HERBIE1

Adding to what 4c6 said, look for something that you think can be improved. Ask around, see what problems folks have with the status quo- scheduling, check lists, streamlining procedures, training- or come up with something you feel needs to be addressed, and provide a possible solution. Unfortunately, just doing your job better than everyone else does not always translate into opportunities for advancement. You need to be proactive and and promote yourself- nobody else will do that for you. Add to your skill set- take every extra course, seminar you can. Here's the thing- you need to figure out exactly what your goal is- to move up in the company- which may mean no longer working the streets, become a supervisor, trainer, or start taking management/office/leadership classes to position yourself for that route. The more tools you have at your disposal and the more hats you can wear, the more attractive and valuable you will become to the company. Find a way to save the company money- that will almost ALWAYS score points with management. LIke you said, be careful to not step on any toes. Couch your proposals carefully as to not offend, simply provide a better way or even another option. Make sure you are seen as trying to help the company- and yourself, not just trying to stir the pot. Lastly, give it some time- you also need to get more experience, but there is no reason why you cannot start planning for the future now, so when your time comes, you will be ready to move up. Good luck.

Update on the patient: ER gave him 4 units of blood, plus the Dopamine and still never got his pressure about 60/P. His CT showed a enough blood in his belly to nearly obscure the aneurysm. Apparently after we dropped him off he developed all the classic S&S's. Line of demarcation at the T-12 level, back pain, etc. Spent 45 minutes in the ER- too long, IMHO, but most of that time was spent waiting for the surgeon- he was not in house at the time. Made it to surgery, repaired, and he's now up and around, probably discharged today or tomorrow. Everyone was amazed the guy even made it to the OR without coding, much less survive the surgery. It simply was not his time.

12 leads are not an option with us yet. Been trained, still waiting for the updated equipment.

12 leads are not an option with us yet. Been trained, still waiting for the updated equipment.

Attorney to EMS? That'll be a pay cut, but I guess you can't put a price on happiness. After you are in the business for awhile, maybe combine the 2 careers? We always need more legal experts in the field. Anyway as Lone Star said, we have a few former and current Detroit area folks who could point you in the right direction. Out of place? Not at all. Folks of all ages are doing this job- some new, some older, but 29 is NOT old for the profession. Many places DO offer ride alongs for civilians- just ask. Usually all it takes is signing a waiver. Welcome to the city, and good luck.

Well, all I can go by is what he said. A glucose level of 205 is nothing I would be worried about- at least in the context of what was going on. It certainly would not explain his hypotension, syncope, or decreased mentation- not nearly high enough.

LOL Smart ass... Carotid pulses present, appeared to be equal, but weak. Slight;y cool, although his jacket was open and the car windows and doors were open in 40 degree weather. Nope. Until we found out he had no BP, CVA was an initial possibility, and as for cardiac, we were also thinking of a massive MI, but no obvious arrythmia.. You are on the right track here. Here's the rub. He had that- "I'm getting ready to die" color you see in massive GI bleeds, but there was no evidence of that- even though he was on a blood thinnner of some type. Again- without knowing what anticoagulant, it could have been anything from Coumadin to Plavix, to ASA. Our 2 thoughts were massive MI, and... After the exam and TX, we were thinking a Triple A. Why? I'm not sure but we were both on the same page with this idea- even though no obvious S&S existed. No pulsating masses, but no, we did not compare lower pulses- by this time he was semi conscious and I was trying to get as much history as possible and pushing fluids to get a BP. In line with our thinking, I began asking about the quality of the pain- no tearing, no burning- just a dull ache. He also specifically denied back pain. We were equidistant between 2 hospitals- one not so great, and the other was a Level 2 trauma center, and we figured this was a surgical case, and if it WAS a AAA, he would at least have a chance there. Got to the ER, we voiced what our guess was going on to the nurses(as if they cared, LOL) There was a medic from a local private there picking up another patient(turns out he's also a part time flight medic from another area), and heard us discussing the call. He asked why we thought it was a AAA. We honestly couldn't give him a straight answer other than a feeling, his presentation, and his horrible vitals. The guy probably thought we were nuts. As I was finishing the report, that medic went back to check on the patient (probably just to prove we were idiots) came back and reported they had 2 liters of fluid on board, Dopamine going, they were getting ready to hang blood- they confirmed the dissecting AAA via ultrasound, and still were only able to get a BP of 60 by palp. The medic looked at us like we were Miss Cleo or something. We told him that being right one out of a thousand times is a pretty good average. The patient FINALLY began to c/o the classic back pain and tearing sensations in his abdomen, but no pulsating mass. They were also waiting for the surgeon to arrive. As we were leaving, the patient was still conscious- not yet intubated, and the surgeon had just arrived to evaluate the patient. The last we heard was the patient made it to the OR, but we don't know if he survived the surgery. Not much we could do for this guy except push fluids. No, we did not check pedal pulses, but with no palpable BP, that would have been essentially pointless- not to mention a diabetic who probably already has CAD and poor peripheral circulation. Diesel therapy- and the proper ER- were this guy's best bet from us.

