HERBIE1

The article made no mention of race. Do you know something else about this story? Clearly it would depend on the demographics of your particular situation, and where the high crime areas happen to be . In my case, the most violent, crime ridden areas ARE black. The last stat I heard was that around 95% of the homicides here are in these areas, committed by blacks, against other blacks. You area may be different. Maybe it's hispanics the comprise the worst areas. Maybe it's white trailer park folks. It's based on the call AND the neighborhood. If I get a call for a shooting, I don't care if it's in the most expensive part of town, I go on high alert- especially if I don't know if the scene is secure yet. If I am in a ghetto area, I'm already on a higher alert because there is a pervasive issue with safety every single day. I don't care if it's a call for an OB, asthma, or belly ache, if the area is swamped with crime, ANY call can be dangerous if you aren't paying attention to your surroundings. LIke I said, the scariest incidents I have been involved with had nothing to do with the type of call I was on, and they were NOT for shootings , beatings, or stabbings. This isn't racism, it's just common sense.

Well played, sir. Let us know if you get a response.

I think someone needs to explain to this asshat councilman that the first thing that is drilled into the head of any potential EMS provider- from the very beginning of their training- is SCENE SAFETY. Before ABC's before any treatment is established- the scene must be safe. Even today, when we go through drills and training scenarios, the first thing we recite is always SCENE SAFETY. We are there to mitigate the medical problem. PERIOD. Unless they change the DOT curriculum and provide law enforcement training and protection for EMS workers, this is an epic fail. There are plenty of times when we may be thrust into a dangerous situation- one we could not foresee based on the nature of the dispatch information we have- but if we know that a scene is unsafe- ie shooter/offender is still on the scene, that means there are 2 distinctly different issues playing out- one of a law enforcement nature, and one of a medical issue. We only have the training to deal with one of those situations. The reality is, that unless you happen to be a block away from an incident when you receive the call, the bad guys are usually long gone by the time we get there- they do NOT want to be caught. Unless we were told enroute to a call that the offender is- or may be- still on the scene, or that the police have specifically requested we wait until the scene is secure, as a matter of routine procedure, I have never waited for confirmation that it's OK to proceed. Yes, exceptions would be when we knew an area is hot-alot of gang warfare going on, previous hostile situations at that location, etc, but here's the rub. You should know your area. You should understand the dynamics at work- what is going on, and when it's prudent to take extra precautions. Talk to other crews. Talk to police and ask them where the recent hot spots are- they will certainly know. In many urban areas, violence is part of the equation and unfortunately a risk providers must sometimes face. In all the years of working in the ghetto, 95% of the dangerous situations I have dealt with were NOT ones where you would think there is an obvious risk. A cardiac call and you happen to walk into the crossfire of an unrelated gang fight. A stroke where a family member comes home and attacks us as we are working a code on his grandma. Standing on the street with a woman complaining of menstrual cramps and shots from a nearby building zip past us. Things happen. We work in the streets, not in a controlled environment like an ER or office cubicle. That is the nature of our business. We take reasonable precautions, but the only way to completely eliminate those risks is to change professions or choose to work in a quiet, sleepy town where crime and violence is not an everyday occurrence. Now those who work in a rural area have their own risks- maybe a meth lab, a crazy shot gun toting land owner who does not like strangers on their property, etc, but clearly their issues are not ones faced in a busy urban environment. For years we had an ongoing discussion about wearing body armor. I purchased a vest, and wore it occasionally, when gang violence was escalating for some reason. It was not provided by the department, and we were told that if it was, then we would have to wear it all day, every day, or risk not being covered for an injury because we did not use the protection provided for us. Some felt that wearing the vest meant we were blurring the lines between law enforcement and EMS. If we walk up on a scene wearing Kevlar, the bad guys could easily mistake you as being a cop. Gawd knows many of them aren't literate enough to read the EMS vs Police identification- all they see is a vest. Bottom line for me- training and experience is key. You mentor new folks, make them understand that the medical procedures are only part of the equation. You need to be aware of your surroundings and the potential hazards we may face in a given area. You take reasonable precautions, but again- if you want a 100% guarantee for your safety, then prehospital care is the wrong business for you.

Arcing/sparking is much less likely these days since the advent of defib pads. When we used paddles, it would occasionally happen- especially with small, thinner patients, when it was sometimes difficult to get good contact with the chest wall.. I've never turned off the O2 when defibrillating or cardioverting, but I usually do remove the BVM from the ET- if the patient jumps enough, it can torque the ET tube if the BVM is still attached to it..

