medic001918

+1 for a well spoken post. I have to agree that you shouldn't ask for advice if you don't want to hear it. No matter what it might be. My service allows us to use our cell phones as well when we're at work. As long as you're not with a patient. As for your example about your boyfriends preceptor having a comment about the phone, that tells us that he's new to the truck and/or service. As someone who is learning under someone else, there's things that you can pay attention to and learn. Study a map. Learn the truck. Read new protocols. Experience in another service doesn't mean much, you're new to the service you're with now. Just as an FYI for Ruff, the walkie talkie phones can be put on vibrate. Mine is on silent all the time at work. So it's not much different then a regular phone call coming in. But then again, I don't use it on scenes and often times it's left in the truck. Shane NREMT-P

We use soft restraints and have 5mg Haldol/2mg Versed on standing order for violent patients. The hospitals actually prefer us to come in with combative patients sedated already. Saves them the trouble of doing it. Shane NREMT-P

The whole talking on the phone thing that frequently can be a negative in an employer or coworkers eyes. Look at the math, if you're talking 6 times at 10 minutes each, that's an hour per 16 hour shift that you're spending on the phone. Most other employers would not allow such a thing in any other line of work. I don't mind talking on the phone, but only after everything that needs to be done is done. That includes knowing about your PSA, stocking of the truck, knowledge of the gear to be used, etc. After everything else is done, you can talk on the phone provided we are not doing anything having to do with a call. As a new person there are other things that can be done with an hour. CME's if required. Geographical orientation. Learning where everything in your ambulance is. Making sure you know your protocols. And probably most of all would be making sure your partners get a chance to get to know you. I know when I'm working with someone new, I can be hesitant to let them tech some calls because I'm not comfortable with them. After all, it's my license since we run medic/basic trucks. Some time spent talking to me or asking questions goes a long way towards me having some confidence in you as a provider. Be interactive with your crew members. They'll come to respect you for it. People tend to talk in this field quite frequently. As a new person, you want to be known for your ability as a provider and as someone that can interact with the people you work with. Not as someone who does nothing other then talk on the phone. Keep work and personal life separate. It can be a vicious circle when the two collide. Shane NREMT-P

If an ALS provider is assigned to the call, they have an obligation to perform an assessment on the patient as part of their duties. If you're present and do not do an assessment, you are being negligent in your care. An ALS assessment is supposed to go into more depth than that of a BLS provider, if for no other reason then the training and understanding of anatomy, physiology and pathophysiology. Shane NREMT-P

I'm afraid I have to disagree with letting a BLS provider deal with everything else if there's a new medic on scene. A paramedic should not be on their own if they're not a solid BLS provider and fully capable of managing a scene. Just because someone is a new medic, does not give them any less of a reason to maintain control of their scene. After all, part of being a paramedic is having the ability to make the decisions that need to be made. This does not just apply to medical and clinical decisions. As scene control can adversely affect patient outcome if done poorly, or improve patient outcome when done properly since a paramedic is technically responsible for the scene, it doesn't make much sense to let someone else assume the role that you're going to be responsible for unless that provider is equal in training and certification. My feelings on the subject are not based on an ego or even being a paragod. They are based on liability and legality. If I'm going to be held responsible for something, I'd prefer to be the one who has made the decisions so that I can fully explain the rationale behind them to someone if the need arises. While the public might not make a distinction regarding BLS vs. ALS, the legal system will. I think it all comes back to training standards and requirements. If you're not capable of managing a scene, maybe you shouldn't be a lead medic? Shane NREMT-P

+1. Have to agree. No need to provide false hope. Shane NREMT-P

Here we have a protocol specifically for downgrading calls to BLS providers. As a medic, we are still supposed to write our own run form regarding our assessment of the patient in case the call ever comes into question. I'm always hesitant to hand off care of my patient to a BLS provider I'm not totally comfortable with because as has already been mentioned; it's me that someone is going to come to and start asking questions. When it comes to BLS vs. ALS assessment, I'm all for a BLS provider doing some level of assessment. However, I have an obligation that an assessment is done thoroughly to my level of care. That means that I may interject questions into the assessment that I feel are pertinent. This will help to complete the assessment and also to steer the assessment in the direction I feel it needs to go. One thing that does drive me crazy though, is when I'm on a scene before a BLS provider and they come in and start stepping all over my assessment. If I've already started, please let me finish. I just might have an idea as to where I'm going with my assessment and I may have already asked them the question. Shane NREMT-P

You are correct. Movement of the patient will create a waveform that could be misinterpreted. Shane NREMT-P

+1 for a well written post. The only thing I can add in regard to the paramedics not using an AED frequently is that we are trained to use a manual defib and to interpret the EKG on our own. Commonly, our monitor/defib is capable of far more then just defib as we can visualize the rythem, pace, cardiovert, control the energy for the shock, etc. That's why you will rarely see a paramedic using an AED as opposed to a standard cardiac monitor. Shane NREMT-P