Noirmal saline. No evidence of dehydration, but that was a quick initial thought.

Good one. Already copied and pasted to share...

Huh?

OK- first time putting out a scenario, so here goes. (Recent call) 1700hrs Called for a 60 year old male seizure patient. Arrive to find said male, sitting in passenger seat of car, being attended to by first responders. Wife- driver- said her husband suddenly stopped talking to her and could not be aroused, so she pulled over and called for help. They had just left their house a couple minutes ago. Despite the nature of the call, she describes no seizure activity. Says he has been fine all day- no complaints, nothing unusual, no prior history of syncope or similar episodes. PMH- CVA approx 1 year ago- minor speech deficits. Htn Cardiac Type II Diabetic Meds unknown, but is compliant with them Wife knows he's on a "blood thinner", BP pills, "diabetic pills" NKA Patient is very pale, slightly diaphoretic, responds only to deep pain. Cap refill severely diminished, nail beds white Vitals- Pupils equal, reactive, but dilated Abdomen soft, nontender No palpable BP Respiratory rate 18 and shallow Lungs clear and equal Pulse oximetry- approx 75%- hypoperfusing Glucose- 205 Sinus Tach in Lead 2 on the monitor- no ectopy (No 12 Lead available) Pt placed in Trendelnberg, IV wide open, nonrebreather, O2 sats still same Pt begins to arouse, vitals rechecked and essentially unchanged, and c/o "ache" in suprapubic area. Said he had one small episode of diarrhea earlier, nausea, no vomiting, poor appetite all day- ate little. Denies SOB, denies chest pain. Fluids wide enroute to ER- still no BP enroute, remains alert, still c/o same "ache", and nausea 10 minute transport to ER uneventful OK- Let's hear it.... (Just to be clear, this is more about thoughts on a possible DX than treatment.)

Had a call the other day for a guy with the typical nondescript dispatch information- "Sick", with "ETOH on board" as a further comment, and it was about 2300hrs. Turns out the guy stumbled onto a bus at the station, and the driver called. Found a 30 year old black male, wild hair, hip/hop looking, disheveled appearance. Had drool coming from his mouth, and was squirming around in his seat. Nobody on the bus knew him, so bystanders were no help. He had the wild eyes, was agitated, dilated pupils, nonverbal, and mildly uncooperative. Immediately noticed no smell of alcohol, so we began thinking drugs of some type- PCP, etc. As we were removing his jacket to start our exam and treatment, we noticed a glucometer fall out of his pocket- along with a packet of Skittles candy. Bingo. Long story short, his glucose was below 20. ALS care, Dextrose and he soon became A/Ox's3. Turns out the guy is an IT worker at a local university, had worked a double shift to make extra money for the holiday season, and had simply forgotten to eat anything since lunch. His last memory was getting on the bus to go home- around 3 hours ago- and about 10 miles from where we found him. Nice guy, embarrassed, very appreciative. I told him he was lucky, since the neighborhoods he passed while disoriented were rough- and he was lucky to still have his wallet, his IPOD, his clothes, and even all his body parts intact. He says he recalled being a bit fuzzy when he got on the bus and assumed his sugar was dropping, which is why he bought the candy, but never got a chance to eat it. We dropped him off at the ER, where he would get a meal, some fresh clothes- (he was incontinent), and presumably he would soon be sent home. So- our thought process went from- oh great- dragging another drunk off a bus- to uh oh- we may be fighting some guy wacked out on drugs, to wow- poor guy, trying to do the right thing and had some bad luck. Never assume anything, folks- even when you are given information supposedly meant to help you.

