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Recently had an elderly female patient from a nursing home who had developed tongue swelling in the am which was progressively worsening. She is on Coversyl. 3hrs prior to EMS the staff administered 50mg Diphenhydramine PO with no noticeable effect. EMS was summoned when patient's sats were starting to drop and she was having a hard time speaking due to the edema. Are there any pre-hospital treatments that are effective here? She has already had a therapeutic dose of Benadryl therefore giving more is probably not indicated. She is not in extremis (and is 97 and has a LONG cardiac history) therefore Epi is probably not a great choice at this time, at least IM. Is there any benefit to nebulized Epi here? What other medications may help this patient? Cheers

Angioedema secondary to ACE inhibitor usage is different than angioedema secondary to an allergic reaction. In an allergic reaction, an antigen binding with a B lymphocyte stimulates the release of IgE, which in turn stimulates mast cells and basophils to release large quantities of histamine, which when bound to H1 receptors produces vasodilation and increased capillary permeability. Epinephrine's alpha effects can mediate this by causing vasoconstriction. In an ACE reaction, the bradykinin that the ACE inhibitor has prevented from being degraded accumulates and causes increased vascular permeability by acting on bradykinin receptors. Why does epinephrine's vasoconstrictory effects not work on bradykinin mediated angioedema? I don't know. Ask ERDoc. This is rapidly moving beyond my pay grade.

Ditto....am 49, over the course of 31 yrs was a milk man, a beer man, and owned a donut shop. Talk about diversity. How i wound up here.. not quite sure. Finished my EMT cert. in July, start with EMSA Tulsa,Ok. on 10/03. Looking forward to an exciting ride and view my age as only a plus. Jake's on the money, great site, great info', good luck.

The Pplat may be a good approximation of static compliance, but does not represent airway resistance (Raw). In fact, the common formulae we use to calculate Raw uses the PIP. Since we are talking about flow, (change in flow = change in velocity = acceleration = dynamic state) and thus movement, an examination of the PIP is valid. To gain a better quantitative understanding of the flow relationship, make a simple model of the lung. Assume a straw is placed into a balloon. The measurement at the distal end of the straw can be called airway pressure or Paw. The measurement in the balloon would be the alveolar pressure or Palv. The straw it's self represents the airways or the conduit for gas movement, thus pressure here will be a function of the product of flow and resistance. However, the alveoli measurement would be a function of volume divided by compliance. Of course, you would have to add whatever PEEP you have in the system as well. Since we are interested in the Paw as it is a function of the PIP as it relates to flow, we can develop a formula to describe all of the concepts as they relate to Paw: Paw = Flow * Resistance + Volume/Compliance + PEEP As you can see, an increase in flow will lead to an increase in Paw.

Oh yes, we absolutely must use a bougie; this applies to both regular intubations (i.e. dead people) and intubations facilitated by medicines (RSI) Anterior laryngeal pressure is not required but its often used so may as well be And Dwayne brother, I know you don't think you are better than any of us here so no problems mate, me on the other hand, shit, I'm so awesome it's just not even worth mentioning .... probably because I'd get struck down for pissing off Jesus with such vial and odious lies

Was the scribbled note the information written on the teletype printout? I didn't watch all of it, and to be honest got to the point where I wanted to throw something at my computer because of issues I'm probably being over sensitive about. Like not being able to define "BVM" (No, the definition is not "ambu bag"), calling asystole "flatline" (really, you're not the general public, you don't get to use lay terminology), and other similar word choice that is entirely inappropriate for a professional giving testimony in a courthouse.

Is this guy better?

I would have a very low threshold for securing the airway in this situation.