The topic of albuterol in CHF patients is highly controversial, as is many aspects of medicine. I will occasionally give it in patients with a CHF exacerbation. But there are a few things that I have to get done before I will go ahead and do that. In any CHF case, one of the most beneficial drugs we can supply a patient is nitro. These patients need to be hit hard with the nitrates and keep them going. I also do a 12-lead as one of my first steps to help rule out an MI. I also want to make sure that I secure IV access and push lasix (or bumex) before giving a breathing treatment. Morphine is always an option for the vasodilation effects, but more importantly for the CNS depression that it causes. This will often take a very anxious patient and bring them down a little bit allowing for more effective ventilation. This is especially helpful if you need to ventilate via BVM. Occasionally I will give a breathing treatment. If a patient has spent some time in CHF with fluid in the pulmonary system, this is enough to cause an inflammation or a form of bronchoconstriction that the albuterol treatment may help with. The breathing treatment is commonly the last step in my treatment of a patient with a CHF event going on. Shane NREMT-P

While I don't agree with the tactic, I wouldn't say that a meth dealer isn't a major crime. Meth is a rather heavy drug and is a major problem in many areas of the country. It would certainly rate up there with rapists and murders. It's not something I would want in my neighborhood. There are other undercover means that they could have applied to get in there to perform this operation. I'd like to know why they chose this one. But that's not really something we will ever get to find out. Shane NREMT-P

Peter Canning's books are bother really good books. I have read both of them and have the pleasure of working with Peter as he is still a practicing paramedic in Hartford, CT. I was even more fortunate to have Peter as my preceptor when I became a paramedic. He is a great writer and a great provider. It's too bad he hasn't written any other books recently. There are some good books out there if you look hard enough. Shane NREMT-P

CISD is a personal thing. Everyone "debriefs" in their own way. Weather it's by talking to a friend or family member, going to the gym, playing a sport, etc. The list could go on and on. Whatever you do to help you deal with the stresses of what you've done. And that applies not only to things on the job, but stresses in general. As far as not recognizing how sick the patients were, that's a separate thing. How far into your class are you? If you're nearing completion, you might want to think a little more about what you've learned in class and how it applies to these calls. It sounds like it was a pretty nasty scene that may or may not have been lacking the organization it needed in order to ensure it's success. I wasn't there, so I can't say. With experience comes the confidence in recognition of what is happening on a scene. Many scenes can be chaotic with countless things going on at once. Hopefully there's someone doing a good job of orchestrating resources to help maximize patient care and minimize scene times. After you've got some calls under your belt, you'll be able to look at a patient or a scene and know when it's time to get moving. One thing that I would reflect on (and I'm not bashing you in any way) is that you saw the "urgency in everyone's eyes but for some reason I didn't feel that as much." This statement is troubling. On a scene of that magnitude (MCI), with the number of providers there displaying a sense of urgency, did you think their concerns were unjustified? Or did you feel you had your part of the scene (your patient) under control? It's just something to think about when working with some experienced providers. There's usually; but not always; a reason for their feelings to a patients presentation. Also, just another point of learning is that you had a "critical" trauma patient that wasn't to the "point of running lights and sirens to the ER." I'm curious about the area you were riding in. How far away was the ER? Remember that in most major trauma cases (sounds like he may have been a candidate based on mechanism, injuries to himself and others involves) you are racing against a clock. If your patient is critical, choose the fastest means of transportation for him. If you're close enough to a trauma center, this may not be with lights and sirens. Your SOP's will also provide some guidance into that aspect of the decision. Just some things to think about. All in all it sounds like you did do rather well. You have much to learn still, just like all of us. We're just in different places in our learning curves. Good luck and post back with any more questions. Shane NREMT-P

As a first responder/bls provider the best thing you can do for this patient is to try to get as detailed of a history as possible. What is this patients baseline mental status and health like? Where are his healthcare providers? If the patient won't really answer any questions for you, you'll have to do some searching in the house for any clues. Search for medications that might give you a hint as to what's going on. Take a complete set of vital signs and perform a thorough assessment. Does he have a head injury from a fall that is causing the mental status changes? You could try to put the patient on oxygen if he'll cooperate with you and is tolerant of it. It sounds as though he already has a complicated medical history. As an ALS provider, this is a patient I'd work up to see if I can find anything wrong with him. Thorough assessment is vital once again. Vital signs, lung sounds, ekg, blood sugar, etc. Treat what I find (if anything). This patient could also have some infectious process working against him and is now going septic causing the altered mental status. Supportive care is probably going to be the best care provided prehospitally. Shane NREMT-P

I'm not sure that I would wait to tell them about any schedule issues until I was hired. If they hire you with a specific time slot in mind and that doesn't work for you, that's a problem. With many places you are on probation for the first "x" number of months that you're on the job. During this time they can terminate your employment for ANY reason. It's better to be honest with them and in my experience this will make them more willing to work with you. And if they can't work with you for whatever reason, you're not wasting your time or theirs and can move on. Ask questions. Good luck, Shane