Understood. Hope you experience more things that make you think. You learn the most from those.

My partner brought a tape(yes, a tape- it was awhile ago. LOL) of that song one day and wanted to play it. It became our theme song. Every time I hear that song now, I think of those times and not the movie. Some of my fondest/craziest/scariest memories I have in this business are from back then. We saw so much crap but really learned the job.

I think a lot of people have "theme songs". Ours was just as corny as yours. This was ours- "Ride of the Valkyries" We used to play this over the PA as we began to roll on a call: You would not believe the looks we got from anyone nearby. LMAO http://www.youtube.com/watch?v=sx7XNb3Q9Ek

Not strange at all. When we go into housing projects/drug houses, etc- usually dark, and "guarded" by gang bangers and their look outs, we would announce ourselves, just so they didn't confuse us with the police or a rival gang. Generally the "guards" would echo our calls, letting everyone know we were not the enemy, and to let us through. LOL

I was speaking in the context of the patient presented in the OP. If a person is otherwise stable and you suspected an opiate OD, IV access is not mandatory if they have no peripheral veins. If I gave the person IM Narcan and their status improved, I see no reason to start an IO, and the hospital would have no problem with it. To me, an IO is not the same as an IV in terms of potential risks, harm, or possible complications to the patient. An infiltrated IV site is not as serious as if you have a missed IO. I need a darn good reason to start an IO- my patient would need to be critically ill, and the patient in the original scenario does not rise to that level in my opinion. We simply say we tried an IV x's 2, etc, or saw nothing viable to even shoot at, and that is a perfectly acceptable outcome. Now obviously if the person is unstable and decompensating, then IV/IO access becomes imperative.

Student or not, your opinion is just as valid as anyone else's. Don't ever be afraid to express it. Again, LOC is merely one of multiple S&S's, vitals, assessments that we check. It's also pretty easy to check if a person is "faking it" or they truly have a diminished LOC. Pupils, relfexes, neurochecks- plenty of ways to determine if your patient's mental status is truly depressed. You also need to consider the age and environment you find your patient. A 20 something, found "unresponsive" in the bathroom of a nightclub- well, it doesn't take a rocket scientist to suspect you may be dealing with alcohol or drug issues. An "unresponsive" 20 something at home, with a group of peers, and you find out your patient was fighting with her boyfriend- well, chances are you are dealing with an anxiety/drama type situation, and alerting the critical care team may not be my first priority. Does it mean you do not rule out more serious problems- of course not, but your index of suspicion changes based on where you find your patient. If you find a 70 year old "unresponsive", chances are the person has real medical issues that may have caused the change in your patient. Would you immediately consider using an ammonia inhalant on such a patient? Of course not. Time, place, circumstances, age- all the result of an appropriate history and observation of the scene and they should help to dictate your care. Good to be proactive and aggressive when treating patients, but don't always look for zebras. You have to put the whole picture together- based on your history, the scene, bystander information, assessments and any tools we have. In the vast majority of cases, these things will paint a pretty accurate picture of what's going on with your patient. If it looks like a duck, walks like a duck, and quacks like a duck... I agree that you may be in a situation where you have a choice of a small, community ER vs a larger, comprehensive hospital and your assessments will determine what level of care a person receives, then at that point, leave it up to medical control. Present your case, paint a thorough and detailed picture- especially if you are unsure as to what is going on- and let medical control dictate where the patient goes. Yes, ultimately you do what's best for your patient, but there is also a limit on the amount and type of information we can gather. Often times the subjective information you provide is crucial in determining the proper course of action once the patient arrives at the ER. The docs have the training and plenty of tools, but they have no idea the surroundings their patient came from, what was going on, the bystanders, the demeanor of witnesses, their statements, etc. That is your job to relate those details to them when pertinent. Dangerous thing to do sometimes. If you have a patient- maybe they have serious psych problems, are very angry at a significant other, etc, and after they take a sniff of ammonia, they can "wake up" swinging at you. Now you have an angry, abusive, and violent patient on your hands who still has whatever issues that made them become "unconscious". Whatever their issues are, chances are you will not be fixing them any time soon. Maybe the just want to get out of some situation, maybe they want to escape some personal problems. They often feel that is they present themselves as "seriously ill"- ie as being unconscious- they can ensure they will be removed from some real or perceived threat and someone will take them seriously. We may have no idea why a person is feigning being unconscious, but even if it's a momentary escape from their world, this is what they want. It's not up to us to decide whether their reasons are worthy of a transport and/or hospital visit. I used to have regulars who would be oblivious to needle sticks, arm drops, ammonia, noxious stimuli- the works, and we KNEW there was nothing seriously wrong with them. Often times they just wanted a warm bed and a meal. Chronic ETOH abusers, homeless- you would be surprised at how tough some folks are. They know the drill, the know how to play the game, and will do whatever they need to just to get what they want. Everyone comes up with their own program, and with experience and time you will determine your own path. Sometimes simply playing detective and asking the right questions of bystanders, family, or even the patient can give you far more information than any exam or treatment we can provide. After you do this for awhile and develop a relationship with your local ER's, other things also come into play. You will see- especially in the case of busy urban systems- that as simple as dropping an IV into someone changes how an ER must handle that patient. Some places require any patient with an IV to have a bed. An example- years ago when we first began administering nebulized albuterol, our protocols dictated that we start an IV, put them on the monitor- the full ALS work up. In the area I worked, we could have literally a dozen asthma cases in a day. Now multiply that by other rigs, plus walk-ins, and an ER could easily become overloaded. A couple ER's asked us to NOT start IV's on simple, stable asthma patients who were mild, maybe with some wheezing, with good sats and vitals. This way they could put them in a chair VS a bed, keep an eye on them, put them on a portable O2 sat machine, and give them more albuterol. Against protocol- maybe, but once they trusted you, they would ask if the person could sit in a chair vs needlessly tying up a bed. They also trusted us to say- "No, this person is pretty sick, I would keep an eye on them", and they would find an available bed for them. Eventually our protocols relaxed and full ALS was only required if the person was decompensating . Now I am not advising you to violate your protocols,(well, in a way I am, I guess), but I think you understand what I'm saying here. Yes, sometimes we are required to do things we KNOW are not necessary because we are limited by our training and scope of practice. But- like most of medicine, nothing is simply black and white, and being a good provider is about seeing those grey areas and making reasonable adaptations as much as possible. We are all in this together, and speaking as someone who also worked in a busy Level 1 trauma center for years, in order for the system to work as smooth as possible, to be effective and provide the best care for the most people, we need to consider both sides of the equation, and the impact of what we do.