There's not much you can do in the field. http://www.medscape.com/viewarticle/484537_3

Her sats were dropping but by no means poor. She had gone from 99% at onset to 93% when we were there. A relative drop of 6% but still not a worrying number on its own. All V/S are appropriate with clear air entry and patient is resting comfortably. Anaphylaxis, which this was definitely not. Although if we got into airway compromise you could argue that it is in that realm. That does bring up an interesting point... is angioedema from ACEi REALLY an allergic reaction? From the reading I have been doing it seems there is no consensus. The general impression I get though is that it isn't really as histamine is not involved. The "best guess" is that ACEi also inhibit the breakdown of bradykinin which builds up and causes the angioedema. So is this truly an allergic reaction? Do they fall into a medical directive that is for "allergic reactions"? I can see that argument. In all honesty the thought didn't even occur to me until post-call (and of course I would have to receive an order from my base hospital physician to do it). Is Epi going to help angioedema? Epi helps edema in anaphylaxis (as far as I understand it) by "reversing" the fluid leakage into the interstitial tissue... is the same pathology present in angioedema? I honestly don't know. Yeah, totally agree there. Unfortunately steroids are not in my arsenal. Otherwise it is probably the most ideal option.

I wouldn't give her adrenaline; a hard time speaking does not automatically equate to poor airway. Where exactly was this ladies angioedema; was it on her face, in her mouth, or you know down her gob? What was her SpO2? Did it improve any with oxygen? Isolated angioedema of the hands, face or neck is a known side effect of ACE inhibitors is in itself not anaphylaxis nor an indication for adrenaline. Nebulised adrenaline may have some effect and is within our clinical procedures for anaphylaxis, again, in the absense of respiratory or cardiovascular compromise (again, "difficulty talking" is not airway compromise) isolated angioedema is not anaphylaxis.

Susan: Take this opportunity to help us understand what it feels like to become addicted? As a Paramedic with degenerating Arthritis, Narcs are in my future I am sure. How will I know when it has become a problem? What does it feel like to "come off" them?

Good question Akroeze! Assuming her lwr airways are not involved, and there is no stridor... Lemme throw this by you... The pt is obviously having an allergic reaction. At this point the swelling (although slow) is becoming an airway problem. We need to do what we can to reduce the swelling and manage the airway. The pt got 50mg PO of benadryl, remember all drugs thet go enteral are subject to first pass metabolism. The dose was also 3hrs ago. so really, as far as bloodserum levels are concerned, she is not "maxed out" as far as therapeutic index goes. In fact, she is probably below. I would give 50IV myself. That aside though I tend to agree with the IM Epi being a little risky with this pt who at this point.... is pretty stable. I would have no problem trialing a local epi via nebulizer to vasoconstrict and somewhat make her more comfortable. Also, getting a little epi into the system is always a good thing during allergic reactions with airway comprimise as it does in fact stabilize the MAST cell, therefore inhibiting the release of more histamine. I also may hit her with a Dexamethosone, or prednisone. It will help with the swelling somewhat, but moreso, we will be one step ahead in case this does go for shit later.

My suggestion for stuff to carry on your person 1 pair trauma shears 1 pen 1 back up pen 1 black Sharpie (Used for more things than you might imagine) 1 small notepad (pocket size) 1 pair sunglasses and a way to store them on your person 1 glove pouch with gloves 1 stethoscope 1 pen light 1 watch with second hand 1 pocket knife, preferably serrated, and easily opened 1 squirt bottle off hand sanitizer, pocket sized 1 duty belt that fits over normal belt and can easily be fastened/removed 1 pack breath mints or gum (to be used or offered discreetly to partner) 1 roll adhesive tape (if you can find the cotter pin assembly for a trailer hitch of the appropriate size, these work great to attach a roll of tape to your belt) 1 cheap cell phone that you won't cry about losing/having run over/getting some sort of body fluid on and has big stupid numbered keys to mash quickly. If you bring your iPhone don't come crying to me later. You might want to invest in a prepaid phone just for this purpose. 1 pair goggles and a way to store them on your person 1 radio (I mean bring your radio with you from the station. Don't go buy one.) 1 pair sturdy boots. I like the kind with a zipper on the side. 1 pocket sized protocol and/or field guide. If you keep looking at it then you might need to review a little more often. For in the truck: A water bottle. The bigger the better. Fill it only from trusted sources. Some snacks. Nothing smelly. Inclement weather and PPE should be provided. Jump packs and what is stored in them are generally in your outfit's SOPs. This list is what I've found useful in an urban/suburban environment. If you work in the great outdoors you might need things like bug spray, suntan lotion, bear mace, etc.