In my case, by far, the most common use for a KED has been to immobilize small children- usually for trauma, but sometimes simply to be able to examine and/or treat a very squirmy kid. It works great, and I started doing this years ago after using the "Papoose" while working in an ER and realizing I could apply this concept in the field. A KED was far easier and more effective than trying to secure a kid directly to a long board. Of the thousands of MVA's I have had, I can recall using a KED exactly one time-long extrication, fairly stable patient- basically just for fun. One other use- a guy who fell into an elevator pit. He had motor and neuro deficits, and I literally had to fight the knucklehead rescue guys to slow down so I could stabilize him before we pulled him out. The chief was NOT happy with me until I later demonstrated by exam that this poor guy had no feeling below his ribs. Dangling over him, about 8 feet down, putting on the collar and KED alone(simply no room for anyone else) took awhile, but there was no other option. I then let the rescue guys hook up a harness to pull him out vertically. I think like anything, ,many times you adapt your tools to suit your purposes. Is the KED a vital piece of equipment- no- there are other ways to accomplish your goal. Can it be useful? Absolutely and they certainly do not take up much room on the rig. To doc's point about EVIDENCE that is does what it's designed to do.-that's another story. Like spinal immobilization, I think in 99.9% of the cases, it is completely unnecessary. I have NEVER seen a cervical fracture in a patient that I did not suspect one. The only cervical injuries I have seen have been multiple injuries with high speed trauma- pedestrians vs cars, motorcycles, etc. One exception to that- a freak occurrence. A 6o year old man who tripped and fell onto concrete while jogging. Laceration to his forehead- nothing more. No LOC, no other injuries, no deficits, healthy and stable with no medical history. He didn't even want to be transported- he wanted a bandage and to finish his run. Something told me to immobilize the guy, and thank gawd we did: Sublexed C-5. It happens, but can we- or should we be able to- foresee any possible outcome? No, because in that case, we should be doing 12 lead EKG's and full work ups on every patient to catch the one in a "million" undiagnosed congenital arrhythmia someone may have. I know some places can clinically clear a c-spine in the field, but it is rare. I understand the POTENTIAL outcome from a missed spinal cord injury, but again- they are rare and with training and solid protocols, that danger can be mitigated. Evidence based medicine. Time for the EMS community- and more importantly, the powers that be- to truly embrace it.

Just- wow. This should be shown at every high school driver's ed class, and I also like the idea of running it during the Super Bowl, and why not the World Series, World Cup, Olympics, and every other major sporting event. Talk is cheap- people need something graphic like this as a wake up call.

Do you know if the ACEP has an opinion on such ideas? Is this something they might be interested in? Has anything like this ever been proposed? Seems to me that the ACEP would have a vested interest in elevating EMS standards, and would welcome them. Obviously there would be no turf wars as there have been with RN's since there's no comparison between a physician and a medic in terms of education. Issues such as advanced scope of practice could be standardized and addressed,and with proper education and training, prehospital care could even alleviate some of the volume at the local ERs. I agree about elevating the standards, and a group like the ACEP could provide guidance, oversight, training, and a standardization of provider skills. I agree now is a bad time for something so revolutionary- especially with all the question marks with Obamacare, but if/when things settle down, this seems like a good idea.

Gotcha. Well, the what if scenarios you do are a great idea. I tell me students to do the same thing on routine calls. ANYTHING can be turned into a teaching moment. Even as a new paramedic, you can still use the routine runs as a tool to run through possible changes your patient can have, but instead of looking at it through the eyes of an EMTB, you can bring a whole new level of options as a newly minted medic. I feel your pain- nothing is worse than feeling dissatisfied with your career. Explore your options, and a change of scenery may be needed. I don't know your family or financial situation, or your age, so moving may not be a viable option.

We have a similar issue with our local city council, and there's only 50 of them. Dozens have done time in prison over the last 5 years or so.

As evidenced by the responses, there are many models of EMS- orivate, fire based, hospital based, etc. The trend in many places seems to be to have an EMT and a medic on an ALS rig. In many areas, this is all they know. Budget constraints is probably the most common issue- 2 medics require more pay, training, etc, and in many rural places are not easy to find because if a person has been trained to the level of a paramedic, they often look for employment where the pay is better. Our ALS rigs are 2 medics, our BLS rigs are 2 EMT's. There has been talk for years about making ALS rigs one EMT and one medic, but obviously that is seen as a reduction in the level of care and has been met with a lot of resistance. In most cases it simply does not matter- a single strong medic can handle the call even if it's ALS. BUT- in those cases where it's a complicated run, that 2nd medic can be vital. As the doc said, sometimes the EKG may be funky, the patient's problems may be confusing, and a 2nd opinion and pair of hands can be crucial. Doctors call in for 2nd opinions/ specialists all day long. Problem is, you never know when you may need that extra help. Every area has their own standards- sometimes they are local, sometimes they are state statutes. You work under the constraints and regulations of your area and become accustomed to whatever your local norm happens to be. If you don't like the way things are, moving on is always a possibility. Beiber- you sound like a bright person and are a credit to this profession. EMT or medic, I would love to work with someone like you who is so interested in advancing their knowledge. Keep asking these quality questions, keep looking for answers, and your patients will benefit from your attitude.

