Just Plain Ruff

Thunder you meant less than 21 years old right.

Let me put my two cents in and my two fists If you cardiovert me without pain meds or sedation unless I'm unconscious, when I wake up I'm gonna clock you. If you cardiovert me agains my wishes no matter how bad off I am I'm gonna come back and clock you There is no reason why you should not tell me what you are gonna do and if I say NO you better not do it. Granted, if I need cardioversion then I'm gonna want it but if you do this against the patients wishes, if they say no then NO Means NO. As a patient I have total control over what you do to me, if I say I don't want and iv you better not give me one. I had a patient one day that was a blue as NAVY blue and he refused. I tried and tried to get him to let me treat him but he said NO I want to die. I explained risks and benefits of refusing and I told him that he would be dead in less than an hour. He still refused. AS a matter of fact I tried to reason with him till I was blue in the face but it didnt' work. We left the scene and just waited around the area. We got called back when he coded and we coded him till we got to the hospital where he died. I cannot believe that there are people on this forum that will come hell or high water do something to a patient even if they said no. There are two posters on this thread that seem to believe that they can do whatever they want to a patient when they are critical as your posts sound like you would do that. You know who you are. If I misunderstood the two of you please correct me if I'm wrong. If I'm not wrong and you would treat a patient against their will after they expressly said NO then I do not want you anywhere near me when I'm sick.

holy crapola and your service hasn't been sued yet? If I read right, the state of texas recommends a 2nd unit yet your powers that be haven't implemented this yet? Thats a lawsuit waiting to happen.

Nifty, I'm not saying that you are being untruthful but getting all that done in 8 minutes is really fast. I don't say I believe you but like Jetblue the airline says now "If someone says it happened, then it happened). But I'm gonna have to say I still don't believe you. full assessment, iv, blood draw, 12 lead and whatever else in 8 minutes that's to me not believable. What I'd like to know is do you have all the prep work done by someone like your partner or are you saying you do all the prep work and the skills in 8 minutes. If so I'd like to see you do it in 8 minutes. Again, I'm not calling you a liar I just have worked for both fast paced services and slow services and to get all that stuff done in 8 minutes you have to be one of the fastest medics out there. It sounds like you are really rushed and I'd be afraid things would get missed. I think that services that require you to do all that so fast are doing a disservice to their patients that they take care of. You may be the best medic in the world but to get all that in in 8 minutes is stretching credibility. Again, if you say you can do it in that length of time then by all means I guess you can. I've worked with well over 200 medics in my 15 years and I don't remember any of them doing all that in 8 minutes. That's just too fast and is chock with the possibilities that you will make a mistake. But then again, if you say it happens and you can do it without issue then Hoorah

Spenac, that's a terrible set of circumstances you have. I'd hate to need an ambulance when you guys are already out on a call. You are saying that you have not a lick of local backup? If so maybe reevaluation is in order but then again if it works then don't change it right? what state do you work in?

OH NO!!!!!!!!!!!!!!!!!!!!!! Don't take away my patches and my badge. the other image that watered down acls and it's cousins bring to mind is the episode of Cheers where Norm got a monkey to wear a postal uniform and had the monkey deliver the mail to Sam. that was a classic episode. One of their best episodes in my opinion.

I agree on the watered down version of acls and it's cousins I remember my first acls class - no helpers and in a room with 3 evaluators - you had better have known your material. It was not uncommon to fail the class. now we give an open book test, we play jeopardy for the final exam. I was a affiliate faculty ACLS instructor and it wasn't uncommon that we were required to give a student at least 3 chanses to pass the test. the skills stations are a joke - they allow books, cheat sheets and you get a group of people in the station. The strong ones were the ones that every weak student looked toward and there was no requirement that these weak students lead a station. There is a saying among some instructors similar to Geico "so easy a caveman can do it"

