HERBIE1

Oops- missed the fact you were a volunteer. Well, hopefully the added responsibility and title will someday help you financially in some way. Either way, good luck.

Congrats on the promotion! Hopefully there's also a nice pay bump to go with the added responsibility.

Kyle, death is a part of life, but for anyone in this field, it is a FREQUENT part of our life. We see all manners of death- stupidity, tragedy, accidents, natural aging, disease processes. Some people can completely shut down their emotions and seemingly not be affected. I think those folks are few and far between. For most of us, it clearly depends on the circumstances. Your response can range from a "Gee, that was too bad", to "Oh my gawd, why did this infant have to die!" When my kids were little(infants), I went through a stretch where I saw 6 dead infants in a month- mostly SIDS, but a couple were homicides and accidents. I was almost afraid to go to work. That was tough- I kept envisioning my own kids. You go home, hug the kids a little tighter, and be thankful they are OK. You get through it. There is no right or wrong way to deal with it, as we each develop our own coping mechanisms based on our own personalities and our psychological make up. You are young, which means in many ways you are at a disadvantage- your lack of experience personally dealing with death can be a problem. It also can be a golden opportunity to start off on the right foot. You are doing the right thing- asking questions, looking for advice. Take what folks tell you, realize the good and bad of what you hear, and then adapt these ideas to make them your own. Until you begin to amass the experiences on your own, it's all you can do. How we deal with the death of a patient also depends on where we are at emotionally. If we are having our own personal issues, you may not be able to cope quite as well as other times. Sometimes the strangest calls get to you. Maybe you form an immediate bond with a family member and empathize with them more than usual for some reason. The thing is, DURING the call, you need to shut out the emotions and do your job. Sometimes that is easier said than done, but you have no choice. We are called to help someone because we CAN do something about a situation, and falling apart during a call won't help anyone. I worked with a girl- good medic, with plenty of experience. Saw plenty of death and dismay. One call we had was an elderly man who suddenly arrested at home- nothing unusual. I noticed my partner was not doing well during the call- slow, confused, tentative, needing to be prompted to do her work- totally out of character. The man died, and afterwords, I asked her what was wrong and why she was out of sorts. She broke down and cried, and told me that her grandfather had just passed away last week, and the emotions suddenly spilled out. It happens. Afterwards you can sit back, reflect on the call, critique your actions, and deal with any associated emotions that surface. Bottom line is now is the best time to examine this idea- better to develop POSITIVE coping skills, then later on when things start to catch up with you and you turn to negative behaviors. Figure out what works for you, and start working on those skills now- they take time to develop. Some folks turn to religion, others to meditation, others take vacations to remote, quiet, peaceful places to clear their heads. Others get relief from just talking about things with coworkers. Others like to keep a separate group of friends who have nothing to do with the business. Everyone is different, and what works for me may not work for you. Good luck.

Well, in the old days, there used to be drunk tanks. Essentially the cops would pick up someone for public intoxication and have them sleep it off in a jail cell for the night. Eventually the slip and fall lawyers capitalized on this and found one of those drunks who happened to be a diabetic, and the process was ended with a big lotto payout. Also, the new designer drugs like Excstasy and Ketamine complicated matters, and often times, those who appeared to be simple drunks are actually overdoses. Game changer. Now it's all about liability and nobody wants to be sued.

These are special case scenarios- extraordinary situations. Normal rules do not apply. Unless he happened to have a bag full of meds, a cardiologist would be in no better position in such a case than even someone only trained in basic first aid. The only difference is, the cardiologist could pronounce the person on the spot. Much of what we do is based on protocols, and often times, people find comfort and security in those algorithms. Problem is, as anyone who's been in the business for awhile knows- those little guidelines can fall painfully short. We need to make decisions on our own- based on advice from medical control- and do the best we can. We are not automatons we are human beings, and that is our best asset- next to our training. If you are the most medically trained person on the scene, then it's your (and the airline's medical control's) show. It happens. Obviously it's no fun being in a situation where you are in over your head. Whether it be something such as this scenario, or if you are presented with a patient with complicated medical issues. You simply resort to what you know, and do the best you can, given your circumstances.