"does not take it due to financial constraints" Noncompliance with medications is probably the biggest reason we get called for seizure patients, followed closely by folks drinking alcohol, taking their medications, and then wondering why they still have their seizures. Very rarely do we see new onset epilepsy- but febrile seizures are incredibly common- generally at least one patient per day. Here it is. Now it's time to get tough with the family and ask how much they love their family member. Ask them if they would enjoy having to care for a brain damaged 23 year old brother/son/etc. I realize there are financial constraints but more often than not, the issue is not the money. Apathy, screwed up priorities are generally the real reason why someone does not take their medications. Nasty as it may sound, I have asked families of repeat customers- and patients after they wake up- if their beer/flat screen TV/ designer clothes are more important than taking their medication and possibly preventing their deaths or severe mental disabilities. Sorry, but sometimes tough love is warranted. Does it work? Sometimes, and I figure if it gets just one person to do what they should, its worth it.

You know it isn't sex that makes a marriage work, but it is taking the time to make love to someone so that they make you and you make them feel like they are the most important person in the world. I do agree with Dwyane in this, but knowing him and how he talks about his wife he dosnt just have sex with Babs. When you give yourself to some completely that is when all of the other aspects of the marriage fall into place, like communication (also very important) and just plain affections. We would like to think this guy is an asshole, and a coward but really when it comes down to it we have no idea what his life at home is like, and is he just acting like a gorrilla because there are "young bucks" around to gloat to. Its just like the "biggest fish story" I am a true believer in these senerio's there is always something more to the story. just my 2 cents worth have a good day

Hi Denny, Thanks for starting this topic, as a student (getting closer to "rookie" status!), I've been wondering about these things also. & to everyone who's responded, thank you also - great food for thought! Cheers, DC

No problem Dwayne: I noticed many people thought the paramedics handled the situation incorrectly because the patient was transported after being in arrest for an extended period of time on scene. This naturally led into conversations about working on scene and the fact that transport was not really indicated as the crew should have looked at terminating efforts. There were some pretty negative comments thrown around about the crew. Again, not necessarily on this site. Now that information is coming out, it seems circumstances beyond the EMS crew's ability to control occurred. I am not following the trial, but I listened to the paramedics testimony. They appeared professional and competent. It seems they suspected things were not right and it looks like they in fact were very aggressive about trying to obtain history and did a thorough patient assessment. They even called and received field termination orders but were overridden by the physician on scene who apparently felt a pulse in spite of all the evidence that pointed to the fact that MJ was clearly dead. Anyway, a good lesson in making premature judgements and assumptions. I'm not calling any one in particular out, but if the shoe fits... Island, you appear to have missed my point. It has nothing to do with what people think about MJ or his problems. My point is about some of the initial criticism of the crew who worked MJ. Edit for an additional point.

I sensed a disturbance in the force, and now I know why. You've been talking about me, Dwayne! As for the OP, do what you think is best. Take your time to make the decision, and consider the pros and cons to carrying any sort of first aid/medical equipment with you. There's plenty of both. Personally, my cell phone is the only thing I keep on me when I'm not at work, and that's honestly always been more than enough. I don't even hardly ever use the basic trauma supplies (4x4s, trauma dressings, etc) when I'm AT work, so I doubt they'd ever see use off duty. You may find that your views about carrying equipment off duty change over time, and you've got your whole career to tweak how you do things both on and off duty, so if you just want to experiment--do it! Test the waters both on and off the clock and see what feels right to you. -Bieber

