HERBIE1

I learned crazy, desperate measures in my wilderness class. Things that 99.9% of people will probably never even think of, much less try. I suppose this safety pin thing could be considered a last ditch effort as well. As you noted, I would not consider this a protocol, in any true sense of the word. If you are alone, in the middle of nowhere, and faced with such a crisis with bleak chances of help arriving, you have 2 choices- do nothing, or try anything. I hope to never be put in such a situation.

Sounds like you've had some interesting experiences. BTW-I really like the white tape to check for respirations in a dark environment. There have been a few times in multiple patient triage situations where that would have been helpful- even in an urban setting. (Dark alleys, vacant lots, houses with no electricity, etc.) I have to remember that the next time a situation arises when I'm trying to assess and treat multiple patients. God bless surgical tape. I use it as a notepad on my pants for V/S or details for a quick radio report, a strip across a patient's forehead to secure them to a backboard is also a great notepad if you do not have triage tags readily available- V/S, triage code, patient's name/age, designated transport hospital, etc.

I "learned" something today. I honestly never heard of this safety pin thing. To me, because the mouth is so vascular- especially the sublingual area- it seems the risk of occluding the airway with blood makes this an ill advised idea. I've seen some nasty tongue lacerations from seizures, but nothing life threatening or enough damage/blood to endanger an airway. Since most seizures are self limiting anyway, I simply see no reason- even in a wilderness setting- to try this. If the person is in status epilepticus, then the first priority is stopping the seizures, and if all you have is cotton balls and a safety pin, the person is screwed anyway. Years ago I took a wilderness EMT class and never learned anything like this. I learned about basic survival skills, about making litters and splints out of branches and, how to keep a person from becoming hypothermic, etc, but NEVER heard of this safety pin trick. I suppose desperate times call for desperate measures, but- WOW.

Aren't you being a bit harsh on the OP? This is a LAY PERSON who took a CPR course, not someone who is a trained medical professional. Lots of people take the class and as we all know, some instructors are better than others. Many people freeze up when presented with an unconscious person- even if they had a proper CPR course. Clearly she's upset about what happened and the last thing she needs is a brow beating over it. if you are talking about dealing with people at risk, well, in any work place folks are obese, smokers, asthmatics, and gawd knows what else.. Does that mean every person in a work environment should be an EMT or paramedic in case a coworker should collapse? Do you recall your first cardiac arrest? Were you calm, cool, and collected? Did you feel 100% comfortable? No anxiety? I know I was a nervous wreck, and I was trained. Now think of someone who's job is to help people become physically fit- not be responsible for providing them medical care and suddenly they are presented with something like this. As a trainer- especially with my own gym, if I were dealing with folks who may in less than optimal health, I think it would be good to get a physician's release, saying this person is able to tolerate physical exertion. That said, however, the victim was 27 years old- not a likely candidate for something like this to happen. Possible- always. Like I said to the OP, she should take a refresher CPR class, obtain an AED, and be prepared in case it happens again. Not fair at all, in my opinion. Edit: You can tell me to pound sand if you wish, but I think you owe the OP an apology. Old school my arse. I've been doing this for 30 years and never heard of such a thing. I also call BS.

Agreed. Of course not every patient encounter results in a lawsuit, but there is no way in the world to determine which ones will come back to bite you. It's generally the simple, innocuous ones that get a life of their own. A simple tummy ache, the patient refuses transport, and it turns out to be a dissecting AAA. You just never know, and have neither the training nor the tools to make a differential diagnosis.

Really? Old? I think I need to get on your email list since I never saw this one before. LOL I'm kinda surprised that anyone in this profession would take offense to this. I've heard jokes from female coworkers that would make a sailor blush. Not right, not wrong, but I'm just sayin...

Thanks, Richard. Back to the basics. Shame on me for not putting that out there at the very onset.