This isn't about safety, it's about APPEARING to be doing something. Think grandma's knitting needles, nail clippers, and gawd knows what other inane "threats" they look for. If someone REALLY wants to hurt us via some IED on a place, it would not be that hard to do. Of course, they also can't concentrate on the real threats- the liberal PC police would get their panties in a bunch..

Oops. Is it just me, or does DC sure seems to have more than it's share of problems?

Sad that this is a young mother of 3, but it does not change the situation, nor the likelihood of a positive outcome. Less than ideal conditions, limited resources, and limited options. Like doc said, if the AED does not advise shock, then clearly the person is in PEA or aystole- neither of which means a good outcome. I'm thinking if this mom recently delivered, we could be talking about a PE or something similar, where there is nothing we can do to change. If you are in the back of your rig, or in an ER, then you would probably work a bit longer, maybe go a bit deeper into your ACLS protocols, but the outcome would probably not change. Talk to the flight surgeon/service, and see what they say. The decision to divert depends on flight time to final destination, time of day, available options to land, etc.

If the person's LOC was enough for them to hold their airway- what was their Glasgow score?- but 6 shots of booze with a normal person would not generally cause them to be so drunk they would lose their airway- BUT couple that with anything else they may have done- drugs, other booze, I would keep an eye on them. First, many times people LIE about their ETOH consumption, about possible drug use, etc. I also do not know if the Adderal and booze has a synergistic effect. Maybe they have an underlying problem detoxifying that alcohol- ie liver problems. Maybe they are running on no sleep, maybe they have no food in their stomach. Point is, when the person is vomiting is NOT the time to realize they cannot hold their airway. Keep an eye on the patient, but no intubation yet.

Generally, the first thing a pilot does is contact his Flight Link, or whatever doc/service they have for medical advice. I guarantee that pilot will turf all medical decisions to someone else. As for diversion- if it were solely MY decision- It would all depend on the time factor- how close is the nearest appropriate airport, time of day, and how far is the final destination. Clearly, diverting to some smaller city with limited medical facilities, maybe dozens of miles from the airport, in the middle of the night- I see no reason. We all know the chances of a positive outcome in such a case are infinitely small, but it all boils down to a legal issue. My guess is that unless their final destination is still hours away, they would simply be told to fly on and hope for the best. Diverting would be a waste of time, money, and efforts. I'm not arguing the likelihood of success in such a case. Again, advise the flight doc of the situation, and I would suspect that once you used whatever tools you had at your disposal, and did a few minutes of unsuccessful CPR, you would be told to terminate your efforts. Even under a legal microscope, I would think you would be on pretty solid ground with such a decision. Extraordinary circumstances, etc. The only thing I would question is the airline's official policy for such situations. I am quite certain they have official procedures in place(subject to revision by a doc, maybe) that deal with such situations.