Thanks for the additional info. Only other question I would have would be pupillary response, nystagnus, etc. Yes, narcotic OD's present with constricted/pinpoint pupils, but only if a narcotic is the lone culprit. Sometimes it's difficult to play Monday morning QB, but given this information, I see absolutely NO need to start an IO on that patient. My take- Give the Naracan IM, and while you wait for it to kick in, supplement her respirations, give O2. Although bradycardic( which in my experience is very unusual for a straight heroin OD), this person is still not what I would call "critical", and in need of immediate IV access via an IO. What I would be aware of is a possible drug combination. These days, many OD's are actually due to more than one drug ingestion- whether it's intentional, or the desired drug happens to be laced with something else. I would also be VERY careful about giving too much Narcan, since there is a real possibility the effects of the heroin are masking another- possibly much more dangerous drug like PCP. Once you remove the sedative effects of the naracotic, you may be left with a patient who is now wide awake, and in a full blown PCP rage. I can say from personal experience, that is an extremely BAD situation.

After a particularly brutal shift, you had to take a nap before you drove home to go to bed...(Did that) Found yourself taking an unexpected "nap" in stop and go traffic ON AN EXPRESSWAY on the way home, and awoke to cars honking and zipping around you...(Did that- scary as hell)

Welcome to the city, new members. Jump in, don't be afraid to ask questions or to put out an opinion. Just be prepared to back up your claims with some evidence and/or logic. Sometimes we simply agree to disagree. We all form our opinions based on our personal experiences, our working conditions, and the area in which we work. What is "normal" for me may be quite unusual for someone else. It's often not a matter of being right or wrong, it's just different. As was said, there is quite a diverse crowd here- volunteers, basics, intermediates, paramedics, and every shade of provider in between. Some folks work as single role providers, others are cross trained, some are FD based, some are hospital based, some are military based, and some are 3rd service. We have nurses, respiratory therapists, doctors, and many others who bring unique perspectives to the discussions. I love hearing from the new folks, and NOBODY- no matter how long you've been in this business- is too old or too bright to learn. Some folks here are so bright it is actually scary. Yes, fire bashing DOES occur here, but in a forum such as this, the emphasis is on the EMS side.