Thanks Ruff, though I not only think that you give my current posts to much credit, but my original posts as well. A few years back I went back through some of my early posts, just to see where I had been, and if I'd made it anywhere...Good God!! Babs had to wrestle the cheese grater from my hands as shredding myself to death seemed the only appropriate punishment for the idiotic shit I subjected you all to. These new posters? Man...after being around here, plus practicing for a few days, they still make me feel like a poser sometimes. They're awesome. Thanks to all for participating. That's cool as hell. And Denny, a last, for now, word of advice? If you follow the path of most energetic new providers that have come before you, we won't see you here any more after a few weeks. The glow wears off. Some folks are going to challenge you to think, and prove that you want to be a good provider, not just a provider, and you may get frustrated and quit. Sometimes this place will piss you off, and other times it may be unfair, but staying here and participating truly will help you to stand out and away from the rest of the EMS sheep. That isn't always the easy way to be, but many of us here believe that it's morally and ethically the best. But staying will take commitment, and a plan. (Speaking of which..it's time to rattle young Mr. Beiber's cage again...) But I have faith in you Brother...You started out different, now lets see if you have the balls to continue the same way. Dwayne

FlamingEMT, if I was ever to refer to a coworker who happened to be homosexual by your login or avatar, I would be brought up on EEO charges, and rightly so. The fact that you do, when you claim to be an activist for homosexuals, is very ironic to me.

There are plenty of white people jokes out there. Black and Hispanic comedians make fun of white people all of the time. Just watch Kat Williams or Chris Rock.

Thanks Dwayne. Always the encourager. I haven't been out of basic that long but I am getting on up there in age. It is an old fart camo avatar. I could change my avatar to something that is more stimulating to your areolar smooth muscle but I will leave that to the Doc and his Weiner Pics. The Avatar is kind of cute though. We were making a small first aid manual for some local classes and I needed a spacer picture for airway evaluation till my model could arrive from school. So I grabbed the mutt and took a picture. The pic with the airway model is soooo much better. Dwayne is right ERDoc. I look forward to your post. I true learning experience every time. Denny389 keep in school buddy. Basic is a good place to start but if you really like EMS keep going. The more you know the more rewarding it becomes.

Wow, is anyone else singing Kumbyya? Thanks Dwayne. I'll admit, I'm here for personal satisfaction. I miss being out on the road. Where I am at now, there are zero opportunities to interact with EMS, except when they bring in a pt. I think of being here as my way of staying in the field and giving back. I agree, there are some awesome people here and the multinational flavor is cool too (though I think we are a bit heavy on the Ausies and Cannucks, lol). As much as we bash them, I still think the vollies are awesome to have here too. We can educate them (generally the ones that stick around want to learn) and I know more than once it has made me look something up when they ask questions. I also have a personal soft-spot for the New Yorkers that come around. As for my picture, I never thought the pecs of a NYS representative would get so much attention. Maybe I'll have to find a similar picture of one of our senators. I hear Schumer has nipples of steel.

And you know what Brother? Without new, intelligent, committed EMTs/Medics this site is nothing but a bunch of old fat guys and gals sitting around telling bullshit stories and losing track of what's coming down the road. It's good to have you here, though I have to tell you I'm a little shocked by your attitude. It's terribly uncommon that we have a brand new EMT that wants to buy and do everything that doesn't either tell everyone to fuck off when they suggest they go slow, or just disappear outright. You're a bit of an anomaly. Thanks for being brave enough to participate, not just in the forums, but to the responses that you've been given. Now, if you want to be a rockstar EMT....keep coming back. Be even braver still and get involved in the moral/ethical/medical discussions. Answer questions to the best of your ability and make sure that you help those that come after you to have the same bright, intelligent attitude. I'm excited to hear your thoughts as you move forward... Dwayne Agreed. Though I hate your avatar pic. Not because it isn't cute, because it's cute as hell. (DFIB, not you doc. Though I'm not pretending that your pic doesn't make my nipples a little hard) But because it makes me think of a young kid, someone maybe just out of Basic... All of your posts get my attention and have me really wanting to read every word. That's a gift. In fact, I love that we've got a bunch of regular posters now that are wicked strong, from all over the world, all walks of EMS at all different levels..I can't think of any time since I've been here that we've has so many really varried smart people at one time here and not have a single "my country/level/education/etc is better than yours" argument in....Man, I can really think of the last one. And Doc, I can't even tell you how cool, and important, it is to see you here posting all the time now. You're a gift. This is EMS at it's best in my eyes and my mind. I'm grateful that I'm allowed to participate. Dwayne