Doc, I've dealt with airlines and medical situations many times. I know it's an expensive decision for an airline to divert(refunds, hotel rooms, rebooking, transportation fees, fuel costs, food vouchers, etc), but trust me, they will do it for far less "serious" reasons than you think. They look at it from a liability standpoint. Personal experience-Flying to Vegas from Chicago with my girlfriend, one day- years ago. About an hour into the flight, we hear the "is there a doctor on the plane" announcement. I look at my g/f- who was also a medic- and we wonder what happened. Saw nothing going on in our immediate area. A few minutes later, we hear "Is there ANY medical professional on board?" Uh oh. I volunteer, tell the flight attendant who I am, and offer to show her my license. She says there is a sick passenger at the rear of the plane. There is an approximately 30 year old woman, writhing in pain and moaning in the aisle. MAJOR drama. At the time, the only medical kit available was a BP cuff, a stethescope, O2, and a couple dramamine tablets. This was pre-AED days. To make a long story short, the best we could figure was that she had eaten a bad Polish sausage in the airport in Ohio a few hours ago, and now had abdominal cramps, diarrhea, nausea. Her vitals and exam were unremarkable, no PMH, nothing appeared to be serious. The flight attendent pulls me aside and says the pilot wants to know what I want him to do- if we should divert or not. Huh? Me? I explain the situation, I speak to the pilot, and he asks me again. He says he could land in about 45 minutes, or carry on to Vegas, another 2.5 hrs or so. I asked what his flight doctor, Med Link, etc wanted to do. They put it back in my hands. I am totally amazed that I am the only medical person on the plane(not even a podiatrist or chiropractor) and I am put in this situation. I tell him she SEEMS to be fine, but it's his plane, and HIS call. I explain to the woman the options and she says she does not want to land early- she'll be OK. We help her to a seat, the rest of the flight was uneventful, and we land, with EMS meeting us at the gate (she ended up refusing transport). Talking with the flight crew as we were leaving and find out the woman and her boyfriend had a little spat shortly after take off, so I think this was also her way of getting some attention from him and everyone else. She may very well had some GI upset- no way to know, but a plane load of people were almost diverted based on my decision- because of a lovers quarrel, and me in the middle of it. The upside of that situation- lots of free booze after I helped, the flight crew was very attentive(much to the dismay of my girlfriend, LOL) and later, a thank you letter and a pair of tickets from the airline. We were also upgraded to !st class for the trip home. I deal with airlines frequently now. They are usually VERY conservative- if there is any question, they will either keep a person from boarding, OR divert the plane. I guess the extra costs are nothing compared to the the liability they may incur from a lawsuit. On long overseas flights, people DO die- sometimes they are discovered dead in their seat, or something happens over the ocean, where diversion is simply not an option. They put the body in a an empty rear seat, in a rear galley, etc, and keep people away.

Triage is at the heart of what we do. In a multiple victim scenario, what do we do if a person complains of a sore finger? Do we do a complete 20 minute neuro exam, functional ability test, ROM, etc, or do we note the patient's complaint, classify him as nonemergent/green/etc, and move on? Same with someone who complains of a problem that we do not have the training, diagnostics, or permission to provide definitive treatment for. Do whatever is in the scope of our practice, and bring the person to a place who can properly assess and treat the patient. Does a triage nurse make a patient disrobe to verify they are having a vaginal bleed-with no obvious signs of excessive bleeding? Do they make a person display their hemorrhoids to confirm their existence and quantify their size before the person sees the doctor? Does that somehow make the triage nurse less of a professional, or not doing her job properly? Yes it is- if it is not in the proper context. Doing "more" is not always better, prudent, or even appropriate. But we are supposed to be "professionals". That means that by gawd, we need to expose- because we CAN. After all, simply telling the doctor a woman was sexually assaulted is not enough. We need to verify that statement and examine her. What professional should be afraid of a bit of legal trouble? Context. Proper time and place. I'm not big on mindlessly following orders without also engaging a bit of reason, logic, and common sense based on my experience and knowledge. That is what separates good providers from average ones. That's a big leap- from making decisions on the care we are trained to do, what we are allowed to perform, and where we transport to vs subjecting a patient to something for our own edification or an ego boost- especially when we KNOW that we have no way to definitively treat that person's problem or even alleviate their anxiety in any way. In fact, we would be making their unease even worse. Not happening. In some cases, a "proper" exam may actually be no exam at all. Exactly. So show me where in your statement that forcing someone to disrobe to see their hemorrhoids or purulent penile discharge fits into such a belief. I see no way how an STD or "piles" would ever be triaged as anything emergent, or even urgent. No, but things like vitals or a pertinent history can and often DO change how a doctor does things. Don't worry doc- our head injury patient- I saw no blood in the ears with my otoscope, the fundi look clear, and I see no signs of a brain injury- that CT can wait for awhile. Come on- really? Our opinions are nice- and depending on your relationship with the local ER docs, they actually may carry SOME weight. BUT- and this is a big BUT- if that doctor does not essentially ignore what you said and do the exam himself, he is being irresponsible, bordering on malpractice. It is now HIS patient, and HIS license on the line, not yours. You get to say- oops, I did an exam, I didn;t see anything, but I guess I was wrong. Then again, I'm a paramedic or EMT, so that's also really not within my realm of responsibility. A doctor has no such luxuries. Understood.