Not to hijack the thread, but am I the only one who found that post hard to read? Remember that on an online forum, your written word is as good as your spoken word. Punctuation and being able to understand what you're writing will go a long way towards your "reputation" on a forum. It shouldn't take a couple of tries to read a two line post. Take pride in what you're trying to say and do it effectively. Shane NREMT-P

Not to burst your bubble, but you're also only 3 months into a very long program with much to learn and many concepts still left to grasp. I'm of the opinion that someone needs experience as a BLS provider. While your program may provide you many contact hours, these hours are far different then learning how to control a scene and how to handle a situation when everyone is turning to you for direction. Street smarts are something that cannot be taught and can only be learned on the street. You are working in countless unpredictable situations and you need to learn to function on the basic level and have a firm grasp of those skills before moving on. That's something you're not going to get in a hospital clinical setting. Good luck though, there are people who have done it and been successful. Hopefully you will be one of them. If you have questions, as always feel free to post up. Shane NREMT-P

+1 for wearing body armor. I wear it daily on the job due to the area that I work with and the unpredictability of the job. Once you're used to wearing it, it doesn't bother you at all. Also forgot to mention in my initial post that I also have five years of martial arts training behind me as well which helps when it comes to control holds to stop a patient from trying to hurt you. Shane NREMT-P

Assaults on providers can and do happen. How frequently depends on your call volume and the area in which you work. I work in an inner city, so there's no shortage of people with nothing to lose and people who live by fighting on the streets. I have been assaulted by patients, both with PD present and without. You try to avoid the problem before it becomes one. If that doesn't work you have physical restraint, and here we have chemical restraint (for paramedics) on standing orders. We can also request the PD (since they are not sent to every call with us). Just be aware of your surroundings and learn how to read people. Listen to others around you as well if they are experienced and get the feeling it's time to leave. Shane NREMT-P

It would depend on the cause of their difficulty in breathing to totally answer your question. One thing that I have done is to sit them upright immobilized with a KED. Keep in mind that this is an incomplete application of immobilization, but as a paramedic here we're allowed some room for independant thought. It's far less than ideal, but better than a patient who can't breathe effectively. Shane NREMT-P

It's a decision by the patient and their family. I would have a hard time not honoring the families request. If you're ever unclear, contact medical control and explain the situation to them. Most of the time they'll go with the families decision. In hospital, they do this all the time while talking to the family. Now as far as a DNI order, a patient can choose what they want or don't want done. There really isn't a law that says a patient has to accept all treatment or no treatment (at least in Connecticut). In the same regard that a patient can refuse a medication or any other treatment modality. I would defiantly want to talk to medical control if your protocol is not clear with regard to honoring a family request. Now some reasonability needs to be made too so as to make sure it's a patient request and not a family dispute clouding the decision. If someone young w/o any obvious problems codes and the family says don't work them, I'd have a hard time with that. But the elderly or patient with a terminal chronic condition codes and they don't want him worked, do your best to honor the wishes of everyone involved. Shane NREMT-P

+1 as usual to ERDoc. Anytime a patient has something in their system that may alter their levels of pain makes them "unreliable" for us to follow the protocol for withholding spinal immobilization. Otherwise, without being there and seeing the car it's difficult to say just how bad the damage was. Many factors come into play such as restraint (as previously mentioned), speed, the other object? From the description you gave, I would immobilize them. Given the same scenario w/o the ETOH on board, and I might not. Remember though that where I work we have a protocol to withhold immobilization. If you do not, then the patient should defiantly be immobilized. Shane NREMT-P

+1 for another well written post coming from Rid. You are 100% right about being able to tell who actually practices and what level they practice at from the way they conduct themselves or explain things in their posts. People should remember that on a message board such as this a written word is as good as a spoken word. The way you compose your posts has a direct impact on people's impressions of you. Shane NREMT-P

I'm curious as to how she knew the five year old was going into respiratory failure if the fire was that bad? If the patient was that close to the door that she could see her why didn't he patient just walk out the door? The smoke couldn't have been that bad if she could tell that much about her patients condition. When I was on the FD if I did something like that, the chief would have been more than happy to suspend me and require me to do some additional training about why we don't do things like that before being allowed back inside the building. Sometimes a poor decision has a lucky outcome which sounds like the case this time around. The other thing I'm curious of is how she's in paramedic school while still in high school? The program I went through has a high school diploma as a prerequisite to enter the program. I thought that was pretty much a standard everywhere, but I could be wrong? Shane NREMT-P

+1 on the BAAM whistle. One of the best inexpensive tools to carry. It works great. If your service doesn't carry them and you can't find one, you can take an ETCO2 detector and put it on the end of the tube as you nasally intubate. As you get closer to the trach, the reading will go up and the waveform will look more organized. It's less than ideal, but effective none the less. Shane NREMT-P