We've had the IO drill for about a year now, yet I have never needed to use it. The only IO's I have done were old school and barbaric, but necessary(critical kids, and those who were in cardiac arrest). The drill seems like a great tool, but between my partner and I, even on someone who is a tough stick, we have been able to find something- even an EJ- to use.

Years ago I had the infamous- and very official looking- business card that said: "The person who handed you this card is a trained professional. Just lie down and do what the nice paramedic tells you to do.!" It actually was a great icebreaker- when I was single, of course- but surprisingly nobody ever took my up on it. LOL I think I actually still have that card tucked away in an old wallet somewhere...

Here's a few more: You are ALWAYS the first one to finish eating- at home, in a restaurant, at a holiday dinner... You have missed more family events, birthdays, holidays, etc. then you have actually participated in... You actually have more uniform related items than civilian clothes... You have caught yourself going through a red light/stop sign in your personal vehicle... You have reached for the microphone while in your personal vehicle to report a crash, traffic lights out of service, an open fire hydrant, etc... And for FD members- You have department T-shirts from all across the country...

The only question I have to this is "What was her respiratory rate?" "Unresponsive" does not say much. What was her Glasgow? What were her vitals? What about her pulse ox? If her O2 sats were lousy, breathing at 2/minute, and she was cyanotic, then I would have no problem with an IO- perfectly appropriate. As for heroin users having poor veins- I disagree. Of the hundreds of OD's I have seen, I would say about 80+% or more who use this stuff actually snort it- only the hard core users shoot it up, thus a person won't necessarily have lousy peripheral veins. IM is a perfectly acceptable route for someone who has stable vitals and O2 sats. Yes, it takes a bit longer to work, but in an otherwise stable patient, there is no urgent need to drop an IO. The IO route is for a person who is in extremis, not someone who is simply just "unresponsive". I also won't bash the provider who did the IO here without knowing more details about the patient.

"Pararescueman Technical Specialist." I double dog dare you to put that on a business card. LMAO

I think we actually agree on this, but differ on semantics. I don't look at what the government wants to do with big pharm and insurance as a take over, but more like forcing them out of business, or at the very least, drastically changing how they operate. Unless they cede control to the government- ala GM- they will be forced to shut down. Even if we go to single payer, government run insurance(gawd help us), there will still be a couple private carriers around for those with big money. In the socialist type, government run systems, these private carriers do exist. Problem is, most of the carriers will never be able to compete with Obamacare, and will eventually fold.

You are absolutely correct, Ruff, but specifically, it will be the middle class folks who are stuck with the bill. I'm all for providing a safety net for folks who need help, but the middle class simply cannot afford any more responsibility to carry this burden. What I fear is that so many people will be carried by the middle class that there will not be enough people paying into the system to allow it to survive. I think we are there now, and it's only going to get worse. If we will have a socialistic type medical system that's fine, but there will also be a heavy price to pay. We will no longer have the best health care in the world- that type of system is simply not sustainable. As for bailing out drug companies and insurance- under this administration, that will never happen- big pharm are the bad guys. The government wants more and more control over private sector businesses- think GM- and will "punish" any firm they feel is too big. They will impose restrictions to the point where no company can sustain itself and the feds will take over. Voila- government run, single payer, universal coverage. Count on it. Do things need to change- yep, but I submit that scrapping the whole system is NOT the answer. \\end rant.. LOL

Yeah, I do that too. If I don't have scratch paper handy, sometimes I run a couple second strip on the monitor and use that, or, I simply grab a piece of 2 inch tape- especially with multiple victims- to get data for a radio report. I started the habit in the ER when I would vital a patient and not have a Triage note handy.

