HERBIE1

Well, you certainly have a unique perspective on that day- a survivor, and now someone who is in the business. Hang in there.

Unlcear who is at fault. Did the ambo have the green light? Either way, that crew did not even slow down- I would fault them, regardless of whether they had the light or not. Even with a green light, you need to slow or even come to a complete stop if necessary. An intersection with multiple lanes, stopped cars and turning lanes- major danger. All it takes is one driver to ignore his surroundings- ie the fact that every other car is stopped for some reason, not paying attention, on the phone, listening to the radio, closed windows. Intersections are the number one location for crashes- that crew pulled a major fail. Luckily, the crash did not look too bad and hopefully no one was hurt.

Welcome to the city, and I hope you join in the discussions. New points of view are always welcome.

Thank God you made it out OK. I simply cannot imagine being in the middle of the nightmare. I hope you are coping OK, UGLyEMT. I don't mean to open old wounds, (and you certainly don't need to answer if you so choose) Were you part of the responders or working in some other capacity?

Absolutely. Thousands were emotionally affected by the events of that day, but thousands more are dealing with the physical effects. Makes me physically ill when I think of how someone can get absolute joy from inflicting pain and suffering on completely innocent people.

I had forgotten about something several here had mentioned- what I DID NOT hear- the planes. I live on a flight path, and am used to seeing about a plane every minute or so flying over ahead, on final approach. They become part of your life and barely even notice them- until they are gone. I recall standing on my porch, looking up, and seeing nothing. Extremely eerie. Then, several hours later I saw a few military fighters streaking across the sky. I recall thinking some horrible thoughts- like I may be witnessing the end of our country as we knew it. In many ways, I was right. God bless those who perished that day, and all the soldiers who have given their lives protecting us.

Agreed. That's why I can differentiate between the 2. I don't care how long you have been doing this job, how can someone be so callous towards a kid- especially a kid with cancer. Like I said, I hope this is not a true story because I would hate to think ANYONE could treat a child like that- especially a health care provider.

My son was in 8th grade and I was taking him to school. I had 2 little ones at the time, who thankfully were blissfully ignorant of the day's events. It was a short drive to school- 10 minutes or so, and as usual had one of those happy talk morning radio shows on when suddenly their news guy broke in, very serious, saying there was a breaking story in NYC- unconfirmed report of a plane crash. At first I thought it was a silly radio bit, but quickly realized it was real- the normally goofy hosts were dead serious. I dropped my son off and quickly headed home. As I listened, they didn't have many details yet, and as soon as I walked in the door, I flipped on the TV and tuned to CNN. My wife was getting ready for work, and I told her something big was going on. Literally, as soon as I switched the channel I saw the plane hit the 2nd tower. My jaw dropped, I felt a chill(I'm getting chills just recalling this), and my first thought was oh my God, we are at war. I sat, transfixed all morning, and when the 1st tower collapsed, I lost my breath. My first thought was- I just witnessed the deaths of hundreds of rescue folks and probably thousands of civilians. I began to shake, and when the 2nd tower fell, my eyes filled with tears. My wife reluctantly went to work. I checked with the wife later, warned her that she may need to come back home because I would probably be called in to work. She said that because she was the only senior staff member around, she needed to stay- at least for awhile. I gave her a couple alternate routes home because they were evacuating the downtown area and the major roads and highways would be packed. She did come home early, I never did get called in, but did not sleep well that night. Every time the phone rang, I assumed it would be an emergency recall because we were under attack. In the event things went south, we set up contingency plans for the kids, where the wife would go, where we would meet later, who would pick up our parents, etc. I told her if called, I had to go. She understood. I returned to work the next day, and recall it was a surreal experience. I was working on a ghetto rig at the time, and was in awe that the vast majority of people we dealt with had no idea what had happened the day before, nor did they care when we told them about it. It was business as usual: drunks, ear aches, tummy aches, BS, drama, OD's GSW's, beatings, stabbings- as if time stood still for them. It was sickening to me and found myself getting very angry. It was then when I truly realized these areas were like the land that time forget- a society and existence independent of the rest of the world. As long as they were not affected, it was of no importance to them, and someone elses' problem. Once I assumed our area was no longer in imminent danger, I knew I really wanted to go to NYC and help- in some way. I had it all arranged, I brought it up to the wife, and surprisingly she was supportive of the idea. I then took a step back and looked at my kids. I realized THEY needed me more than NYC did. I knew I could not leave them.

In all fairness, I am guilty of telling a regular belligerent drunk and/or abuser, seizure faker, feigning unconciousness, etc that I was looking for the biggest needle I could find, one with the square tip, etc. Inappropriate- maybe. Do I feel any remorse over it? Nope.

This isn't even remotely funny as a joke, and despicable if actually true. If that was my child, I would not rest until that nurse was fired.

Ours is supposed to be orange as well, but I don't recall ever seeing one that color. It's always been a fax or Xerox copy. I assume the originals are in the doctor or lawyers office.

