HERBIE1

That truly will be an honor- and very emotional for all. Congrats.

Our NTG protocol is BP related. Anything over 100/P is OK. I understand it is theoretically possible for Ventolin to induce chest pain, but in the thousands of chest pain cases where a person also has asthma, I have never seen it. To me, I'd be pursuing the cardiac ischemia aspect of this. O2, NTG, ASA, etc. Too often, Chest pain. MI symptoms are atypical: only SOB, only a general malaise, only "heart burn"(in my case), only nausea, etc. You need to do a complete history- precipitating factors, onset of symptoms, vitals, etc, and I think they will point you in the direction you need to follow. I agree with you on these grey areas being very important. Anyone can be a cookbook medic, but often it takes some experience, assessment skills, and detective work to dig a bit deeper to get to the truth.

Ask your instructor and/or ask the provider you will be riding with what is appropriate for their service.

What was the patient's S&S's that caused the asthma treatment? History of present illness? Sudden or gradual onset of the SOB? Degree of distress? Lung sounds, pulse ox, etc? Is a 12 lead EKG available? If I had to guess, I would say that it sounds like the SOB is secondary to angina or an MI. Is the chest pain pleuritic- ie is the patient complaining of pneumonia type symptoms, and opening the airways is causing him to be able to breathe more deeply, causing the pain? Ventolin can increase oxygen demand by increasing the heart rate, which would explain the chest pain after the treatment had started. Personally I would be aggressively treating the chest pain, which- barring asthma symptoms- would hopefully alleviate the chest pain and the SOB. Unless the person was actively wheezing or tight, I wouldn't be as worried about the ventolin. I would throw this to medical control, outline everything and ask which protocol they wanted you to pursue. Lots of questions.

Ug- it's odd which calls can get to you. Nothing wrong with it at all- it simply means you are human. Sometimes our defenses are down- personal issues and distractions can sometimes make us more vulnerable. For many, holidays are a difficult time of year- we remember loved ones and friends no longer with us, and can become melancholy about our losses. Tough. Hang in there.

Just because you can move it does NOT mean it's not fractured and/or dislocated. That "rice crispies" feel sounds like crepitus- broken bones rubbing together. Sounds like you very well could have a boxers fracture of your metacarpals. Good luck.

I think you are misunderstanding the original question. To me, the OP was about WHY it would be necessary to fully immobilize a person who has already been walking around with their injury for an entire day. Does it look awkward seeing someone sitting in a bed with a c-collar on- sure. Maybe I'm wrong, but I don't think the person had any intention of refusing such a request.

Depends on WHERE those fractures are. Could be a sublexation, could be a spinous process that was chipped off- hard to say without knowing the details of the injury. A wrong turn of the head could damage or even sever the spinal cord. It has happened. Sitting on an immobile ER bed is also not the same as transporting in a bumpy ambulance where a sudden jolt, turn, or movement could be bad news.

The definitions of morals and ethics have already been posted, so I won't retread that. The point is, these are PERSONAL things. If part of your job is to insert an IV into an inmate so that lethal drugs can be administered, then you have 2 choices- do your job, or look for work elsewhere. I assume you would already know that this is a possible part of your job when you are hired, so if you object to capital punishment based on personal beliefs, you should not be taking that job. If this suddenly becomes part of your job description and you have a problem with this- then you are indeed faced with a dilemma- object to this new duty, or accept it. Again- you are not deciding the punishment for this person, or whether or not they are guilty of their crime. NOTHING is certain in this world. I agree that putting an innocent person to death is unacceptable. So, the question becomes- can we prove beyond a shadow of a doubt that we have the right person sitting in that chair or on that gurney? We are dealing with a human element, which means NOTHING is perfect. The standards used in court are proof beyond a reasonable doubt. Thus, if anyone on that jury believes there is any possibilty the accused did NOT commit the crime, they should not convict. Another question- what is the appropriate punishment for someone who commits premeditated murder? For many, if someone intentionally takes a human life, then 3 hots and a cot on the public dime, til you die is NOT an acceptable punishment. As it stands, some states DO allow for capital punishment, but are reluctant to actually carry out the sentence. Like I said, put a moratorium on older cases, but from this day forward use every possible tool to verify guilt. In many cases, the question in a murder trial isn't whether or not the person committed the crime, but WHY they did it. Often times the defense suggests there are extenuating circumstances that should allow for leniency for their client. They were abused as a child, they are insane, it was a crime of passion, etc. So in the cases where the evidence is irrefutable, I have NO problem "pulling the trigger" on these people, so to speak. I see too many cases of people who have been convicted of taking another life serving time and being released back into the public.If even one of these folks repeats their crime, it's one too many in my book. That means the system has failed,and to me that's just as unacceptable as putting an innocent man to death. Recently I read about a guy who murdered his girlfriend, served 15 years of a 30 year sentence due to 1 for one good behavior time off, and will soon be released. By my estimation, that is wrong on every conceivable level. Has justice been served to the victim or their family?

