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Greetings, Comrades. Rumours of my demise have been greatly exaggerated. I can't believe some of you actually bet money I was dead. If you did, may all your children be born naked! Anyhow, I'm down, but not completely out yet. Don't pull your bets yet, because they will most likely pay off this year. I took a long hiatus to avoid creating [more] drama here and distracting from the forum. I didn't want to start a pity party, but as some of you know, I've had serious health issues since my injuries in Iraq. I certainly won't be returning to practice. Or walking. Or even wiping my own arse. My piss glows in the dark. And it takes all the strength, energy, and coordination I have just to type this. But shyte happens, so I'm cool. Nuff said. No worries. I've been devoting my attention to spending my time with family and friends, who keep my spirits up. I'm not a real fan of Walt Whitman (after all, he's from NY), but I often echo his thought that, "I no doubt deserved my enemies, but I don' t believe I deserved my friends." My thoughts exactly, Walt. And many, many of you here are my friends, so I owe it to you to keep in touch. If I have ever pissed you off or offended you, either intentionally or unintentionally, I apologise. I only hope that you recognise that it was most likely my passion for the future of this profession that drove my tendency to get carried away at times. Of course, sometimes I'm just an arsehole, but I apologise for that too. No excuses. There's not one of you here (over the age of 21) that I wouldn't happily buy a beer and get small with. Especially if you're hott. Anyhow, other than the occasional trip to the doctors at the VA, my life is pretty much spent in this bed, in front of this piece of shyte Macbook, so I hope to start spending more time here. I dropped in yesterday and read through some hot threads, and it got my juices flowing like the old days. I do miss you guys! Life is not total boredom here. Family from Japan came to visit me two days before the earthquake and stayed for a week. It was great to see them, but I sure hated to see them return home. The next week, half a dozen colleagues I served with in Iraq came to visit me. These weren't just guys I was stationed with; these are all guys who were actually patients of mine at one time or another. One had been so seriously blown up that I was certain that he died after I put him on the helicopter. Today, he's alive and well and looking great. The scar from my trach is more obvious than the rest of his many scars, lol. He's not complaining though. And getting to see him again was the greatest thing I've experienced in the last three years. I truly hope that all of you have the opportunity to experience that kind of satisfaction once in your career. Okay, getting really tired now, so I'll catch up with you soon. Kisses (no homo, not that there's anything wrong with that). And don't drink any water in Iraq, Rob

Hey, everyone. So I just finished day two of a five day stint today, and I had a couple of interesting calls and a good learning experience from one that I'd like to share with you guys. Patient number one was a female in her early twenties complaining of abdominal pain and difficulty breathing. Shortly after arriving on scene, I determined she was in diabetic ketoacidosis (blood sugar of 346, Kussmaul respirations present, abdominal pain and polydipsia) and I got her packaged and ready to go with an IV line running wide open. Unfortunately, I'm not (or wasn't) that familiar with just how quickly an open line should flow in, and while I checked it periodically to make sure that it wasn't flowing in more than I wanted to, it didn't occur to me that in my ten minute transport time I should have gotten the full liter in, and it also didn't occur to me until when we got to the hospital that she had had her arm bent and had kinked the line--which is why only about 150 made it in. My other mistake on that call was to let my uncertainty about our clinical guidelines and protocols get the better of me. I should have given the patient pain relief, but I didn't due to the fact that I was more concerned with what admin would say about mixing protocols. As it turns out, I would have been fine, but the real lesson learned here was that I need to be developing my treatment plans FIRST, and worrying about how it fits into my protocols second. I know what treatments I want to give, but I oftentimes get too wrapped up in worrying about what my protocols let me do that I start thinking only in the form of protocols as opposed to sound treatment. I spoke with Dwayne about this call afterwards, and he really helped to set my head on straight. He told me that I need to be putting the patient--not protocol--first, and he's absolutely right. Treatment plan first, how I'm going to make it work within my protocols second. It's about performing sound clinical judgment, and either finding a way to make your protocols agree with what you know the correct treatment is or getting on the radio and getting the doctor involved so you CAN perform the right treatment. And I know this sounds like common knowledge, but it really is a hard balance to get right, especially for a new paramedic. And even though I later found out that I COULD have treated the patient's pain no problem, it's the simple fact that when I'm assessing my patients, I'm not thinking of how I need to treat them, I'm thinking of what protocol I'm going to work under. So Dwayne's message to me was a good wake up call, and one I'm not going to forget. I'm not out to blatantly violate protocol, but my primary focus needs to be on how I can make this patient better or at least prevent them from getting worse and on how to at least treat them appropriately. And thankfully I got the chance to redeem myself in a way on my last call today, where I forced myself to take a step back and think about what TREATMENT I wanted to give, and then later found the protocol that made that possible. I'm not too proud to admit I messed up today. I had a chance to positively impact a patient and I let it slip by me due to my incompetence (not double, triple, quadruple and quintuple checking my IV line) and due to my preoccupation with protocol over correct treatment. And I'm sure I'm not the only one who's ever made this mistake, and if you work under pretty rigid protocols like I do, you've probably found that it can be hard to do what's right and still be within your protocol. Dwayne, you're the bravest paramedic I know, I've gotta say it, man. You are the epitome of what our mentality towards patients should be. You lost your last job doing what's right, and though it can be hard for us to stand on principle over practicality, you've proven that if any one of us want to be half the medic you are, we have ABSOLUTELY got to put the patient first. I wasn't doing that before, I knew the lines, could recite the mantra back and forth, but it takes more than just being able to read the script to really be that kind of paramedic. I know I get a lot of praise here for being "such a promising newbie", but the truth is, I'm not half the paramedic you guys are. If you guys could see me in action, you'd see just how green I am and how much, for all my words and strong beliefs about what EMS is, I haven't lived up to the message I've tried to deliver. But I'm going to do better. Because I want to be THAT paramedic who never compromises, who never puts anything but the patient first. I messed up today, and I messed up before today. And to be honest, I'll probably mess up again. But I'm going to try not to, I'm going to try and follow through with that I say, to act in accordance to my very strong beliefs about medicine and EMS. And maybe, just maybe, some day I'll really be worthy of all the kind things you guys say about me. But that day isn't today, and it isn't tomorrow. But every patient I see, I am going to remember what you said, Dwayne. I'm going to keep your words in the back of my mind and I'm going to try my damnedest to do what I claim to believe in. So thank you, Dwayne. You forced me to take all my philosophical bullshit and really prove that I mean what I say. And every day, I'm going to consider it a challenge to live up to the things I say and the beliefs I hold about medicine. And this is my challenge to the rest of you guys. If you've been letting protocol dictate your treatment, if you've been thinking protocol first and correct treatment second, if you've been saying the words but not living up to them, I want you to change that. I'm not asking you to violate your protocols, I'm asking you to think about what is the BEST treatment for your patient, and either finding the protocol that lets you deliver that care, or getting on the horn and asking your physician to give you orders that provide that treatment. Practice what you preach if you're not doing it already, and if you already are, make sure your partner is as well. Because that partner could be just like me, waiting to here the same words Dwayne told me, to break them out of their "what protocol do I use?" shell and back into thinking like a paramedic.