With no medical training other than a CPR certification, it is not unusual for someone to freeze up when presented with such a situation, so don't beat yourself up over it. The problem is, if part of your certification is CPR training, then you need to be able to do at least that. Think of it this way- the person is already dead, so you will not harm them. Seizures occur for lots of reasons- someone has a seizure disorder, and it seems in your case, due to heart problems(basically a lack of oxygen because the heart is not working correctly). Now for future reference- First, while someone is seizing, without advanced medical training and medications, there is nothing you can do to stop it. It will seem like an eternity, but most people stop on their own in a couple minutes. Check their wrists and necks- they may have a medic alert ID that explains any underlying medical problems they have. Protect them from harming themselves(pad their head, move them away from anything that can hurt them, and NEVER stick anything in their mouth while they are convulsing). They will not swallow their tongue- it's a fallacy, but they may bite it, or their cheek. Not generally a major issue at the time. Additionally, while a full blown, grand mal seizure is happening, the person is NOT breathing. Give them oxygen if you have it. They will begin breathing, they may remain unconscious, or they may wake up confused, combative, and have no recollection of what happened to them. If they do NOT wake up, then it's not a simple seizure, as it appears in your situation. You go through the CPR steps you were taught- Airway, breathing, circulation. You say there are nearby hospitals in your area, but what about the EMS system? How quickly would trained personnel respond? I would reconsider the idea of an AED if you open your own place if you can at all afford it. Some locations even require them for certain businesses and public places, so I would verify that is not the case for you. They are VERY EASY to operate, and even have step by step directions on them. Again- if the person is NOT dead, the AED will do nothing. If they are not breathing and have no pulse, then it can save their life. Take a refresher course in CPR- like any skill, if you do not lose it, you lose it. Lay people who learn it often never need to use that knowledge, but as a personal trainer, there is a greater risk something like this can happen on your watch. I would also make it a job requirement for all employees to be CPR certified, as well as trained on an AED. EMT training is fine, but I would take it one step at a time. Relearn the CPR so you become more confident. See if you can procure an AED. Good luck.

Well, I am much more likely to believe an automatic BP cuff reading from a patient lying on a stationary ER bed, than in a moving ambulance. We do not use automatic cuffs, and I admit there are times it would be convenient, but I still prefer getting an audible BP. If presented with a choice, I trust myself before I trust a machine. It's simply a basic skill and we should all be proficient at it.

Richard- I love that guy! I have his screen savers on my lap top, and use his power point templates for my lectures. I met him a few times, had a few beers with him, and he is an excellent and dynamic lecturer. I highly recommend seeing him if you ever get the chance. He also does a very moving tribute to a former partner who died of cancer, I believe.

Tons of reasons for syncope, and as was mentioned below, what you describe is classic orthostatic hypotension. In a healthy person, it's generally because you may be dehydrated. Without getting too technical, a simple explanation is when you stand up, your blood vessels constrict to force more blood return to your heart. If your blood volume is low(dehydration) the vessels can only do so much, and you do not get adequate blood flow to your brain, causing a momentary feeling of lightheadedness. Generally your body will quickly compensate by increasing your heart rate, and restoring adequate blood flow to the brain. Obviously medications and disease processes complicate and affect this, but increasing (noncaffienated) fluid intake is the easy answer for a healthy person. When we take orthostatic vital signs on a person, we compare the BP and pulse in a sitting/supine vs standing position. In a person who has significant internal bleeding or dehydration, etc, we can see an increase in pulse rate upon standing, a rise in their respiratory rate, or a drop in their BP if their body is not properly compensating.

Agreed, doc. I would also add that "when" question should be applied in many situations. Just because you CAN do something does not mean it's what may be best for the patient, given a particular set of circumstances. Paradoxically, doing "everything you can" for the patient sometimes means doing less. Judgment is not something that can be taught- it's the result of experience and training, and I happen to think it's one of the most important skills I have.

LMAO Personally, I thought it was hysterical(I'm still giggling as I type this) but then again, I was also never accused of being PC. I see nothing inappropriate about this- the forum is marked with a warning that adult content may appear in it, so I see no problem with this. The only thing I would add is maybe a NSFW description on the title, but they are BREASTS for gawd sakes, not some porno clip. Lighten up, people. We all need a good laugh every and then.

Well, as I am sure you know, the dirty little secret in the medical/legal world is that even if you do everything by the numbers, it does NOT mean you are insulated from potential litigation. Nothing like a dead or disabled victim to get some judge or jury to award a huge judgment for a plaintiff, or force a settlement- regardless if the accused have followed all the rules. One little errant or ambiguous word in a report, or from a witness is all it takes to put someone through legal hell. A "good" attorney can make even the best intentions of a provider seem suspect, and they can make even the best written report seem like a "Dick and Jane" book. Most of the time, things are pretty cut and dried, but every so often, we get "one of those calls" where good judgment, (along with the usual CYA principles and protocols) is key to covering your arse. I don't know about you, but I do not make nearly enough money to accept responsibility for going out on a shaky legal limb. It's been said a million times here- It's much easier to simply transport, then spend the requisite time and energy explaining/justifying why you did not.