I agree Azcep, the threat of letting your license lapse and then having to obtain the training and classes would be a daunting task. Unfortunately I work so limited EMS that at the end of my licensure period I will be letting it lapse. First off I cannot afford the classes anymore to renew and also I do not have the time to get the hours. Sure many will say you can get it online but I have a different career path that I'm on so I'll let it lapse. I still have 2 years left on my license so I never say never but to get the amount of classes required would be a herculean effort. It will be an easy decision to let the license lapse as I've not worked in the field for over 6 months and do not see myself going back in the field anytime soon. But I can see how it's a much more pressing issue for those medics and emt's who do not have classes and education to keep their licensure up readily available. To some out there the closest class might be 200 miles away. Azcep you also bring up a good point - increase the education of the providers and have quality providers and the salary and pay go up

unfortunately with the more schooling we are going to get the argument, YOU have to pay me more. That is a valid argument if we are talking about services out there who require a 2 year degree or more but many services are happy with just getting someone who passed the emt or medic curriculum. A 2 year degree does the following 1. promotes professionalism in having a better educated employee - those with less education will learn by example and some will even go back to school 2. Provides someone with a well rounded education - remember folks - many people leave the EMS profession after several years to pursue other more lucrative and prestigious careers. Having at least a 2 year degree will help them get to that stage 3. The public can feel better about the profession because the profession finally has the same amount of education time that a basic RN does. If a 2 year degree was required then the employers would be forced to look at keeping educational standards high but unfortunately at this time the bar is not set very high. Consider a small town service or even a service that is in an urban setting. There is nothing written that they have to provide CEU's. Many services still require the employee to foot the bill. Don't even get me started on providing the ability to go to conferences and state wide meetings, there's no money in it for them. Let's take a look at the state requirements - In missouri if I can recall right you need 150 hours of continuing education over a 5 year period giving you 30 hours per year that you have to have. I know of many employers who do not provide education for their employees. If the service does not provide them then you have the requirements of getting to the class, paying out of pocket for your class and then finding a class either that fits in your days off or finding someone to fill your shift. This all leads me to this: The more education that is required for a medic or EMT to get into the field directly will correlate with the amount of continuing education that the state will require. The state can get away with the 150 hours in missouri due to the short training time required for becoming an EMT or medic but what will be in store for these medics and emt's if there is a mandated 2 year degree. I am afraid that with more education comes more continuing education effectively forcing some to really scrounge for classes and education to fulfill the state requirements. This also will directly correlate to the amount of education that the registry requires if you do not live in a registry state. I am all for more education, I have a BA, EMT-P and masters degree as well as several courses in religious studies that I'm taking now. the more the merrier. But is there a limit to the amount of education required for our profession. My wife is a LPN and she is not required to have any Continuing education. I'm not sure what RN's are required to have but it's a far cry from 150 hours in 5 years. Until we have the same status as RN's then we will always have to prove ourselves. So to make a long post short (too late) education is the cornerstone of our profession. But do the ends justify the means? Do we force a 2 year degree, why not go to 4 year degree while we are at it? I know Dust is in favor of this but I am not. I'm not even really in favor of a 2 year degree. I think that if we are to have a 2 year degree requirement then the upkeep of education on our license will get out of hand. IF we can come to a educated medium and a meeting of the minds and not require a huge amount of CEU's to maintain certification then a 2 year degree is a great idea. If we require a 2 year degree and also large amounts of CEU's per year then we are going to force some to leave the profession. A little more information(approximated hours and cost) ACLS 16 hours approx 200 dollars(maybe more) PALS 16 hours approx 200 dollars(maybe more) BTLS 16 hours I believe 200 bucks(maybe more) ABLS 16 hours approx 200 bucks (maybe more) The above do not even cover all the ceu requirements in terms of broken down hours such as cardiac, respiratory, ob, ortho etc etc. You then either go to a refresher of 40 hours. You will need 2 refreshers to get your hours in the 5 years. My refresher was approximately $360.00 Assorted other courses to completely fill your re-registratoin requirements up. If your agency does not provide CEU's or pay for them then we are talking a significant outlay in money to keep your certification. Let's now take a worst case scenario look at future requirements to maintain certification if we require a Associates degree. the feasible requirement could be upwards of 3 times the amount currently required. How can that be fair to the provider? This is only my imagination(my son uses his a lot) and it might not ever get that bad but the way some state agencies and the registry work this might be reality.