Ruffems - I bought my pulse ox on Amazon. No Rx required. A lot of folks with COPD are using them at home now. As far as carrying extra gear in my personal vehicle, any accident I see will invariably be 25 - 30 minutes before the ambulance arrives. Some of the equipment isn't mine but the local EMT school lets me carry it when I travel (KED, Splints)My jump bag is pretty basic kind of like UglyEMT's. Local LEO always want to help but have no EMS training so it is good to have someone around that can help them "not hurt the patient" with good intentions. I don't think any of you guys are mackin' on the ones that do carry gear. Everyone’s situation is different, call times, transport times and community expectation change by region and environment. If I roll up on a MVC and someone is already "working" the scene I try to get a verbal transfer report if I am a higher level of training. If the first responder is a medic I will try to get him to hang around and help. This is highly unlikely. The closest EMT-I is probably at least 800 miles from my AO. I don't automatically think the first responder is a tool, especially if he has invested in his own gear. He may prove me wrong but I try to give the benefit of the doubt.

Always carry a change of clothes. A good ipod and red bulls.

Don't spend the money on the expensive electronics. They will be of no use. If your job/dept gives them to you, that's a different story. As was said, stethoscope, trauma shears, basic first aid supplies and you are set.

I carry a jump kit thats pretty basic so it might give you a good starting point. I have used everything it it from time to time on scene when I pulled over off-duty. 4x4s, 2x2's, some roll gauze, band-aids,tape, one or two trauma dressings (some car accidents have big bleeders) a SAM splint, a couple of crevats, several pairs of gloves (amazed how many times a cop asks for a pair to help out),shears, a BP cuff, scope, I personally carry an airway kit because I needed one once and didn't have it so I have added it, a tube of glucose a pad and pen and finally an adjustable collar. Don't forget a rescue blanket. Sometimes I carry ice packs and heat packs if I remember to restock them after use. Anything more is overkill and the rig responding will surely have it. Its just in a samll bag with a star of life on it. It really is basic considering what I have seen some folks pull out of their trunk. I think of it this way, what are you going to see on the side of the road? MVA so the collar and bleeding control is handy same for the SAM, blanket and ice pack. Possible cardiac related so having your scope and cuff beyond that pray for a quick response from the rig. Possible diabetic emergency so there is your glucose. Beyond that anything else probably wont be getting used. Almost forgot my reflective vest with EMS on it. Just want to be safe LOL As for how to act on scene, the same way you would on duty. Calm, collected, polite. When the LEO arrives or the rig gets there give your report the same as you would to the ED Nurse (well maybe just identify yourself to the LEO). If you get a hot shot its my scene kind of person just let them know your level of training and explain why (politely) you are going to stay with the patient until higher care arrives. As for what to carry on your person. Scope, shears, pens, pad, reference guide if your so inclined. I also carry a small flash light (about 2 inches long runs on a AAA). I do carry a pen light because it always seems like the one in the bag is dead or dying. In the winter I do add a pair of Mechanics Gloves just so my hands stay warm and don't stick to the stretcher. I have had my PPE gloves stick and rip so I usually just pull them off switch to the gloves for the lift then reapply fresh PPEs. (Im wierd so take that with a grain of salt if you like). As far as the cargo pockets, it has been said good for the wrappers and stuff to keep your area and even the back of the rig clean and clear (please nothing with blood or fluids on them). Keep it light and remember the rig should have it if you need it. Hope this helps and welcome to our little world here.

