HERBIE1

As was noted, we probably acquire more little critters on us than we realize. Problem is how many people strip nekid before they walk in their homes? What about your shoes/boots? Belts? What about jewelry- watches, rings, earrings? Pens, pencils, penlights, trauma shear handles? Point is, we could really get carried away with the idea of protection and disinfecting ourselves and our environment. Common sense, prudent and reasonable measures, and I'm OK with that. One thing I do as we check out the rig every day- I use those large alcohol wipes that come in a big container. I clean earpieces, microphones, stylus for the lap top, keyboard keys, handles, electrode leads, buttons/control dials/knobs, flow meters- any surface I can think of that may have been contaminated. Seems to have worked for me- I rarely get sick.

No offense taken, bud. Problem is, there really is no justification to NOT take all those precautions. I was certainly not bragging about the good ole days, just pointing out a fact. When I started, I was in college, doing volunteer work as a newly minted EMTA (now EMTB) We would do stand bys for road races and other special events as well as disaster assessment through the Red Cross. We had a team of 3 guys, we bought all our own supplies- via the school's health service, LOL) and had a great time. Many times we were up to our elbows in blood, we loved every minute of it, and it was even a badge of honor. Of course, this was also pre-HIV days, so we honestly did not worry too much about BSI. Even as a new medic, I often took off a glove to get a better feel for a vein on a tough stick. Again- not saying it's right, just a fact. Times do change, us old timers SHOULD change, but too often old habits die hard.

It's not about how much the test actually costs, it's about how much an insurance company will pay for it. As we know, that cost is quite different than what they would charge someone who pays cash. Hospitals, labs, and other providers have contracts with the insurance company, so the "cost" is a relative term.

Without a doubt. High stress jobs are notorious for this problem. Then again, the nationwide divorce rate is incredibly high too.

Agreed. What is the point of "proving" someone is faking it? All they need to do is complain of some vague, nonspecific problem and they need to be evaluated anyway. Folks spend way too much time worrying whether a call is legit or not. We all know that a significant portion of our workload is BS(some areas more than others)-it's just part of the game.

Placing your hand on a chest is indeed one way of checking respirations. Check the abdomen- sometimes it's easier to see it rise and fall vs the chest. Depends also on the depth of their respirations, if they are a mouth breather- like a baby, COPD'er, or someone who is dyspneic. Keep at it- you'll get it. Just like anything else, it takes practice. Listen to as many chests as you can. As an aside- one of the hardest things to learn are breath sounds, and until you know all the variations of "normal", it will be hard to tell what an abnormal sound really is. One suggestion, try looking at as many folks as you can and see if you can count their respiratory rate. Listening to lung sounds you can also get their respiratory rate AND their heart rate. Your instructor is correct BTW- if people know you are watching them, they will alter their breathing patterns. Depending on the situation, I try to gauge the person's breathing as one of the first things I do. Walk into a room, look at the person- especially if they do not see you yet- and you can get a pretty good quick baseline reading. As soon as you start interacting with them, their anxiety causes them to speed up.

Honest reply? I already wear glasses- I do not put on safety goggles over them. As for a mask- depends on the situation. As for other providers, heck-I'd say maybe 50% use a mask/ face shield, or goggles. Wrong- I suppose, but I also didn't even wear gloves when I started this business either.

See if you can talk to current and/or former employees to get a handle on how the business operates, what their priorities are, working conditions, pay, etc.

Wow. RIP, brother and sister. Sincere condolences to their families as well as all the grieving coworkers. You are not alone.

I'll echo what has been said already-also from personal experience. You simply get too close to a situation- you have no perspective. Your "normal" may seem quite "un-normal" to an outsider, or to you when you are working in the role of a provider. We all assume- too often incorrectly- that everything is stable at home. It's our sanctuary from the insanity of what we deal with at work. Then, something happens to change that status quo, and it rocks our world. Why didn't I do something? Why didn't I see the signs? Why didn't I realize this problem was getting worse? What kind of provider am I if I cannot even recognize the signs I could easily detect in one of my patients? Usually we take off our provider hats when we walk in our front doors- for good reason- the down time is important. Problem is, we then become blind to a problem that may be brewing at home- until something/someone wakes us up. I will also suggest getting help for yourself as well as your spouse. The guilt over not recognizing the warning signs or changes can and will eat you up. Trust me- I know EXACTLY what you are going through.