that was good Michael. Now what is your item to find

see through tuba's not to be found but I found a see thru tube [web:4666239159]http://images.google.com/imgres?imgurl=http://floridaparks.co.uk/assets/page-content/adventure_island/attraction.07a.180x130.gif&imgrefurl=http://floridaparks.co.uk/adventure_island/caribbean_corkscrew.html&h=130&w=180&sz=18&hl=en&start=13&tbnid=JLubQA_xBaa2rM:&tbnh=73&tbnw=101&prev=/images%3Fq%3Dsee%2Bthrough%2Btuba%26gbv%3D2%26svnum%3D10%26hl%3Den[/web:4666239159] Find me a picture of this place: The Valley of Achar

[web:2b73753fea]http://images.google.com/imgres?imgurl=http://www.geelongadvertiser.com.au/images/uploadedfiles/editorial/pictures/2007/02/18/brit2.jpg&imgrefurl=http://www.geelongadvertiser.com.au/article/2007/02/18/1491_news.html&h=424&w=350&sz=107&hl=en&start=1&tbnid=dVNWqLByfhnsgM:&tbnh=126&tbnw=104&prev=/images%3Fq%3Dbritney%2Bspears%2Bbald%2Bhead%26gbv%3D2%26svnum%3D10%26hl%3Den[/web:2b73753fea] how bout a scanalizer

http://images.google.com/imgres?imgurl=htt...%3D10%26hl%3Den [web:b9ae6f7695]http://images.google.com/imgres?imgurl=http://www.emergencydispatch.org/articles/images/1697215.jpg&imgrefurl=http://www.emergencydispatch.org/articles/TireAmbuCrash.html&h=150&w=200&sz=14&hl=en&start=2&tbnid=-Qk7benoiLSgOM:&tbnh=78&tbnw=104&prev=/images%3Fq%3Dambulance%2Baccident%26gbv%3D2%26svnum%3D10%26hl%3Den[/web:b9ae6f7695] now show me a yellow lizard

ambulance

http://images.google.com/imgres?imgurl=htt...%3D10%26hl%3Den Now go find me a banana covered in chocolate

You think that one's bad go to this site. http://www.jwcaketops.com/wedfigurines/occ...ationscover.htm And here's one for 100 bucks http://www.coloradocarla.com/Paramedic&amp...lTechnician.htm talk about over priced.

you know ebayer's are fickle people 95% of all bids are received/placed in the last 10 minutes of the auction. I never price my auctions high. They usually start at 99 cents or 1 dollar But if it's an item that there is a specific price I won't take less than then I will put a reserve on it but some people won't bid on reserve auctions because there is no guarantee that if they win the auction but for less than the reserve then the selle may not sell it to them. And never never set it for 7 or 10 days. those never get the bids that the 1 and 3 day auctions do. I always also put a buy it now option too. Shipping can also be a deterrent for bidders. depending on the item a shipping price too high is a death sentence for a auction

anyone notice that there are no bids yet?

The Pentagon announced TODAY the formation of a new 500-man elite fighting unit called the United States Redneck Special Forces (USRSF) These Texas boys will be dropped off into Iraq and have been given only the following facts about terrorists : 1. The season opened today. 2. There is no limit. 3. They taste just like chicken. 4. They don't like beer, pickups, country music or Jesus. 5. They are directly responsible for the death of Dale Earnhardt. The Pentagon expects the problem in Iraq to be over by Friday.

Being the cynic, I think that a radiological incident is one of the incidents we are least prepared for and as a result the majority of those responding will be either very very sick or they will die. I know of few ems agencies who have any type of gear to respond to an incident. Protective clothing and monitoring equipment I have never seen. Dirty bombs are foreign to most ems agencies other than they know it involves nuclear radiation but apart from that if you ask them what their plans are for this type of incident they look at you with a blank face or the deer stuck in the headlights look. I think we are in trouble if something big happens.