Seriously I don't know what I would have done if this site was not available to new EMT!! Amazing responses you guys are telling me and making me think twice before I do anything dumb!! I am taking all these tips and advice into considerations. Keep em coming!!! Thanks

Plus, aren't pulse oximeters consider medical equipment and you need a Dr. Order to buy one? Maybe I'm wrong but I don't think I am. Let me ask the collective hive here. What do you think of the EMT or Medic who stops on scene to help the person, you arrive and are met by said EMT who has put the patient on oxygen and a pulse ox. Seriously, what are your initial thoughts about this person on scene? I've been on both sides of the coin. More often on the negative response from the arriving ambulance than good. Was told by a fireman who was the only guy to get on scene in a fire truck. Ambulance and other trucks still on the way. Rollover accident on the interstate. Three patients, three ejections, 2 of three critical. The guy tells me, "You can leave now, I've got it" I told him I wasn't leaving. He got pissy, said I'm the shift captain and I'm in charge. I said fine, are you a medic or EMT? He said emt. I said I'm a medic, I've already begun treating these people, they are your patients but I'm the highest medical person on scene so they are mine until your ambulance gets here. First arriving law enforcement officer arrives, the fireman tells him to remove me from the scene. I told the cop the same thing and the cop said I could stay. When the ambulance got there I gave them report and they said thanks. I did tell the medic as we were loading one into the ambulance that the captain tried to force me off the scene and the medic said "The guys a tool. He's the last person I would want treating my dog" or something to that effect. I sent a letter to the fire department but I never received a response. I also had a great response from a small ambulance service when our ambulance stopped at a bad crash. We initiated treatment, resuscitation as a matter of fact. Ejected patient with significant head injury. Crash just happened. We had patient intubated and worked the patient until the responding ambulance arrived. Got a letter of thanks to my EMS Supervisor for the help on that one. But seriously, think about what your response would be to the off duty emt or medic, out of their jurisdiction helping out by putting Oxygen and a pulse ox on the patient? I'm sure viscerally it's a negative one.

I would add to my previouse post that that is what I carry to work because the ambulance has all the other equipment. In my truck i carry all that other stuff, Jump bag, KED, glucometer, thermometer, pulse oximeter and a long couple of long kelly's. I have them because I stop to render aid when not on duty and purchased most of it within the first six months after graduating EMT school. At work I use the company's equipment.

Wow, you sound just like someone else on here, I just can't figure out who it is.

Let me ask this question Why can't straight people make gay jokes when Gays do it all the time? Why can't whites or mexicans say the N word when Black people say that word all the time even in front of my children at various public functions? Why can Blacks say the word Cracker to a group of white people but when a white person says the N word he get's attacked or worse? Why isn't the Gay community up in arms when an openly gay actor plays a womanizing man on "how I met your mother" but when an openly straight man plays a gay actor he's chastised for it? Why can two black men made up as two white women in a movie yet when the idea is posed for the same but it being two white men it's deemed racist? These are all questions that I've asked as well as some of my friends ask. Why the double standard? Should there be a double standard?

I don't know FlamingEMT2011, aside from the information published here in the City. I do know, from dealing with folks from all walks of life, if they are in any group that feels, or actually is, oppressed in some manner, that they use self depreciating humor, but woe be to anyone outside the group that attempts using it. 2011 may simply be doing that with the avitar.

Do you think its at all ironic you're decrying homophobia with a blatantly stereotypical homosexual character as your avatar?