I have actually run into that a couple times. We work the patient, but I do ask tactfully why the change of heart. Obviously the outcome was inevitable, but as doc said, you will never get in trouble for trying to revive a patient- especially with a conflict like that. I would also contact medical control ASAP and put the ball in their court. I've even had hospice folks call us which is a real puzzler. Turns out they called because the family panicked at the last minute when the inevitable finally happened. I tore that nurse a new one for putting us in the trick bag like that- she should have known better and/or better prepared the family. So if a person is getting hospice care at home, with a valid DNR, you do not honor it? Really? I agree that unless I have that piece of paper, it may as well be nonexistent. I've also heard the - "My lawyer has the" DNR". They offered to call the lawyer for me. I declined. The only exception is speaking on the phone with the patient's doctor, verifying the PT is a DNR. I have had that issue a couple times- the DNR was being updated, amended, etc or the patient arrested far sooner than expected and they simply did not have the copy of the order on hand. Once, the patient was discharged from the hospital- earlier that day I believe- and the patient arrested. The doctor was completely in shock on the phone- she assumed the patient had at least 6 months or so. She kept saying- "are you sure"? As the doc said, unfortunately this isn't always a black and white issue, as much as we would like it to be. One of the many joys of the medical/legal profession, I guess.

Seems like most are in agreement here. I agree, Atropine first, while getting ready to pace. However- Based on the vitals, by definition this person IS unstable (hypotensive, altered LOC), which means in my system, TCP is the treatment of choice. That said, in similar situations I have pushed atropine first, and it sometimes works- at least in the short term, but I ALWAYS would apply the pacing pads next, just in case. It also depends on the patient- some folks can tolerate that BP very well, and altered LOC could mean they are a bit weak or sleepy. You could have a patient who can tolerate those vitals for a surprising amount of time, or they could be rapidly decompensating right before your eyes. Clearly you would be more aggressive(pacing first) in those situations. I've had patients who call for general weakness, and upon exam, we find they are walking around with a complete heart block, possibly for a day or more. Would I immediately strap them down and start pacing? No- one step at a time. Evaluate and treat the patient, not just their stated problem. Obviously it can also depend on how many hands you have, but unlike trauma, medical/cardiac calls are situations where we really can make a difference.- We can at least stabilize the patient and buy some time for the hospital to get their ducks in a row- notify cardiology, get an internal pacer ready, notify the interventional cardiology suite and/or OR, notify family, etc. As was noted, medicine is an art, and yes, protocols are guidelines, but sometimes there's more to what we do than simply cookbook medicine. Experience gives us judgment and perspective, and we need to use that. To me, that is a defining characteristic of a good provider- balancing book smarts with common sense.

I've seen it many times. There always seems to be at least one family member who does not accept the fact their loved one is terminal. They object to even the mention of a DNR, family fights develop over who has power of attorney, some who can't wait to carve up grandman's estate for their inheritance, some who somehow think their family member will suddenly wake up from end stage Alzheimers and be fully cognizant and functional, or the metasticized cancer that has ravaged someone's body will suddenly clear up and the person will be cured. I too understand the intent of a verbal order, but I would much rather see that topic broached at the hospital, with tons of witnesses- and a team of lawyers- to back up that decision.

That is scary(verbal DNR), and something I would not want to deal with. I see HUGE potential problems with family disagreements. Even with a written DNR, there may be conflicts within a family, but at least you as a provider, that written DNR covers your arse.

I think you bring up a very important point- patient education. We, as EMS providers can play a crucial role in this process. I am always amazed at how little patients know about their medications, their diseases, and how to properly take care of themselves. We all know about the diabetics who may KNOW about proper diet but CHOOSE to be noncompliant. What we do not know is how much has been explained to them, or more importantly, how information much they retain. Often times newly diagnosed diabetics end up hospitalized because they were in DKA, they were having kidney problems, or gawd knows what else. Think of all the information they will get before they are discharged- new medications, doctors explaining how the person must now watch their diets, etc, a dietician may come in, but often times these folks are on information overload. Explaining the importance of regularly checking their glucose levels, of taking extra caution with wound care, and how vigilance may keep a person from having problems down the road. Folks need to be reminded- especially the elderly- of the dangers of carbohydrates. People will SWEAR they have not eaten sugar, but admit to having a major liking for bread or pasta and wonder why their glucose is always elevated. We need to educate folks about these things and not simply assume someone else already has done it. Simple things like taking their meds at the proper times, about therapeutic levels of drugs, about taking some meds with food, about why someone with chronic a-fib is at risk for blood clots and strokes, etc. Even simple "BS" calls can be teaching moments and the patient can only benefit from the information. We should never assume that a person who has had a disease for a long time is doing what they should. Maybe they are getting forgetful, maybe they are getting lazy, maybe they are getting depressed and giving up. Just a few questions can shed light on a problem before it gets out of control.