First, I would not worry about whether or not the local transport agency was getting short changed- it's supposed to be about what's in the patient's best interests. Issues like that are for policy makers to hash out. I would be very careful about your policy. First, how do your approach these nontransport calls? What do you tell the person? How do you evaluate them- V/S, lung sounds, EKG, pulse ox, glucose, etc? The patient will always ask something along the lines of "Will I be OK to go by car, and not an ambulance?" That's a loaded- and very dangerous question, which requires an honest answer. Obviously the situation depends on their chief complaint, but often times their stated problem is only the tip of the iceberg, and they have underlying problems that DO require immediate evaluation. We simply do not have the diagnostic tools or training to rule out many problems. Blood work, Xrays, CT's, ultrasound, etc. You may be putting your license-and your employer- on shaky legal ground by encouraging or implying a person does not need an ambulance. Obviously someone with a hand laceration where bleeding is easily controlled does not need an ambulance. They may need sutures, a tetanus shot, or even an XRAY, but someone with a vague complaint like abdominal pain can be anything from gas to a ruptured appendix. I do understand your concerns- especially in this economy. Ambulance service is EXPENSIVE, not everyone's insurance will cover it- especially if it is deemed not an emergency, but that is NOT our call. If you are willing to wait with a family for them to arrange a car transport, then clearly this is not an issue of getting back into service quicker and not wait on an ambulance. Anyone who refuses transport needs to be advised fully of potential risks(however remote), as well as the costs. It HAS to be the decision of the patient and/or their family. As long as they are fully informed- and not coerced into making a decision- then you should be OK as long as you accurately document and converse with medical control. You will never get in trouble for encouraging transport, but you CERTAINLY can if you do not transport someone who turns out to be very sick. Example: Years ago, I had a patient(round 30 y/o) who's family called because she was complaining of a head ache all day, and was just laying on the couch. The patient had no idea the family called us, wanted nothing to do with us, and was angry at her family for calling us. Her vitals were normal, although she was a bit photophobic, so I said she could have anything from a simple head ache, to a migraine to a CVA. I told her we would take her to the ER- it was literally about 6 blocks away. She refused, said she would call back if needed or have her family take her to the ER. Documented the run, called it in, and never gave it a second thought. A few hours later, we received a call from another crew who was at the local ER. They heard this patient's family in the ER, extremely upset- apparently her head aches got worse, they brought her in via private car, and she promptly had a seizure at the ER and went into a coma. Turns out she had a subarachnoid bleed and died later that night. We covered our arses, but of course the ER's first question was why we did not transport earlier. We arrived later at the hospital with another patient, I explained to the staff what happened, and they understood. Would the patient's outcome have changed if we transported earlier? The doc at the ER said probably not- it may have simply delayed the inevitable. Point is, sometimes the simplest things can turn BAD, which means encouraging people NOT to use an ambulance can have very serious- and unexpected- consequences.

Totally agree. Listening to and deciphering heart sounds is not easy- especially in the back of a rig, with lots of noise and distractions. To me, that's like buying an Indy race car for a newly licensed 16 year old driver. It may look really cool, but that kid will never be able to use the car to it's full potential.

Good luck on your registry exam and welcome to the city!

I'd be worried about internal bleeding- long time alcoholics have clotting issues. Any of her injuries are worrisome and have the potential to cause bleeding- head and extremities, abdomen, as well as liver issues etc. I would also be concerned about potential seizures- it seems she's on the verge already. Any cerebral atrophy from the ETOH abuse-which would mean further concern about a head bleed. Electrolyte imbalances- due to probable poor nutrition could create cardiac issues. I'd also be worried about ARDS or other respiratory problems so I would closely watch her breathing. Someone like this- chronic alcoholic, PLUS high energy impact injuries- has the potential for being a train wreck.

Congrats and good luck with the job!

Assuming there is no other behind the scenes drama going on, the only numbers that matter are dollars and cents. If the city can provide the service cheaper, that is the direction they will go. I would bet it's also a pissing contest between the city and the FD. Traditionally, public service is the sacred cow(as it should be)- the last to be affected by budget issues, the last to endure lay offs, etc. I would bet that the FD overplayed their hand, and failed to take into account just how bad the economy is right now. Departments are seeing cutbacks, fire houses are closing, members are being laid off- it's unheard of in the business, but these are desperate times. Are they in the middle of contract negotiations? Did someone on the FD commit a major screw up recently? Is someone on the department running for public office, or speaking out against the city lately? Again- there's more to the story- the city simply did not decid to yank the services of the paramedics for no reason.