It would work on me. The threat of large bore IV's works well too. Then again, I've also seen people who seem to be completely immune to inhalants.

Define "personal" information. If it's not actionable- as in the case of an admission of child or elder abuse, where we are required to report it-, like you said, it's not protected health information, so there is nothing to report.

I'm going to disagree with this statement: If you are going to have a child then you need to focus on that child or children 100% and not work) If this was 30-40 years ago, I would agree with you. In today's economy, while I have no data at my fingertips, I would say the number of stay at home moms with a single wage earner dad(or vice versa) is a fraction of what it used to be. Depending on where you live, it is almost impossible for most families to survive on one income- the 2nd spouse usually at least works part time. Is it possible- yes, but the cost of living in your area needs to be low, or the single income is sufficient to allow one person not to work. For new families, just starting out in the workforce(she says she's 25) it would be tough to support a family. Yes, I grew up with a stay at home mom, as did nearly every one of my friends, but that is no longer the case- especially for those in this profession. I got married late- at age 34- and I was making a good buck at the time. My wife worked full time(still does) but thanks to my platoon schedule, with a little help from mom when I was working, I was essentially a stay at home dad. Tough- sure- but I also wouldn't trade it for the world. I got to be involved with my kids, I got to experience many of their "firsts", and even now, I can remain involved in their school and their lives. That is something I never had growing up- my dad left for work at 5AM, came home at 6, ate dinner and fell asleep- 6 days a week. It wasn't wrong, but it was also no different than the majority of the families at that time. Times are different now. Again- obviously the best possible scenario is for one parent to be home- at least while the kids are young. All I'm saying is that in today's world, that is a very difficult thing to be able to achieve for most.

While I am unfamiliar with that particular program, it is the wave of the future. Hospitals have been doing it for years now- everything is electronic. It may be a pain in the arse, but the advantage is easier accessibility to information. In the case of EMS, it's generally all about generating a bill faster. It also means Q&A is easier, easier retrieval of reports for potential litigation, etc. Within 48 hours of a transport, our system has a bill in the mail. Of course, reimbursement rates are another issue entirely- they still average around 1/3 here. It saves money, time, storage costs, and personnel- most of the work is down electronically. The programs have gotten better, and hopefully you guys will have input as far as how it will be set up, and the nuts and bolts of how the program interfaces with the user. Additionally, pay close attention to the type of laptop they use- we now use Toughbooks, which are far more durable that our first models. Problem is, they also become obsolete rather quickly, so make sure the project is set up with frequent upgrades of the software AND the hardware.

Well, a trauma center is a different story. When I worked at a Level 1, they would also do similar techniques to quickly establish a baseline LOC. In a busy ER, with multiple critical traumas rolling in, needlessly tying up a critical bed and resources only harms patient care. In a slower ER, the staff may have more time to do hand holding and such, but the reality is, it's about triage and properly allocating resources. Like you mentioned, if you commit a lot of resources to a patient who may not need them, what happens when that critical, unstable trauma rolls in? When I was in that realm, the trauma docs were also much quicker to RSI a combative patient then they would in an average ER setting. Why? Again- triage and time management. They could spend 30 minutes or more trying to calm and/or restrain a difficult patient and then be able to assess them, or they could gain control of the situation and quickly assess and treat them.