Hey, we could be trained in all types of procedures and equipment, but there is a fundamental issue here. The entire medical profession needs to get on board with the idea and support not only this idea, but the whole notion of prehospital care. We have an opportunity to advance the profession. If we further integrate EMS into primary care, then we would fundamentally change the way care is delivered. Would it be cheaper, more cost effective, more efficient to provide things like ultrasound, inoculations, wound checks, or other home health care? Maybe, maybe not, but it would be a huge departure from the original intent of EMS. Yes, we SHOULD evolve, but how far? I'm not necessarily against the idea, just wondering where this could lead.

I recall this topic discussed before, but.. I can see the value in such a tool in very specific situations. In a rural area where access to primary care in limited, and transport times are measured in hours. It could potentially help rule out a more serious situation that would require air transport vs ground, it could mobilize hospital staff needed for a surgical case, etc. Obviously the cost is a huge factor, and I question how many smaller, rural areas could afford it without some subsidy or grant, maybe from a hospital.

LMAO I like that one, Richard. Seems similar to the "paralysis by analysis" issue that lawmakers or management types often have a problem with.

What if it's surgery to fix a fractured foot, debride an ulcer, or implant a catheter to administer pain medication? DNR's aren't exclusively used for terminally ill patients either. Many of us have advanced directives(dealing with feeding issues, organ donations, funeral arrangements, etc and a DNR is simply part of that package.

Try a different method of learning- maybe your style of learning has changed over the years. Maybe you used to be a visual learner, but now you need to adapt your study habits. Try a different source for learning- a new book, a new web site, etc. Flash cards, rhythm strips- whatever you need. Go back to the basics and start from square one, as if you had never seen this information before. Maybe you made some assumptions/short cuts/ pneumonics/tricks over the years that have skewed your interpretation of cardiology and EKG's. As you noted, if you don't use it, you lose it. That's why so many of us are rusty when it comes to pediatric cases. Even in a high volume system, things like a pediatric medical arrest are rare. A couple months ago I had a patient who was allegedly around 3-4 months pregnant and had a prolapsed cord. It was a shock because the call came in as a woman in labor, and just prior to our arrival on the scene, we were told the "baby" was out. Imagine my surprise when our "baby" was actually about 3 inches of the umbilical cord. It took a moment to readjust- and I had to instruct the first responders on the scene in the proper treatment. I was rapidly going through the protocol in my head- it had been awhile since I had dealt with this. After the call, I went back and reviewed my OB/GYN emergencies just to brush up.

I admit it has probably been at least 15 years since I have used the MAST suit on a patient- we no longer even carry them. I do recall that in our system, penetrating abdominal injury was a RELATIVE contrainidication for MAST, meaning we could apply them, inflate all but the abdominal compartment (needed a DR's orders), but impaled objects and eviscerations were absolute contraindications. Pregnancy meant that with an MD's orders, you could also apply the suit and only inflate the legs. Below is the part of the scenario that I was initially stuck on, and made a couple assumptions based on my interpretation of the situation. This simple phrase to me meant that there were 2 BLS rigs, and I would be able to jump on board with only one of the 2 patients to provide ALS care, so this was essentially about triaging. I may have misinterpreted these parameters, and if so, mea culpa. Your in an ALS response car and are met at the scene by 2 x BLS in an ambulance. You can only take one patient. I assumed that this meant there were 2 BLS rigs, and you- as the ALS provider- would be only able to provide ALS care to one of the patients, while the other would be transported BLS. I was trying to come up with BLS interventions and prioritizing the patients based on what I could do for them. As I mentioned, as an ALS provider, there would be little prehospitally I could do for the GSW to the abdomen. If the patient with the potential for a tamponade or pneumo crashed, I could provide help for that person beyond the scope of an EMTB . I was thinking in desperation mode- try everything you can based on a difficult situation- which is really what much of our jobs often entails. Obviously, transport times also play a key role in the decision making process for triaging, treatment, and transport. Brings back memories- some horrible, like power washing the remnants of a GI bleed or bloody trauma from the suit. When I first started in EMS, MAST pants were part of the protocol on nearly every cardiac arrest- traumatic or medical. We became quite proficient at quickly applying them- and even learned that by putting your arms through the suit's legs(which were already closed by the velcro) and grabbing the patients legs, we could simply slip them on the patient and all that was left was to apply the abdominal portion and inflate. The hardest part of the process became getting the suit out of the case- and keeping the ER staff from cutting them when they arrived at the ED, of course. LOL Like the studies now indicate, their value for autotransfusion may have been neglible, but I found they were quite effective for splinting things like pelvic fractures. The patient was more comfortable, it made patient movement easier, and the often bumpy transport was much more comfortable for them. Who knows-maybe MAST will someday make a come back since things in EMS old is sometimes new again: Think sodium bicarb. I sincerely hope that rotating tourniquets have gone the way of the dinosaur, however. Thanks for keeping an old fart like me on my toes, Lone Star.

Horrible and tragic. Sincerest condolences to our entire EMS family down there.

I never thought of that, doc. I assume this is something that needs to be preapproved by the patient, their designee as part of the surgical consent?

Based on the reports I have seen, it was mainly property damage with a few minor injuries. Hopefully that is the case and nobody from the city has been affected.