP? 1. Yes. Abd palpation is indeed indicated in the general examination of abd pain. However, it should be done at the proper time, by the proper person, utilising proper technique. And, of course, it should be deferred if the clinician determines a potential for exacerbation of the situation by the manoeuvre, or if it causes too much discomfort for the patient. Remember, it's going to happen again, probably at least twice, in the ER, whether yo9u do it or not, so there is little to be risked by deferring it in the field. 2. I'm a little mixed on this. There are instances where I would say this may be indicated. However, none of those instances would involve an acute abdomen, as in this case. And even then, it should be done only under the close supervision and guidance of an advanced clinician who has confidence in the EMT or student. 3. As already well stated by VentMedic, with the current state of EMT training in the U.S., I have to say 'no', abd palpation probably should not be taught in the basic EMT curriculum. Hell, for that matter, there are a lot of paramedic schools that shouldn't be teaching it either, because their students are neither the anatomical or physiological foundation necessary to properly implement and interpret the results. Most of them are wholly incapable of even identifying where organs and structures are located within the abdomen (and yes, my students get verbally quizzed on that within the first hour of showing up to my ambulance for a ride). And I am not for just doing shyte that looks cool, just to look busy, when it offers no benefit to the patient. 4. Should the OP have stopped the student from palpation as he did? Yes. No doubt about that. However, the reason he had to do so is because he FAILED to establish the ground rules and a clear line of communications with his student at the beginning of the shift (this, of course, is an assumption. He may have, and the student may have just been an idiot.). Before you ever make it to your first patient with a student, EXACTLY how things will work should be discussed, understood, and agreed upon by all parties involved. As an educator, I encourage my students to be assertive and pro-active, using initiative to be a part of the team. This should be tempered by the student's knowledge of his/her own limitations, of course. If a preceptor wants to play 'mother may I', then such problems are obviously going to arise quickly. For this reason, I also counsel my students to establish the communications and ground rules mentioned above, whether the preceptor brings it up or not. In this case, it appears that both student and preceptor FAILED in this, and both need to learn a valuable lesson from it. Ideally, the student would have known the limitations placed upon him by the preceptor ahead of time, preventing him from overstepping his role. This would have prevented the embarrassing incident in front of the patient. And it would have given the student a good question to write down and remember to ask the preceptor and instructors about after the run. I do believe I would like to have seen the verbal intervention handled a little more diplomatically, if for no other reason than to avoid worrying the patient. Instead of the old, "DON'T YOU EVER..." line, perhaps a gentle, "Uhhh... I think we're going to just defer the palpation to the ER, okay?" Yeah, I know that when you see something wrong about to happen, it is sometimes difficult to remain calm and diplomatic. However, that is what is expected out of a preceptor. You are, after all, a professional educator. Try to sound like it.

My experience in NYC was the same as how Richard B described it. For Charleston County EMS, you're considered clear the moment you show at the hospital. It's not uncommon to have the next call show up on your screen before you unload your pt from the bus. They have ePCR's with Zoll interface, so all the ED gets initially is vitals and ECG's. There is a 24 hour requirement to fax the completed report to the hosp. It's absolutely miserable to play catch up with four or five half finished reports at 0200 hours, or even at the station computer after your shift has ended. Fairfax County FRD won't dispatch you for another until you give the available signal, which is after the report is completed in it's entirety. We have Toughbook ePCR's like CCEMS. We also believe that we shouldn't be entering info into the ePCR while actively engaged in pt care. If you have an intern in the back with you, or are still onscene with other medics working the pt, then you may get a few things entered, but that's it. Typical ALS turnaround times in the County average 30-45 minutes, unless it's a complicated call with many interventions or an arrest, which naturally require more carefully documented, more extensive reports. I have a few thoughts about writing reports during pt care and being forced to clear the ED prior to PCR completion: CCEMS officially says that you shouldn't enter info during pt care, but it's unofficially encouraged (mandated even) that you get as much documented as possible, since it's highly likely that you'll be forced out of the ED prior to completion of the PCR. This obviously results in poor pt care if you're the sole provider riding in the back with the pt. There are many questionable unwritten rules at that place. If a crew has to play a constant game of documentation catch up with several reports during their shift, it becomes increasingly difficult as the day goes on to accurately document each report. You have maybe four or five reports with varying degrees of completion. It can be challenging to remember the details and pt interview from a few calls in the morning when it's now eight or ten hours later. This policy greatly increases the likelihood of inaccurate or even fabricated documentation, IMO and from personal observations. If it's policy to have crews be made available and handle calls without completing reports, then how important is it really to have a run documented by the crew? By making it policy to allow the crew to leave the ED with an unfinished document, only a verbal report to the ED staff, the agency is saying that PCR documentation is not necessary for the ED to treat the pt. Think about it - if you have 24 hours to complete and fax a report (or even 3 hours as some agencies require), the PCR is largely irrelevant to in hospital pt care at that point. the only importance the PCR holds at that point are billing, QA/QI and maybe some potential medicolegal issues. Subjecting crews to the constant game of PCR catch up throughout the shift, and into the overnight, only adds to burnout poor job satisfaction, and attrition.

Sounds like this town needs to build a closer hospital! Also, congrats to going paid. I also enjoy the critical patient's where I have the "bunch of paid ff/emt's" that can do cpr, drive, carry, lift, retrieve equipment, secure the scene, etc.

I'm sorry, but you do not let a student jab at a patients abdomen who has a c/c of abd pain, and than proceed to tediously press again and again on the patient's belly to show proper technique. If you want to teach the procedure, that can be done on a patient who is not in pain, or another classmate. And while I find the cited article interesting, it is not enough to convince me to abandon my practice of palpating an abdomen with a suspected dissecting AAA as little as possible, and I sure will not be letting a student do so.

Palpating the abdomen could not rule out or rule in anything you have listed here. Your presumptive diagnosis for the above is easily obtained by taking a proper verbal history, a physical exam (excluding probing the abdomen)and a series of accurated vital signs. In additon by not delaying transport and not taking the time for auscultation palpation and percussion of the abdomen the patient will reach definitive care and feel relief sooner. Tell me sir can you yourself, through palpation, tell the differance between Gastroenteritus and Diverticulitus? Would it matter if you could? Frankly, even if I could tell the differance I would still just tell the ER the patient has an acute abdomen along with the history, signs and symptoms I had found as I would not want to be responsible of possibly misleading the Doctor causing him to miss a real problem that I may have missed on my exam. The specific diagnosis of non traumaic belly pain is far beyond my skill set and scope of knowledge.

Children based EMS...