Thanks, Dwayne. I think we operate on similar wavelengths. Not a good sign for you, bud. LOL Often if a patient has a funky or weak pulse, I go back to the chest a 2nd time to listen and confirm a pulse rate. Maybe I'm getting hard of hearing in my old age... In training, I recall listening to poor quality tapes of abnormal lung sounds and thinking "what the hell am I listening to"? The rales sounded like wheezes which also sounded like rhonchi. None of it made sense until I started hearing it in the context of a live patient, watching their respiratory patterns and rates, and correlating their signs and symptoms with what I was hearing. Suddenly the light bulb came on, and it all started to come together. I can't tell you how many times I have found unexpected rales in the posterior bases of a patient who I thought was clear. All it takes is one person in pulmonary edema who codes and you cannot revive them to be REALLY aware of their respiratory status and get a good baseline set of lung sounds. Quick- but related story- to toot my own horn. A couple weeks ago, my next door neighbor(actually their babysitter) asked if I could come over and take a look at their 10 year old kid. Seems he suddenly developed chest pain, and was crying. Mom was on the way home- ETA about 15 minutes, and asked the sitter if I could come over and check on him. Normal, healthy kid but scared, and to make a long story short, I did a BP, pulse, and quick exam. Everything seemed to be fine- anxiety was my thought. I also checked his lung sounds- clear a bell- BUT- I also heard something else. I picked up a heart murmur. I repeated the lung sounds, and yep, something was there. Mom shows up, says they had a similar episode a couple weeks ago, had it checked out, and everything was benign. She also mentioned that the doctor noted a murmur, but felt it was nothing to worry about. I was VERY glad mom said this since it validated what I heard, so I then felt it was OK to mention that I heard the murmur as well. She thinks the kid is freaked out because he heard the doctor say he had a "problem" with his heart. She packed him up, and went to the hospital. Apparently the doctor did a full cardiac workup- echo, EKG, Xray, blood work, etc, and they were supposed to follow up with a cardiologist as a precaution but everything seemed to be OK. Still unsure if the pain was related to the murmur or simply anxiety (my guess). Now I do recall learning about assessing heart sounds, but obviously there is little use for that in prehospital care, and it's certainly not something I listen for. The point of all this- besides an ego stroke- LOL- is that unless I understood what I was "supposed" to hear, I would have never realized anything was wrong.

Something EMTANNIE mentioned made me think. She spoke of her disdain for the habit of chewing on a pen while working. Obviously not a good idea. So I started to think- what odd habits have I developed over the years? For some reason, early on when I started an IV, I would remove the angio from the pouch, take off the plastic sheath to the catheter, and put that sheath in my mouth before I started the IV. Just a nervous habit ffrom when I was new I guess, but it stuck with me. I finish whatever else I am doing, and just before I make the call to medical control, I throw it away. Still do it to this day. Odd, but since it's sterile, I see no real harm other than the fact that it's some weird oral fixation I have. LOL Another IV habit- after I start an IV, I remove the needle and put my foot over it- whether it's on the floor of the rig, the house, or the sidewalk. It started as a way to keep track of my sharps, and to keep myself or anyone else from getting a needle stick. As soon as the IV site is secure, I pick up the needle and put it in a sharp box. It started when there were no such thing as safety angiocatheters with retractable needles, but I continue this habit today. So- what odd habits do you folks have?

I NEVER thought Obamacare was a good idea. The same people who were shouldering the burden before will still be required to do it after this law goes into effect. As for the nuts and bolts of the plan, many of the details are still emerging- who could have possibly read through all that language to see exactly what was in that bill? Even so, most people did not want this reform, yet here it is. You don't "fix" one problem by creating another one. Problem is, as was noted by Ruff and Dwayne, it still costs tens of millions to develop these treatments and medications. If a company will be penalized for making a profit- whether or not we think that profit is excessive- why on earth will they put out the money for R&D if they will not see a return on their investment? Sorry to our friends up north, but people are not flooding Canada to get the new, best, and most promising treatments for their diseases, they are coming HERE. If we move towards a Canadian style health care system, who will pay for the innovations we so desperately need? People who need top notch medical care come here from all over the world for a reason. What happens when that reason is gone? We will have a mediocre system like the rest of the world. This is about a cradle to grave entitlement and dependency that some think is a good idea. I fail to see any long term benefit in that.

I'm not sure about the cause for the high divorce rates in our business, but I'm sure infidelity plays a large role. All the things that we complain about our profession- odd hours, sleep deprivation, financial strain from a low paying job, high stress- are also major contributors to marital problems. When I worked in ER's, I wouldn't say there was a lot of bed hopping, but MANY folks were divorced. Honestly, in the food service business where I worked for years, I found A LOT of people cheating on spouses, with an associated high rate of divorce there too.