God Damn it! I've spent the last few years convincing like...three our four people here that I have some decent opinions and now you have to come and stick your fat head in again?? Let me talk to your nurse privately for a second, would you....? As most here, I have very few, if any, opinions that haven't been shaped by you in some way, and that's pretty amazing considering I wasn't a child when I started.. I know you're life isn't easy now, and I also know that you've made your peace, but apologizing for pissing people off? That is just pitiful..though I'm confident that we've not pissed each other off any... Good to have you back Brother...This will be good for you! You're going to find that there are some tough, wicked smart, determined new providers here that will challenge you...I'm guessing that you'll manage ok. Plus, some folks you knew before will surprise you with their new cert levels... I think that you'll soon see that not only have we missed you here, but that you're still needed here as well. Dwayne

Well the whole situation sounds immature and unprofessional. If you can’t work in a professional manner or work as a team with such a trivial matter then how do you function as ambulance professionals? The issue should have been solved there and then, instead it escalated to potentially impact on a call when you were being dispatched. Maybe some education in conflict management for all employees wouldn’t go astray.

You know what man, I couldn't have been prouder than when I talked to you today. You took responsibility for what you did and didn't do, and I'm very flattered by your comments. But there is a flip side. And many here are about to explain that to you. I've been fired twice now for doing what I believe was top shelf medicine. (Another time for just being an asshole..heh..but that's another story.) And each time I left my family without an income so that I could follow my morals and ethics as I understand them. The vast majority of the medics/nurses/basics that post here on a regular basis make me look like a monkey fucking a football when it comes to knowledge and practice. That's just simply the truth. You know why I focus on patients first and protocols second? Because I'm not smart enough to do what I believe to be the very best medicine that I can and at the same time constantly be comparing it to my protocols to make sure that I never get jammed up. I tried in the beginning and found that I could paralize myself with second guessing care vs covering my ass. I'm just not that smart. There are many here that can, and do, do both. So I had to make a choice. When I was in Afghanistan, I called my wife Babs once when it appeared obvious that I was going to get fired if I followed my conscience instead of my supervisors orders..she said, "If you choose to hurt your heart so that you don't get fired, I won't ever thank you for that. If you choose to damage your paramedic spirit so that you can keep earning that paycheck..don't come home expecting me to call you a hero, because I won't. Do what you always do...do the right thing. If that gets you fired then fuck em...come home and we'll get naked..." And I have followed her rules every day, on every patient, since that time. That works for me brother. Some people that I respect trememdously have shown me respect in return because they are confident that they won't ever have to question my direction. But if you're not prepared to get fired, not prepared for people to call your medicine bullshit simply because they are afraid to do what they think is best...then follow you protocols only. People rarely live or die based on our care. Some times they suffer more or less, and yeah, sometimes they live or die. But you have to make the decisions that are right for you, and the beautiful young woman of yours. Billygoatpete told me after I got fired last..."You know, I've never known a good paramedic that hasn't been fired.." And I believe EVERYTHING he tells me... You had a couple of good calls my friend. The lesson here is to find the happy medium. Don't become a "Screw the protocols" cowboy, but don't be afraid of every intervention because someone else may have been afraid of it... Protect your patient...from illness, and death, from pain, both physical and mental, and do so to the very best of your abilities within your guidelines and you should be coming up roses. But someday when you get your ass canned because your supervisor wants you to be a protocol monkey? Call me, or any of about 100 other decent medics on this forum, and we'll get you hooked up... :-) Dwayne