The problem is, the "transport" state of mind is too often what happens even in 911 services. Much of what we do is NOT an emergency in any realistic sense of the word. To me, it sounds like you need to readjust your thinking of what EMS is all about. Yes, IFT's generally mean completely routine, but if you are frustrated now, I think you will also be frustrated when you find out that so much of your day even as a provider in a 911 service will also be nonemergent. That frustration/burnout happens to those folks as well. Obviously the change will be good- new challenges, new responsibilities, etc. Not sure the "side" you are referring to here. Many services do both IFT's as well as 911 calls- you just need to look around. A change of location may be necessary to open up enough possibilities for you. Usually the new folks- even medics- must start out on doing IFT's, and work up to 911 calls. These companies may have contracts with nursing homes, clinics, dialysis centers, and hospitals, AND have contracts to provide 911 service to a community. Obviously getting on with a fire department is another possibility- either as a single role provider or cross trained. Do your homework. You are welcome. I think most folks come to crossroads in their careers- some earlier than others, and sometimes we come to these crossroads more than once. Burnout, frustration, unreal expectations, low pay, tough hours and working conditions- all contribute to the problems, and if you are not content with the job, then it merely adds fuel to the fire. First and foremost you need to get a handle on why you wanted to do this job, and what you expect to get out of it. YOU are responsible for your happiness, and your first priority is to focus on that. You have taken the first step- admitted there is a problem, and you even identified it. Now you need to come up with the "why's" and arm yourself with knowledge and a plan to change things. Talk to old timers(like here) or among your trusted coworkers. Find an instructor, doctor, or anyone else in the field who can offer you some perspective and guidance. You may find you just need a change of scenery, or a completely new direction. Good luck.

Good to hear some positive news for a change! Congrats to the Ruffs, and here's hoping everything goes smoothly.

The only experience I had with nitrous is years ago working in an ER. Really no fear of overdosing- usually it was self administered by the patient. They would be forced to hold the mask themselves, and by the time they were sedated enough, they no longer had the strength/control to hold the mask anymore, and they would simply drop it. The procedure would be completed and they would soon wake up.

This does not surprise me one bit. I would also add that with the advent of cell phones, speed and voice dialing, people are no longer required to recall things like phone numbers. I have friends and family who have retained the same phone numbers for many years, but now that I either call their cell phones, or simply use my address book/recent call feature, I can no longer recall their numbers from memory. I have only used GPS in rental cars- nice feature, but I do just fine with Map Quest. I look up a location, print up directions and/or a map if needed, and it's all I really need. I certainly see the benefit for someone who travels to new places frequently- ie a salesman, or a frequent traveler, but it's just not something I worry about. I realize that when I purchase a new car, many models now come with GPS as a standard feature, so eventually I may rely on it in the future.

Drug seeking is perfectly appropriate to include in this discussion, but certainly not the overriding issue. Whether or not someone needs analgesics is based on many factors- type of injury, pain tolerance(yes I know- a subjective idea), underlying medical conditions, vital signs, stability of patient, associated/complicating factors, etc. Besides cardiac chest pain, the vast majority of when I use an analgesic is for a serious orthopedic injury- fractures and other trauma. I've occasionally provided it(with medical control consent) to someone with kidney stones. Many places have very limited options for analgesics, and often times they are opiates or other heavy duty medications. Simply doping someone up without being able to provide a differential diagnosis is not a good idea. We have no Xray capabilities, no ultrasound, or blood tests, so I think it's reckless to simply provide pain relief with no real understanding and/or confirmation as to what the problem may be. We may aggravate and/or mask a condition and delay definitive care. Mistake, in my opinion.

Done.

Not much more to add to this other than after the last few days, my already incredible gratitude and appreciation of our soldiers has grown exponentially. We had soldiers- young and old, from all branches of the service- pay their respects to my nephew. Some simply came in, said nothing, paid their tributes and moved on. Every one that I saw I attempted to shake their hands and thank them not only for their sentiments but also for their service. Every single one of them said it was "their honor and privilege". To all the soldiers here- and everywhere- Thank you for all your service. I will never forget.