I will take a different tactic here. First, welcome to the city. Next, thanks to my platoon schedule, when my kids were little, I was essentially a stay at home dad- my wife worked full time too. It was difficult coming home with no sleep, and having to care for the babies. I was not running a service, but I was still working full time- often picking up OT to cover expenses. Occasionally I would have mom take the kids for a couple hours so I could get some sleep- when I was simply too exhausted. Point is, it CAN be done. Will it be easy? Of course not. There were many days where I was at my wit's end- kids were fussy or sick, acting up, etc, and I thought I was losing my mind. Based on your post, I sense you are overwhelmed, and if that's the case, something will suffer. I don't know your family situation, how much help you get from dad, friends, family, etc. I will say that your kids need to be the priority, but if it's a matter of money, you will need to figure out what will work for you. Sitters, family, friends, nanny- whatever. I know a lady who went back to work (she was a FF/medic) 6 weeks after having her kid. Dad was out of the picture by then, so she was on her own. She had a full time sitter, and as such, she barely saw her own child. To me, that is not acceptable- someone else is raising your child, but sometimes we have no choice- circumstances dictate our actions. You need to decide what you want AND what you are able to tolerate, and hopefully come up with some type of balance. Good luck.

To your point about age- There is certainly something to be said for having a little "snow on the roof". LOL Yes, the patient or family will generally assume you have been around the block if you have a few grey hairs, and unless you act like a rookie, they will never know. I think an older provider makes people assume you've been doing this awhile, and this is usually the case. Bottom line-your demeanor, professionalism, attitude, and how you preform your duties are what instills confidence in a patient. Often times simply taking control and being calm in the midst of chaos is the single most important attribute we can have, and puts the patient, the family, and any bystanders at ease. With age comes life experience, and often times this alone is enough to convey an image of authority and a feeling that whatever is going wrong, you can handle it. In this respect, I think a new provider who happens to have more birthdays than most has an advantage over someone who is younger.

In many areas, for years "poppers" were almost a first line drug. Not saying it's right, but that's the way it used to be. Now, as was noted, "proving" someone is faking is a waste of time and is basically irrelevant. If they are going through all the trouble of feigning unresponsiveness, let the hospital deal with the drama. Whatever the reason for their act, it's nothing we will be able to "fix" in the brief period they are with us. Psychological issues, domestic problems- nothing we will be able to cure in a few minutes. Besides, in my book- quiet, compliant, and passive is far better than angry and combative. I found that over time, many people even developed a tolerance to these things- they simply had no effect on them. Now some of the justifications I heard for using them are so that we do not "overtreat" someone who has no serious medical issues, but if we check a blood glucose, maybe push Narcan, then what else will we do for someone who has stable vitals? Yes, there is a cost factor, but really, we cannot be concerned about that either. If a person has a simple syncopal episode- from fear, emotional distress, pain, etc, then they will quickly wake up on their own anyway. Treat the underlying problem and transport.

Gotta keep those CPR instructors in business! More changes- not exactly a surprise. I'll worry about this if/when our system protocols change. I took my first CPR class around 35 years ago. The changes that have been made since then are incredible- especially it seems within the last 10-15 years or so. Stair step respirations, pausing compressions to give ventilations, elevating the importance of compressions vs ventilations, immediate defibrillation, immediately calling for help vs doing CPR THEN activating EMS, CPR for 2 minutes THEN defibrillation, increasing the compression rate, changing the depth- the changes are endless. That's fine, because to me, even half assed bystander CPR is better than nothing at all. Clearly the most important link in the survival chain is early bystander CPR, and this is also the most difficult part to enforce. In the 80's, I think the dangers of HIV and other infectious diseases kept many folks from doing CPR, or providing basic first aid. Standards were changed, there was a push for education, but I still think people are skittish about contracting some type of communicable disease if they help people.

My opinion- brush up on the basics. Make sure you have a firm handle on the all the BLS stuff- it will make paramedic school a lot easier. Buy the books for paramedic school, read ahead, but be careful to not get carried away.

Like any skill, starting an IV takes practice. A lot of practice- there's simply no way around that, and simulations can only do so much. Preparation and technique. Have everything you need ready and easily within reach. I found that working for the privates when I started out, where the vast majority of my patients were elderly, with the tiniest veins imaginable- was great preparation. If you can master getting a patent line on a contracted, squirming, bedridden senior in a nursing home, an IV on a healthy adult is a cake walk. Key is to use the same basic technique every time. Someone may have veins that look like a city water main, but unless you use proper technique, you can still "blow" the vein. Experience will teach you that certain patients require extra care- someone who takes prednisone long term will have very fragile veins, making good technique crucial to success. Same with long term diabetics, or someone who may be taking coumadin. Do a little "homework" before you start- check their history, inspect the area- recent attempts may complicate your efforts- or even show you a possible site in a difficult patient. Ask the patient who has frequent blood draws where the best place to use is- they will know.