Our goal is treatment and transport of the ill and injured. Not fighting with people. Training in appropriate restraints to be used sparingly, yes, absolutely. Training in martial arts? No... gotta agree with Mobey here, if you're needing that frequently you may want to re-evaluate your scene-safety criteria. Yes, occasionally you may need to extract yourself from a sticky situation. Will you have the advantage if you have martial arts training? Totally depends on the situation. Wendy CO EMT-B

I have in the past, but won't do so again. It's simply shifting responsibility, and really only gives false hope to the parents. Not to mention places providers in danger needlessly during a code 3 transport. Dead is dead, no matter what the age. I don't advocate refusing transport, simply informing them completely of the risk and benefits of proceeding. Including telling them that realistically you won't make it to the receiving, and even if by some chance you do, you realisticlly won't survive the surgery, or the organ dysfunction associated with it. Not saying "there's a slim chance" that, again, gives false hope. The physician and transport team both saying, in unison, "I don't think you will survive the trip, how do you want to proceed?" is what's needed.

I have no problem trying to uphold his wishes as long as it is made crystal clear what his chances of dying from this bleed are(which I'd say are around 80-90% as described). If he still feels he wants to go through with it, we'll go. Emergency medicine does a crappy job if INFORMED consent. We get consent, but we rarely talk about the downside. If I told you "the only way you'll live is to go somewhere else" would you do it? Now how about if I told you "In my opinion there's a statistically improbable chance you'll live if we transport you somewhere else but most likely you will die enroute prior to ever reaching life saving care". Changes the picture a little doesn't it? This question rarely gets raised in normal EMS but regularly comes up in CCT and critical care as a whole.

Gastric lavage and charcoal are not the harmless interventions many have thought them to be. The old "activated charcoal binds everything" is not true, and it conveys benefit in a very few overdoses. When it does, it is not the single dose of charcoal we have been taught, but multi-dose activated charcoal that is given repeatedly. As per the American College of Medical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists, it should only be given for carbamazepine, dapsone, phenobarbital, quinine, or theophylline. If aspirated, the charcoal causes a horrible aspiration pneumonitis. The aspiration risk goes up if you are shoving a tube into a conscious patient's throat. The sorbitol can also cause potentially serious fluid and electrolyte shifts. For single dose activated charcoal, this position statement from the same organizations provides some guidance: "Single-dose activated charcoal should not be administered routinely in the management of poisoned patients. Based on volunteer studies, the effectiveness of activated charcoal decreases with time; the greatest benefit is within 1 hour of ingestion. The administration of activated charcoal may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to 1 hour previously; there are insufficient data to support or exclude its use after 1 hour of ingestion. There is no evidence that the administration of activated charcoal improves clinical outcome. Unless a patient has an intact or protected airway, the administration of charcoal is contraindicated." Gastric lavage has not really been shown to improve outcomes in poisonings either, and it comes with some serious downsides. The same groups put out a position paper on gastric lavage as well. "Gastric lavage should not be employed routinely, if ever, in the management of poisoned patients. In experimental studies, the amount of marker removed by gastric lavage was highly variable and diminished with time. The results of clinical outcome studies in overdose patients are weighed heavily on the side of showing a lack of beneficial effect. Serious risks of the procedure include hypoxia, dysrhythmias, laryngospasm, perforation of the GI tract or pharynx, fluid and electrolyte abnor- malities, and aspiration pneumonitis. Contraindications include loss of protective airway reflexes (unless the patient is first intubated tracheally), ingestion of a strong acid or alkali, ingestion of a hydrocarbon with a high aspiration potential, or risk of GI hemorrhage due to an underlying medical or surgical condition." Benzodiazepine overdose, like xanax, is typically pretty benign. In a medical setting where you can monitor their oxygenation and protect their airway if needed, there is no need to administer an counteragent (flumazenil. NEVER give this for a poisoning. You know what? Never give it.) or expose the patient to additional risk of complications from gastric lavage, whole bowel irrigation, or charcoal. There are specific cases when one or more of these may be useful. 'zilla