Has anyone heard of giving nebulized lasix? This article is pretty interesting. Credit is posted at the bottom of the article which I display here. THE USE OF NEBULIZED MEDICATIONS FOR THE TREATMENT OF DYSPNEA Defining Dyspnea and its Impact on Quality of Life Dyspnea is a subjective experience, often described as shortness of breath, or an unpleasant awareness of breathing. It is not necessarily associated with objective measures of respiratory function such as oxygen saturation or hypoxemia. Some patients with profound dyspnea have no objective measures of impaired respiratory function and some with extensive pulmonary impairments may experience no dyspnea.¹ Dyspnea may or may not be accompanied by a cough. Dyspnea is both common and distressing in dying patients. Ripamonti and colleagues² reported that more than 70% of hospice patients with advanced cancer or lung disease suffer dyspnea in the last 4 weeks of life. Both dyspnea and cough can negatively affect a patient's daily activities such as bathing, walking, and talking. The patient may become more isolated, dependent on others, and experience spiritual exhaustion.¹ Assessing Dyspnea The patient's self report is the best indicator of the presence of dyspnea and the amount of distress it causes. To assess dyspnea, staff can use an adapted 0–10 intensity rating scale. (For example, “if 0 is no difficulty breathing and 10 is the most difficulty breathing you can imagine, what number describes your breathing right now?”) This same scale can be used to evaluate treatment efficacy. Treating Dyspnea Medical treatment should focus on identifying and treating the underlying cause of dyspnea whenever possible. Treatable conditions such as tumor obstruction, pleural effusion, ascites, infection, and anemia are associated with dyspnea in palliative care patients.³ Common interventions for managing dyspnea include both pharmacological and nondrug treatments. Examples of nondrug interventions are Positioning the patient (most often this is in an upright position which helps make room for the lungs to expand) Using pillows to prop up the patient Cool air from fans, air conditioning, or an open window Calm, reassuring caregivers Relaxation techniques Pursed lip breathing Frequently used medications and treatments include Oxygen Steroids Bronchodilators Sedatives Oral and parenteral opioids Anxiolytics and tranquilizers Nebulized Medications Opioids Opioids have been used treat dyspnea since the end of the 19th century, although the mechanisms by which opioids are effective are poorly understood.¹ Today, opioids are a standard treatment of end-stage dyspnea. However, the systemic side effects of opioids, such as sedation, confusion, urinary retention, and constipation, sometimes are unacceptable. Nebulized opioids may relieve dyspnea by acting locally on opioid receptors in the lungs, thereby decreasing systemic side effects. Despite the potential advantages and effectiveness of nebulized opioids, there are few published studies documenting the effectiveness of this route of administration for end-of-life dyspnea. The studies that have been published are case series in small sample sizes. There are no randomized controlled trials, which are considered the “gold standard” of establishing the efficacy of therapies. Comprehensive reviews of nebulized opioids conclude that there is no evidence to support their use in the treatment of dyspnea.4-6 The reported side effects of nebulized opioids, though rare, include respiratory depression and bronchospasm. Some authors have suggested that fentanyl may be less likely to cause bronchospasm than other nebulized opioids.5 Although there is little research to recommend this route of administration, nebulized opioids are used clinically in specific situations. Anecdotal reports support fewer dyspneic symptoms in patients who use nebulized medications. This is an important factor to consider when collaborating with physicians to provide comfort to residents who are experiencing dyspnea. At Franciscan Hospice, we use nebulized opioids on an intermittent basis. If a patient expresses a preference for using nebulized medications, then that would be our first choice. Often we use sublingual morphine first to see how this works for the patient, as well as how easily the caregiver can administer this form. We use other opioids if a patient has had (or believes he has had) an allergic reaction from morphine. The patient's historical experience with opioids is important; we do not want to suggest something that causes increased anxiety resulting in increased dyspnea. Other medications Most of the literature about nebulized medications for dyspnea concerns opioids. However, other medications also are used. For example, there are case reports regarding the successful use of furosemide in terminally ill patients with dyspnea.7 Nebulized local anesthetics such as lidocaine have been used to treat cough associated with bronchoscopy, and there is anecdotal evidence for their use for persistent cough; however, they should be used with caution because they can cause anaphylactic reactions and impaired gag reflex. Moreover, they can leave a bitter taste.