I'm afraid that you will have a difficult time with this request. Because of HIPAA, and lawsuits, anyone who values their job will be reluctant to do this. Regardless of your attempts to block out identifying characteristics, it is entirely possible SOMEONE will recognize an area, a car, a home, a situation and want to file suit. I would go with the suggestions of recreating scenarios. Talk to folks, come up with ideas, and stage them. Use actors, EMS personnel, friends and family- whatever. EMS providers have plenty of experiences to draw from- not to mention fertile imaginations.

Good one. LMAO

If we go strictly by definitions, ethics and morals have nothing to do with participating in a capital punishment execution, as long as it is a possible sentence for a crime. It is not hypocritical to participate in such a process. You are NOT deciding the legality of capital punishment, and unless you are on the jury, you are NOT the one who decides the sentence of the criminal. The person's fate has already been determined by law. As a matter of fact, if you are picked for a jury in a capital case, and the death sentence is a potential outcome, one of the things a lawyer asks when they are enpaneling the jury is if the accused is found guilty, would you be able to sentence them to death? If you say no- based on moral or religious grounds, you WILL be excused.

Sounds like a solid technique to me. I will palpate a BP as a back up- in case I'm not sure I heard the systolic number correctly. I know-not entirely accurate, but sometimes folks have really faint BP's, and confirming that top number is important to get a baseline. The only thing I will say is that often times, enroute to the ER, I will only palpate a BP, because it may simply be impossible to hear anything accurately- especially if the person has a weak pulse to begin with. If you are not moving, and it's just you, your partner, and the patient, you can control the noise level. If you are on scene, or with a bunch of folks, sometimes quiet is a relative term. LOL

We could argue morality and ethics all day. Very subjective topic, and as such, there is no right or wrong answer in that regard. I would toss a doctor in with a medic, at least in terms of only being PRESENT at the execution. They did not decide a person must die, but merely are ensuring that a legally mandated sentence has been carried out. Is the person who administers the lethal injection, throws the switch, or hits a lever to release the cyanide capsules actually KILLING someone? Not in a legal sense of that word. If the AMA or any EMS organization ever BANS their people from participating in an execution, than I suggest they can easily find willing replacements who could then be trained to fill their roles. Again- all the doctor needs to do is sign the death certificate. As we veer off on a tangent- I agree that you need to be as close to 100% certain as possible of the guilt of someone in order to put them to death. I also agree that mistakes have been made in the past, but this was also long before technology and DNA studies existed. I would have no problem saying that from this day forward, whenever a capital case comes up, DNA tests MUST be performed, as well as any other confirmations currently available- including confessions, CSI technology, physical evidence, eyewitnesses- build a solid case based on irrefutable proof. Call me a barbarian, but I simply feel there are some crimes that require the ultimate penalty. Not life in prison, no solitary confinement- in certain cases, the crime is so horrific, that the only "civilized" punishment is to forfeit your life. Anyone who has been accused/convicted before this arbitary time will never see the light of day. Prison for life, with no chance of parole- just in case there was a mistake made.

Good question, and sure to generate some interesting debate. Well, what about the physician who is present at executions? Aren't they violating their Hippocratic oath simply by being there? The only person who can sign a death certificate is a doctor, so by law they must be part of the process in some way. Do they need to be present at the actual execution- maybe not. Anyone can be trained to place EKG leads on a patient to confirm asystole, but wouldn't a trained medical professional- EMT, nurse, or doctor must be present to assess an absence of pulse and spontaneous respirations? Would simply confirming death be somehow considered as facilitating that death? From a moral/ethical standpoint, I guess the provider must decide for themselves if they want to participate in the process if they know it will be part of their required duties. In a sense, anyone involved in an execution is merely carrying out a sentence that has already been decided by the legal system. They are not the ones who determine that a person will die, but merely the instruments who carry out a predetermined fate. Personal opinion- I would have no problem doing this, and yes, I am pro capital punishment, given the right circumstances. I suppose being against the death penalty might be a deal breaker for most.

I first saw those disposable scopes years ago in a first aid station at a special event I was working. I could not believe my eyes. Later, when I saw some supposed "professionals" using them in the field, I was just appalled. Have a little pride in your work, folks. You can only be as good as the tools you use, and if you have some lousy disposable set of ears, how on earth can you hear anything? How can you accurately assess lung sounds? To me, it would be like a police officer using a Saturday night special 22 caliber gun as their primary weapon. Convenient, cheap, and small, but would you really want to trust it? I've had 2 personal stethoscopes in all my years of doing this. The first one I bought while in paramedic school. Probably ran me around $100 back then, and it was far more elaborate then I needed. It lasted me around 15 years, until one of the tubes got a cut in it. I replaced it with another similar model, and I still have it today. LOL No offense intended, triugs...

Yep. Years ago I used to dispatch, and I know how folks can lie about their problems just to get an ambulance. You'll never get rid of that element, but the system is also designed to cover the arses of the department, the municipality, and those in the dispatch center. Often times the call takers and dispatchers KNOW a con is going on, but simply have no choice but play the game.