Ruff had a great idea about the refresher course. Also, as several have noted, every so often we get thrown a curve ball we have never learned about. Example: A couple years ago, we received a notice from a local hospital that 2 patients in our area recently had LVAD's implanted and were being discharged home. (Left Ventricular Assist Devices). I assumed they were similar to balloon pumps, but honestly I had no friggin clue what these things were. Luckily, soon after this, a local hospital offered a seminar- sponsored by the companies that manufacture the devices. It was one of the best decisions I ever made. I got to play with the devices, see what they did, how they operated, learned what to do if the device or one of it's parts failed, how to resuscitate these patients(NOTHING like you would expect) learned what to do if a patient calls and has one,, who to contact to reach out for help on the device, and much, much more. We even met several patients who had the device implanted, and they explained what they were all about, issues they have had with the devices, and how best to help them. There is no way in the world I would have known what to do if I had not attended this class. I ended up educating others about it, but there is no substitute for getting the information first hand, and thank gawd I did spread the word because shortly after that, one of them ended up dealing with a patient with an LVAD. Point being- you'll never be fully prepared for what you will see- regardless of the quality of your education. With all the medical advancements, we need to be on our toes and keep up on current trends. Reread your texts, reread your notes, retake your exams and quizes. Ask people to quiz you to be certain you have a good grasp of the material, and constantly ask questions. You can make up the gaps in your knowledge- it will just take a bit of work. As for the clinical aspect, once you are comfortable with your knowledge base, the skills and confidence will follow. That is always the hardest part- regardless of your paramedic education and training. Good luck.

Being in the field puts prehospital providers in a difficult spot. Once you are done with class, your learning is up to you. Even if you are an active learner, when you work by yourself in the field, there is no one there to tell you when you are doing something wrong. As others have said, be very mindful of the company you keep. Talk with people who stay on top of what is going on in the field and are willing to accept changes to procedures and protocols. Stay as far away from the people who say, "Why are we changing? We always do it this way."

I am not trying to sound like a jerk, but I learned this lesson a long time ago: You decide what kind of day you will have every day. You can not let others control your life, which is what you do when your blood pressure goes up over what someone else said or did. The minute you show any emotion because of what someone else did, you have given them control of your day, it is like you are a puppet on a string. Example: If I said something mean about your momma right now, it could piss you off to the point of you punching me. But on the other hand, you could say "crotch does not know my momma, he has never even met me, so therefore he is trying to piss me off and control my day". Let it roll off of your back, its not worth being upset about. I worked for a large urban system that was on 24/48s and the shifts were brutal with the normal EMS abuse you would expect. I went to work cussing and I came home cussing. Then they switched to 12-hour shifts, and I figured out I could transport 6 patients, or not transport 10 patients. Once I quit argueing with the dumb patients and just started transporting, all the stress was gone, and my smile returned. When I saw that change I realized I had been letting others control me.

1. That D50 can be given P.O. (by mouth). 2. Never get a refusal on a drunk, especially one that has endured any form of trauma (even minor). 3. That glucose machines are not always accurate. 4. That some drug ODs actually present as hyperventilation, until they quite breathing about 15 minutes later. 5. For every flight of stairs you are climbing, you can add another 100lbs to the patient, same for every foot of space-width that is lost in a mobile home hallway. 6. When patients say "I am dying", they are usually right. 7. Treat the patient, not the monitor, some folks have some ugly rhythms, but it is what they live with everyday. 8. Always check your truck completely, the day you dont will be the day you are missing a piece of equipment, at the worst possible moment. Especially if you work a busy 24, cant tell you how many times I have had to go to the last call location or ER to get equipment that was left by previous shift. 9. Never leave a patient that has called 911 more than once in a day, it is bad to have to explain why a patient called 3 times, was not transported, and died. 10. To combat the medication errors mentioned before, do not put medicine vials that look identical right next to each other in the drug box (albuterol and Atrovent), put medications that are potentially deadly (Heparin, Dopamine,) in its own separate ziplock bag and label with magic marker so you have to be a double dumbass to grab the wrong bag. If you have meds that are almost identical, switch the vendor on one so you get a different color box or size of ampule. Ideally, you should have a dial-a-flow or pump on medications that can be deadly. 11. Not all doctors graduated at the top of there class, and many ER Docs are not ER Specialist, but may be a dermatologists who is working part-time (especially the more rural you get), sometimes you have to step up and be a patient advocate. Thats a good starting list.