First, welcome to the city. Second, although your age may limit your employment choices- as you noted, most fire departments won't hire you- jobs are out there. Do some homework about salary, as the financial needs/wants of a 57 year old are quite different than those of a 20 year old. If you decide to follow through, do some ride time to get a feel for what the job is all about- you need to understand what the realities are vs any preconceived notion you may have. If you do get involved, it will be like a drug- addicting, and you never can get enough. Best of luck.

Here's the deal. Much of what you say is pretty accurate. The problem is,in many cases, we are not in a position to make a decision as to the need for transport to an ER. Yes, I am reasonably certain that we would be safe not transporting something like a finger laceration. But, with all the possible permutations of medical issues- one symptom masquerading or hiding another illness, a yet undiagnosed/hidden medical condition, or a patient who has a complicated medical history, you are taking an awfully big chance by downplaying the need for a transport and ER evaluation. Yes, we get medical control to document our encounters, but that documentation is only as good as the report the provider relates to the telemetry person. Maybe it's a new/subpar/lazy EMS worker who does not accurately relate all the details. Maybe the provider did not do a thorough enough exam. Maybe the provider missed a key piece of the puzzle in his/her exam. That puts the provider, company, department, medical control, and obviously the patient in the line of fire. Even a subpar doctor has a multitude of tests, exams, and procedures available to them in order to come up with a differential diagnosis. We have no such luxury. Does the system need to change? Obviously, but we need to be very careful about how we proceed, and certainly we cannot unilaterally begin to change that system. Yes, far too many people are transported to, and seen in ER's that are NOT emergencies. I also see no quick fix- too many political, legal, and philosophical barriers to overcome. We also need to separate out from this discussion a patient's refusal, vs a provider telling someone there is no medical need for them to be transport. BIG difference. Most systems operate under the assumption(legal based) that an emergency is defined by the person who is calling for help. As such, it would be difficult to stand up in court and say- sorry, but I did not feel that person was in any medical danger. Good luck defending that decision. Yes, insurance companies also define an emergency- at least in terms of whether or not they will pay for an ambulance or ER visit. That's a different story, and an issue between you and the insurance provider's specific policy. So we have an "emergency" or medical necessity defined quite differently, depending on your point of view. Bottom line- this is a complicated issue, and few of us have the financial and legal resources to defend a borderline decision, should the need arise. Yes, we DO make judgment calls, but I am far more comfortable with my judgment after 30+ years in the business, vs when I was brand new. Regardless of my experience, there are still situations that give me a significant "pucker factor"- even though I am doing everything by the book. I've simply seen too many incidents where bad things can happen, and some of them far beyond the control of the provider.

Since when did we become so thin-skinned that we can't take a little joke? Is anyone really worried the public will think this was an accurate portrayal of what we do? The old saying is that there is no such thing as bad PR. Personally I think we could use all the exposure we can get. Sheesh, folks- lighten up.

Well, sadly in this economy, salary is a legitimate concern. Obviously WHERE you work is a significant factor- the cost of living in a big city is a lot higher than in a rural area. Private provider, 3rd service, fire or hospital based- all things that impact whether or not you can afford to follow your heart and not your pocketbook. As was noted above, benefits are another HUGE factor. Starting out as a youngster, most people do not pay much attention to things like insurance, pensions/401K's, or IRA's, but they can be deal breakers. Around 30 years ago, I was pretty new, and had a "minor" medical problem. Started out as strep throat(used to be an annual thing for me), progressed to tonsillar abcesses. Ended up dehydrated, and spent a week in the hospital getting it I&D'd, IV antibiotics, and rehydrated, I did have insurance, but the plan was so lousy it cost me a small fortune out of pocket. Spent quite awhile paying that bill off- especially since I was probably making around $8/hr at the time.