³ The Franciscan Hospice experience with nebulized furosemide (Lasix®) or bupivicaine is limited. In two patients, nebulized medications were ordered after traditional oral medications failed to provide relief. Furosemide was ordered for a patient who was NPO but still desired diuresis. Bupivicaine was ordered for a patient with a persistent cough who did not respond to cough syrups or oral opioids. Both patients died prior to using the medications; however, we felt comfortable offering this route as an alternative when other therapies failed. Examples of Nebulized Medications Used in Hospice and Palliative Care Opioids Small Volume Nebulized (SVN) Morphine: 5–10mg with 2.5ml saline (unit dose) every 4 hours prn dyspnea, can use along with albuterol unit dose. Hydromorphone (Dilaudid®): 2mg in 2.5ml saline every 4 hours prn shortness of breath. May use with albuterol unit dose. Fentanyl Citrate: 25 micrograms in 2ml of saline every 2–3 hours, prn dyspnea. Other Agents Furosemide (Lasix®): 20–40 mg in 2.5ml saline once or twice daily, prn dyspnea caused by fluid retention. Mucomyst®: 1–2ml of 20% solution via small volume nebulizer every 4 hours, prn thick mucous. Bupivicaine (Marcaine®): 0.25%, 1–2 mls every 4–6 hours, prn cough; begin with 1 ml every 6 hours, titrate to relief of cough, no eating or drinking for 30 minutes to 1 hour after the treatment. Tips for Working with Patients receiving Nebulized Medications When using nebulized medications, remember the following: Teach the resident not to hyperventilate and to breathe deeply during the nebulizer treatments. Have the resident sit up during the treatments to ensure full expansion of the chest. If holding the nebulizer is fatiguing for the resident, enlist the help of family members to assist. Avoid the use of facemasks for nebulized treatments, as these tend to give the resident a feeling of suffocation and cause trapping of aerosolized droplets in and on the nose. Observe the patient's technique for using the nebulizer. Instruct the patient to place the mouthpiece between his or her teeth, with the lips closed around it. Also instruct the patient to keep his or her tongue below the mouthpiece.8 Summary Further research with larger samples of patients is needed to explore the effects of these nebulized medications. However, clinicians can assess the appropriateness of providing nebulized medications for symptom relief in their individual patients. This decision is based on the patient's and family's goals, and the efficacy or lack thereof from other forms of treatment. Providing comfort to our patients and families is the goal each of us strives for in hospice and palliative care. -------------------------------------------------------------------------------- This month's Tip was provided by Pam Ketzner, RN, MN, CHPN, Educator, and Michael Lindgren, RPh, Pharmacist, from Franciscan Hospice, Tacoma, WA. References Coyne, P.J. (2003). The use of nebulized fentanyl for the management of dyspnea. Clinical Journal of Oncology Nursing, 7, 334-335. Ripamonti C, Fulfaro F, Bruera E. Dyspnoea in patients with advanced cancer: incidence, causes and treatments. Cancer Treat Rev. 1998;24(1):69-80. National Cancer Institute (2004). Dyspnea and coughing in patients with advanced cancer. Available at: http://www.nci.nih.gov/cancertopics/pdq/su...fessional/page2, Accessed December 16, 2004. Jennings, A.L., Davies, A.N., Higgins, J.P., Gibbs, J.S., & Broadley, K.E. (2002). A systematic review of the use of opioids in the management of dyspnoea. Thorax, 57, 939-44 Johnson, D. (2004). Nebulized opioids for dyspnea: fact or fiction? Retrieved November 23, 2004 from Available at: www.jasonprogram.org/nebulized_opioids.htm Joyce, M., McSweeney, M., Carrieri-Kohlman, V., & Hawkins, J. (2004). The use of nebulized opioids in the management of dyspnea: evidence synthesis. Oncology Nursing Form 31, 551-559. Kohara, H., Ueoka, H., Aoe, K., Maeda, T., Takeyama, H., Saito, R., Shima, Y., Uchitomi, Y. (2003). Effect of nebulized furosemide in terminally ill cancer patients with dyspnea. Journal of Pain and Symptom Management, 26, 962-7 Krames On Demand (2004). Using a nebulizer. http://www.kramesondemand.com/HealthSheet....ContentTypeId=3 Accessed December 21, 2004.