Thanks. I had no idea. (sarcasm) Otoscope? I would love to know how many prehospital providers use those. Anyway... We report what we see. Let's pretend we did use an otoscope and see an inflamed tympanic membrane,and the person seems to have a case of otitis. We don't carry antibiotics, so what exactly do we do? We report this to the doc, and will he simply write a script, based on our findings, or will he also take a look? We could tell him we think- or a patient suspects- she is pregnant and is having abdominal pain, so will he order an ultrasound simply based on our word, or do you think he might confirm that pregnancy with a beta-HCG test? I've never had a complaint either, but I also do not go beyond beyond my scope of practice. I do not pretend I spent 4 years in medical school plus a residency, plus having a whole tool box full of diagnostics.tests, procedures to confirm my diagnosis, nor do I have a definitive way to treat something like an ear infection, hemorrhoids, an STD, or PID. I can SUSPECT- and am usually correct- what may be going on with a patient, but unless I can definitively treat a condition- based on my training and available resources and protocols, I also stay within my well defined boundaries. Actually, an ER doctor CAN "fix", or at least begin to mitigate many "cardiac" problems. If he runs his tests he may see no reason to immediately activate the cardiac cath team because the patient is suffering from a muscle strain, angina, or indigestion. He will probably call for a consult in such cases, but the person will also not be immediately rushed to the cath lab for an angiogram. Again, we use our powers of observation, any tools we have, a detailed history, and an APPROPRIATE exam, and we can paint a very good picture of what we think may be going on. It's up to the doctor to confirm or shoot down our suspicions. I am very good at what I do, but I also do not expect ANY doctor- even ones that I have known and worked with for years- to simply accept what I say at face value. God forbid- if anyone I know is sexually assaulted(barring a massive bleed), and I find out someone in EMS wanted to do a vaginal exam just because they want to prove they are a professional- I will be doing business with that provider. First, we are not trained as ob/gyne's, we are not trained to look for, evaluate, or collect evidence, and we may very well even compromise a criminal case- and the benefit is only to the ego of the provider, not the patient. Good luck convincing an attorney that you are a "professional" while trying to justify why you did an internal or even cursory visual exam on a rape victim who is not in any way medically unstable or having massive trauma. Just be sure to provide the documentation of your rape advocate training, of your evidence technician background, and the protocols that allow you to do all this. If someone is complaining of penile discharge, tell me exactly WHY I need to expose and evaluate that discharge? What benefit would that be to the patient? Will I be inserting a swab to obtain a C&S? Will I be confirming a case of syphilis, chlamydia, or gonorhhea, while prescribing a course of antibiotics? I have no protocols for STD's in my system. Describe what the patient says with as many details as possible, evaluate their vitals, add any pertinent subjective data(appearance, demeanor, scene information, etc), and report your findings to the doctor. THAT is our job. We are VERY different than the ER doc. In every way. In terms of training, skills, experience, available resources at our disposal, responsibility, and liability. The proper expert in our case is medical control- the person who wrote your protocols, the person on the other end of the radio, or the ER doc where you deliver your patient. He/she is the EXPERT in their field, and has far more training and tools at their disposal than we do. Would you simply take the word of some bystander who claims they are a medic, and tells you that the trauma patient you are called is not really injured? Would you walk away, would you base your care/treatment/transport based on their statements, or would you provide the care and treatment you are trained to do? EMERGENCY medical services. That means we are trained to mitigate, fix, or maybe only transport- someone within very specific guidelines, in very specific situations, to obtain very specific- and generally temporary- outcomes.