Well, obviously there would need to be numbers to back up such a statement, but since the majority of first response is about PR, even the appearance of "qualified" help is enough to appease most people. Most people have no idea if someone is qualified, if they have the right resources and/or training or not, unless they make a major screw up. In many areas, EMS calls indeed look like a disaster response. Tons of people, although many are standing around with hands in pockets- quite impressive. A first responder fire apparatus, an ALS equipped apparatus, an FD or other transport unit, maybe a supervisor, maybe PD, etc. It's all about appearances, but some folks do wonder why they ask for an ambulance and get fire trucks. Even if the care received from the FD is top notch, they still need a way to get to the hospital, and there are NEVER enough ambulances- FD or 3rd service. The dirty little secret of EMS is that the transport component of a medical response is ALWAYS the limiting factor, and one that is usually overlooked.

The article does not mention WHY the change in service. It must be political. Too many questions. Like- who was originally responsible for the transports? I'm not a fan of most fire based EMS services, but if the FD never provided the transport to begin with, why would you deny the fire paramedics the chance to render care until the ambulance arrives? This sounds incredibly stupid and a lawsuit waiting to happen. I highly doubt this will last for very long.

Those on the political left aren't going to like this one... The ANT AND THE GRASSHOPPER This one is a little different ... Two Different Versions ... Two Different Morals OLD VERSION The ant works hard in the withering heat all summer long, building his house and laying up supplies for the winter. The grasshopper thinks the ant is a fool and laughs and dances and plays the summer away. Come winter, the ant is warm and well fed. The grasshopper has no food or shelter, so he dies out in the cold. MORAL OF THE OLD STORY: Be responsible for yourself! MODERN VERSION The ant works hard in the withering heat and the rain all summer long, building his house and laying up supplies for the winter. The grasshopper thinks the ant is a fool and laughs and dances and plays the summer away. Come winter, the shivering grasshopper calls a press conference and demands to know why the ant should be allowed to be warm and well fed while he is cold and starving. CBS, NBC , PBS, CNN,and ABC show up to provide pictures of the shivering grasshopper next to a video of the ant in his comfortable home with a table filled with food. America is stunned by the sharp contrast. How can this be, that in a country of such wealth, this poor grasshopper is allowed to suffer so? Kermit the Frog appears on Oprah with the grasshopper and everybody cries when they sing,'It's Not Easy Being Green...' ACORN stages a demonstration in front of the ant's house where the news stations film the group singing, “We shall overcome.” Then Rev. Jeremiah Wright has the group kneel down to pray for the grasshopper's sake. President Obama condemns the ant and blames President Bush, President Reagan, Christopher Columbus, and the Pope for the grasshopper's plight. Nancy Pelosi & Harry Reid exclaim in an interview with Larry King that the ant has gotten rich off the back of the grasshopper, and both call for an immediate tax hike on the ant to make him pay his fair share. Finally, the EEOC drafts the Economic Equity & Anti-Grasshopper Act retroactive to the beginning of the summer. The ant is fined for failing to hire a proportionate number of green bugs and, having nothing left to pay his retroactive taxes, his home is confiscated by the Government GreenCzar and given to the grasshopper. The story ends as we see the grasshopper and his free-loading friends finishing up the last bits of the ant’s food while the government house he is in, which, as you recall, just happens to be the ant's old house, crumbles around them because the grasshopper doesn't maintain it. The ant has disappeared in the snow, never to be seen again. The grasshopper is found dead in a drug related incident, and the house, now abandoned, is taken over by a gang of spiders who terrorize the ramshackle, once prosperous and peaceful, neighborhood. The entire Nation collapses, bringing the rest of the free world with it. MORAL OF THE STORY: Be careful how you vote in 2010.

Welcome to the city. Sounds like you have the information you need. Just be aware, although EMS programs do vary wildly from state to state, there are basic standards established by the federal government. Ask a lot of questions about licensing and reciprocity to ensure you take the proper classes. I have no idea what- if any- credit you can transfer from your program in the Philippines.

I hear ya, Richard. Although-with all the bitching and moaning we do among ourselves- fire vs EMS, single role vs cross trained, etc- we still ARE a family. Any time someone needs a hand, who's the first to step up when we need it? Same for police. We have a great relationship with our police officers- they are great. As dysfunctional as we all are, who else would want to hang with us? LOL