Ok, my biggest mistake is this one About ayear out of medic school. Had a patiet in a paced rhythm but no pacer spikes visible on the lifepak 10. Gave 100 mgs of lidocaine and they nearly arrested. Was humbled in front of the physician at the ER. One more - I didn't have to learn this lesson but I saw it in action and it nearly cost me my job. Take responsibility for a mistake. Three man crew. 2 medics in back for a eclamptic patient. She starts to seize. I pull the narc box out per the medics orders. I open it for him. He then proceeds to give what at the time was Valium 5mg. She eventually stops seizing and we arrive at the ER. Go in the ER, give report and return to the ambulance. EMT says "Why did you guys give her morphine?" I said we didn't. Medic who gave the med looks at the syringe and goes white. I imagine I'm white as a ghost too. Medic says "Let's get out of here, I'll take care of it later" I went NO FREAKING WAY, that's a med error and we need to report it. He refuses says I gave him the wrong syringe. I tell him he's full of crap. I walk into the ER, find the doctor and explain what happened. The doc says "no wonder she has pinpoint pupils". I return to the ambulance and the medic is way pissed. Silent treatment all the way back to the city. I request a meeting with the supervisor. WE meet up at headquarters and my medic partner blames it on me. The supervisor asks who pushed the med and the other medic said that he did push it. So into separate rooms we go, one supervisor for the medic in question and one for me. Our stories don't match. In the end, the physician called the station and said that they had a honest medic on staff (ME) and that the patient suffered no long lasting effects from the error. The Emt said that the other medic just was going to "fix it" and that really sealed that medics fate on this incident. The other medic was removed from duty and ended up getting fired for something else that I cannot remember. We never worked together again and he never talked to me again. Not a very big loss if you ask me but had I not have stood up and took responsibility for my part and the other medic refusing to take responsibility for his part, it could have ended up very differnetly. Always take responsibility for what you do, your integrity is very easy to lose and nearly impossible to get back. So personal responsibility is not taught much at all.

lol some of these things, you guys definitely SHOULD have been taught in class! A few of my own: - The need for resilient patient advocacy in the face of everyone else (partner, police, supervisor, fire department, family) wanting you to take a shortcut. Don't ever get lazy or forget that your patient comes first. - How critical the turn-over report really is. Specifically, the first 10 seconds of a turnover report. You make an impression either way, but it is up to you to capture your audience or not. They won't wait for you. - How little we really know. Be humble. You are the brains and experience out in the field but anywhere else in medicine you are just an infant with an ego. Try to remind yourself of that on a daily basis. - Don't fall into the trap of eating out all the time. - That it isn't your emergency. People say this all the time in school but it doesn't really hit home till you're out there for a while. It is your job to be calm and retain the ability to look at things objectively. That means you need to stay above the hysteria by whatever means necessary. - How important it is to look and act professionally at all time. It matters more than we realize, to both our patients and our colleagues. - Continuing education. Do it. Not just the minimum. Find out what the outcome was with your patients and reevaluate your approach constantly. - etc.

Those Paramedics are absolute fucking retards, demonstrate piss poor medical knowledge and generally embarass themselves. The Prosecutor asked him to spell oropharyngeal airway, he just doesn't answer, probably because he can't spell it. The second Paramedic answers he intubated Jackson without help, well, he just proved he is a retard, it takes another person to provide anterior laryngeal pressure and introduce the endotracheal tube over the elastic gum bougie. Makes me want to hurl a whisky bottle at the telly

Anyone that utters any gay jokes or anti gay statements should be fired on the spot. I am tired of straight people turning a blind eye to this type of BS.