Here's where the professional part comes into play. Does the person have normal vital signs? Is their story consistent with how they present? What is their affect/demeanor? What is the circumstances surrounding the story- the scene, the family members or bystander attitudes? Will someone lie? Of course. They can lie about drug use, they can lie about the chest pain they are having or how long they have been dealing with it. Do they lie about taking their medications appropriately? Of course they do. Now if a woman is claiming they are merely spotting(as in someone who is in denial they are having a miscarriage), yet they are tachycardic, hypotensive, pale, and clammy, then yes, IGNORE what they say and do your job. Common sense. Wrong.That is EXACTLY the scenario where I said that we DO need to expose. Yep. We are medical professionals, but we also are supposed to have common sense and use good judgment, based on our experience. Blindly following some protocol is not the hallmark of a true professional. Making a patient uncomfortable, embarrassed, anxious, or upset is the exact opposite of what we are supposed to be doing. Until we are required to test for STD's, obtain a UA, or do an internal gyne exam, I am using common sense. I feel no need to "prove" I am a professional. Obtain a good history- especially relating details from the scene(anxious family members, curious behaviors, etc). Countless doctors have told me that is one of the most valuable things we can do for them- give them info they simply cannot obtain from the patient or family members. They are diagnosticians by training- why do they need us to verify something we cannot treat or alleviate? We all have a role to play in medical care, and we need to understand our place in the process. To me, this is like some ER doc attempting a procedure usually handled by a specialist. Yes, he is a doctor, but is it really appropriate to do something that may have minimal benefit, just because he/she CAN? Doctors call in specialists all day long for something beyond their area of expertise. Why should we be any different?

So if the woman has PID or the man has an STD type symptoms, exactly what will we be doing for them? We are not obtaining cultures, we are not getting a UA, we are not doing swabs, we are not doing an internal exam. Ask the appropriate questions, and you can give more than an ample report to the ER. Probably 99% of any situation can be assessed with a few pointed questions. Bleeding? Vaginal bleed- how many pads have you used? Discharge? How long? Trauma? LMP? Pain? Unless you have an imminent delivery, massive bleeding, other extreme gyne EMERGENCY, or it's a trauma situation where you need to expose everything, there is no reason to be examining someone's genitalia. There needs to be a damn good reason. It doesn't matter if WE consider ourselves medical professionals, in delicate situations like this, the opinions of the patients, family members, or bystanders are the ones that count. Again- if it's necessary, then by all means, but my point is, it is RARELY necessary for us to do such an exam. If it's appropriate, then you need to examine- while maintaining the patient's privacy and dignity, and with a female witness(or provider) if at all possible.

Welcome to the City. As was noted, I would use your current job to start thinking as an EMS provider. (Obviously AFTER your current responsibilities are taken care of). As you obtain more knowledge about the body and diseases, look at your patients through the eyes of an EMT AND a CNA. What would you do if your diabetic patients seemed lethargic? What would you do if your cardiac or renal patient developed difficulty breathing? What kinds of complications would your expect to see develop in a bedridden patient, and how would you address them as an EMT? Good luck, and study hard. The more you know, the better off your patients will be when you arrive.

Well, we have many items on our rigs that we do not use often- even in, or maybe BECAUSE of- a high volume system. I can think of many tools/meds/procedures we have use and carry, yet use only rarely, if at all. How many cricothyrotomies have folks done in their career? What about IO's? How many needle decompressions? More studies need to be done(evidence based medicine) to further show the value of US as a diagnostic tool. Again- given the right circumstances, within the right system, I can see it as being valuable, and even potentially life saving. Problem is, with the economy such that it is, with budget cuts, and many services having trouble simply getting basic supplies and equipment for their rigs, ultrasound would be a a superfluous luxury. Additionally,- and probably key-is the system medical directors would need to buy into the idea, and would need to develop very specific protocols that would mandate it's use and integration into patient care. Think 12 lead EKG's here- unless the protocols are developed, and US becomes a standard of care for certain suspected complaints, even if a funding source was found(grant, donation from hospital or drug company, etc), the unit would be little more than a novelty item. Again- I'm not questioning the potential of using US prehospitally, just the practicality and feasibility. Seems to be this would be a very location/system specific thing. Some systems would benefit immensely from it's use, while for many others, I think it would become a large, expensive paperweight.