Skull Fractures Isolated linear nondepressed fractures with an intact scalp are common and do not require treatment. However, life-threatening intracranial hemorrhage may result if the fracture causes disruption of the middle meningeal artery or a major dural sinus. Depressed skull fractures are classified as open or closed, depending on the integrity of the overlying scalp. Although basilar skull fractures can occur at any point in the base of the skull, the typical location is in the petrous portion of the temporal bone. Findings associated with a basilar skull fracture include hemotympanum, otorrhea or rhinorrhea, periorbital ecchymosis (“raccoon eyes”), and retroauricular ecchymosis (Battle's sign). source: Emergency Medicine: A Comprehensive Study Guide, Companion Handbook (September 1, 2001): by David M. Cline, John Ma, O. John Ma, Gabor Kelen, Steven Stapczynski By McGraw-Hill Education - Europe

I find that to get rid of the evidence you should burn the item. Or take a pair of scissors and remove the spots that way Otherwise, I have found that if you get a tub of oxyclean and tide and make a paste, let it sit for about an hour and then rub it in, put it in a washer with very very hot water and run the cycle. should have awhite shirt again.

I am afraid that this is setting a precedent that we are not wanting to go towards. If you say "hey we'll see you in 30mins or less" or better yet "walk in the door and you'll see a provider right away" and you SET up hospitals that cannot afford to do this. 95% of the time the patient will and I repeat WILL be seen by a nurse and that is misleading since patients seem to think that they will be seen by a doctor in 0 minutes. Again we are catering to the people who don't want to wait for their doctors office appointment and come to the ER and dang it I've been guilty of it but It was justified. My son had a dr appointment at 2pm his fever went from 100 to 104.5 in about 30 minutes I bypassed the docs office. But for our society we are already pampered and coddled when it comes to healthcare. We want it quick and if we cannot get it RIGHT NOW we go to the ER and get mad when we have to wait there. By golly it's an emergency room and my emergency is more important than yours. What's next, parking lot docs or better yet, call the ER and they diagnose and treat over the phone and deliver the medications to your door I have never agreed with a 0 minute wait time or 30 minute wait because it sets up unreal expectations of the public that they will be seen by a doctor. You gotta love hospital marketing departments. oh and one other thing Medicine will NEVER EVER be paperless - I'm in that line of work, making hospitals as paperless as possible and there will never be any such animal as a paperless hospital

In my understanding suspended means you can't drive cause you are suspended. If that is the case then as Dust said and I agree with him "You are hosed" until you get that off your license And it may never go away - it might show those years as suspended and then an insurance company will want a detailed explanation of the suspension. The ambulance service as well as the insurance company will want to know something else. If your license is suspended then why are you still driving. If you are suspended I take that to mean that you cannot drive legally. This my friends is a prime example of how our actions in the past have direct consequences to our future plans and present situations. I'm not picking on the original poster at all I'm saying that the things you do now have consequences, to quote from Casablanca "Maybe not today, but soon and for the rest of your life"(not complete quote but you get my drift). for many of us it's too late because our actions have been done and the consequences are here now or will be. But for the youths reading this who are teenagers, please think about what you are doing and try to think long term. Keep in mind that what feels good right now may not feel so good in a year. If your license was indeed suspended and you weren't supposed to be driving while suspended then the ambulance company and their insurance company will most likely drop you like a hot potato.