PCP- Dwayne did a great job of walking you through the intricacies of actually getting the BP. I will echo his suggestion of making sure you have a GOOD stethescope. I actually saw a crew on a rig for a local private using those disposable type scopes made from plastic- probably company provided. I could not believe it. Do yourself a favor-shop around and get a good quality, stethescope, made by a reputable company. Ask Santa for it, or splurge and buy it for yourself. It will be one of the best investments you can make for yourself. Obviously you do not need a $500 scope designed for a cardiologist, but don't go cheap on this item either. And yes, like Dwayne said, I HAVE been doing this awhile, and just as soon as I finish my Ensure shake, I'm going to beat the crap out of him with my walker...

Generally we never get any details like "possible ETOH on board"- only a couple dispatchers attempt to give us that. I appreciate their efforts, but like you say, very rarely does the information correlate with the actual problem. We'll get a call for a diabetic, when in fact it's someone who has a cut on their hand, and they happen to also be a diabetic. Part of the problem is that we have a 2 tiered system, and many of the dispatchers try to make every call ALS if possible so they do not get caught underdispatching something. Even if they follow the protocols, they are afraid they will be caught in the trick bag if they send the wrong type of unit. Hanging in there, bud. It's gonna be a rough holiday season for us. Hope all is well with you and yours, my friend. Nothing at all wrong with coming up with a first impression- you have to start somewhere. You need to have a jumping off point, but you also cannot have tunnel vision and possibly disregard clues/information that may take you in a completely different direction. Most of the time things are pretty straightforward and uncomplicated, but not always. It's important to keep your options open. Example- A patient who is in severe respiratory distress may initially present as an asthmatic with diminished lung sounds and wheezing. You begin treating the person with albuterol, and when their distress lessens and their lungs open up a bit, you realize they are also in pulmonary edema and have rales, so you now must shift gears. Could be you are dealing with cardiac wheezing, or a person with a cardiac condition AND asthma. Constantly reassess vitals, condition, and ensure something else is not happening with your patient. Many of our patients- especially the elderly- have multiple medical problems, and alleviating one issue may simply aggravate or expose another.

First step- palpate the brachial artery. I know this sounds silly, but many people simply guess as to where that pulse is actually located. Once you FEEL the pulse there, place the scope directly on it. Also good suggestions from others about having a good stethescope with a proper fit in your ears. Most scopes come with several sizes of ear pieces- choose the ones that fit you best. You also need to understand the difference between the bell and the diaphragm portions of the device. The bell side is used for low pitched sounds, the diaphragm portion for the high pitched ones. Make sure you are using the correct side- it's easy to have them flipped and never realize it. As soon as I put the ears on, without even looking at it, I tap the bell and diaphragm on to ensure I have the correct side in place- a habit I developed 30 years ago and still do to this day. Sometimes the head may be slightly turned- ie not locked into place, and you won't be able to hear a thing. Some places use electronic varieties, which can be useful in noisy settings like in an aeromed situation- or someone with bad ears. LOL As for lung sounds, it takes a lot of practice to become proficient. Listen to yourself and anyone else who will let you. Use both sides of the scope and see the differences in what you can hear and the quality of the sound. Remember to go back and forth on both sides of the chest and back- at the same levels- to compare and contrast what you hear. Different patient sizes/body types and medical conditions will also affect how well you can hear things. Good question. As the old saying goes- the only silly question is the one you did not ask. If you don't know, then how will you ever learn?

Sounds like you have the right attitude, bogusdill. It's important to set the bar high and to have goals. Sometimes it's not easy doing the right thing- whether in your job or your personal life, but in the end, YOU need to look at yourself in the mirror and like what you see. As you note, there are all types of people in this business, and not all of them may be someone you want to take care of your family member. Always strive to be the type of person you would want to take care of your loved ones and you won't be steered wrong.

Think speed traps.

Just listened to the lung sounds, but never heard what you described. I imagine it would also depend on exactly where the aneurysm was, how big it was, and how badly it was dissecting. I never asked for the exact location of the tear, but I assume it was very low so even if we listened to bis abdomen, I wonder if we would have heard it. Interesting- I never even thought we could auscultate for this, but what you say does make sense.

Welcome to the city, eh! Don't be afraid to jump into a discussion. Always looking for fresh points of view and opinions. Fair warning- we have some real smart folks here, so you will need to properly defend yourself and your ideas.

Thanks. Very interesting call. I LOVE these things- trauma may be exciting for many- it's always fun to see the various ways people get broke, but I love a good medical mystery. Keeps the brain working. We were wishing we had a student with us for exactly the reasons you stated- atypical presentations are always tough for a new provider to wrap their heads around. You finish school and have a laundry list of common S&S's that you learn to look for, and you want your patient to fit that criteria. Problem is, too often the patient- and their disease process- does not believe in following the script. LOL Sometimes you forget to actually look at the patient, evaluate them, add everything up, and THEN come up with a working hypothesis as to what may be going on. Happy Thanksgiving to you too, aussie!