Well put. In a nutshell, you need to do what's best for yourself. The reality is that not everyone can be an advocate or change agent for a cause. The bottom line is you need to take care of yourself and your family first. Then, if you are in a position to, and are so inclined, you can get involved in trying to change the pervasive culture. You need to make a living, and standing on your principles is fine, but in the end, if you cannot pay the bills or support your family, then I suggest you need to either reevaluate your career, or accept that your employment situation may not be ideal. It's a choice we all need to make- follow your head or your heart, and luckily sometimes both paths complement each other. Sometimes not.

Sounds great on paper, but as the article points out, reality is much different. Politics injects itself into every corner of our lives-and yes, even medical care. Look at our soon to be implemented Obamacare. Agree with it or not, politics has decided how medical care and insurance will be provided and administered to us. I submit that despite all the rhetoric and posturing from all sides, the primary reasons for implementing this plan have nothing to do with helping people.

A DNR is not necessarily disease specific. DNR's can be as specific- or as general as the patient wishes them to be. Obviously, the more details included(No intubation, no pressors, no feeding tubes, no CPR etc), the less chance of any ambiguity. The correct title of this document is actually "Advanced Directive". DNR is probably the most common directive under that heading. Clearly, each case is different, and you need to take into account the circumstances, the disease process, etc. This is where judgment and compassion come into play because gray areas do occur, and as always you want to abide by the patient's(or legal representative) wishes and the spirit of the document's intent. Well said, RIchard. When my dad died suddenly, while he was on life support, we had the opportunity to donate his corneas, skin, and bone for grafts. At first they needed to rule out cancers, and other issues, and once they did, they were able to allow this to happen. Dad never expressed specifically his wishes for donations, but being the type of person he was, I am sure he approved. Like you-when I'm gone, my family is well aware they can have whatever parts they are able to take from me since I won't be needing them any more.

For someone who is essentially apneic or has agonal respirations, obviously it is pointless. To me, nebulized naloxone is a longer term tx that is used for someone who may be lethargic, and you want to gradually improve his level of consciousness.

Sorry, but single role in an FSR union is not true representation- especially since you are the minority. First and foremost, FIRE departments are out to protect FIREFIGHTERS. By and large, they promote and fight for things that primarily benefit FSR, while occasionally throwing a bone to EMS. Yes, they are forced to provide medical care, but if you were somehow able to wave a magic wand and eliminate the medical portion of their jobs again(like the good ole days), most would JUMP at the chance. It all depends on what you want to do with your career. It can be frustrating to be underrepresented, but if all you are looking for is a paycheck, benefits, a stable job, and doing something you love, that's fine. I don't know how old you are, but over time, working in a high volume area will take an emotional and physical toll on you. Once you are able to retire, you still want to be able to have a good quality of life. Sometimes that means moving up to a position off the streets. That's why so many single role providers become cross trained-not necessarily because they love fighting fires, but for longevity's sake. Changing locations/employers is always an option, but not always practical or even feasible. So many factors to consider- cost of living, pay, benefits, housing costs, etc.

OK- so the problem wasn't as much that YOU were offended, but it put you in an awkward situation. Understandable. I think a simple NSFW warning would have solved the problem, BUT- again, there was the adult humor caution. I have my page configured to show any new posts, and I also do not pay attention to which forum the posts originate from. Then again, I do not attend(although am an occasional adjunct professor at) a Catholic University.

Well, the OP said that he tried to dissuade folks from being transported by EMS. That's the wrong attitude to have, and goes against what we are supposed to be all about. There is also a huge difference between actively trying to change someone's mind, and laying out their options if they are on the fence about what they want to do. As you note- ultimately it is the patient's decision, and as long as they meet the criteria for an informed and competent refusal of transport, we must honor their decision, but certainly not try to make it for them.

Good luck to both of you, and welcome to the city!