HERBIE1

I guess this is about semantics, but then again, many of our medical/legal issues are exactly that. Again, DNR is too generic. As we know, under the umbrella of advanced directives, there is a lot of latitude, and folks can be very specific about their wishes. No feeding tube, no intubation, no pressors, no CPR, no defibrillation, etc. I would also consider cardioversion a treatment, not resuscitation. The person may be very ill, but still not in cardiac arrest. Clearly there are many variables here. Did the family and/or patient produce- or even make the crew aware of a DNR BEFORE they started their assessment and treatment, or did they produce it AFTER you started your interventions? Did they claim there was a DNR but were unable to produce it? Was there some question about the validity of the DNR? Is there a family conflict about the situation- does one family member suddenly have 2nd thoughts about the DNR when presented with the fact their loved one is actually now dying? I had that happen to me a couple times, and was instructed to start CPR and transport, and let the hospital sort it all out. These situations are always tough-there are too many potential gray areas. Emotions run high, and you have no idea the family dynamics and issues involved.

Welcome. The problem is, in a scenario, with so many different local protocols, often times there is more than one "right" answer. What I may be able to do may contradict protocols in your area.

I'm confused- how is applying a monitor breaking a DNR order? It's simply a tool to check vital signs, but electricity or meds based on what you see is a whole different ballgame.

That's all they need to say. The paperwork is meaningless at that point.

Unfamiliar with local protocols, but- I would give the GSW to the BLS guys, Start a couple large bore IV's(omit this if the BLS guys cannot transport with the IV's) 100% O2, high flow, treat for shock, bleeding control. MAST pants if applicable, treat for shock, and tell them to run like hell.. Why? Because other than large bore IV's, there is nothing more an ALS provider can do prehospitally for a GSW to the abdomen- at least until they arrest. Unclear where that bullet went, or where the damage is. I would do the same treatment for the SW, but would take this patient because if they do develop a pneumo or tension pneumo, we can decompress that, whereas a BLS guy cannot. In a triage situation, both patients would be considered reds or critical, so in your scenario, you need to dig deeper and consider the details and make a judgment call.

Not to play semantic games here, but I would also verify exactly what that DNR said. Was it no advanced interventions, no CPR, no defib, no intubation, no pressors? I would start CPR and immediately call medical control. Let them decide if you discontinue CPR and honor the DNR.

Like any shorthand or abbreviation, it needs to be universally understood and accepted or it's useless since nobody will understand what you are trying to say. As was noted, the greek letter psi is used. With some services radio "10 codes" are used, and years ago on the privates, we used 10-96 to designate a psychiatric(or potential) patient during radio traffic. In a written report, I would use an medical diagnosis- bipolar, schizophrenic, depression, etc. If you are seeing bizarre/abnormal behavior without a prior diagnosis, you simply describe what you see and hear- suicidal ideations, anxious, flat affect, visual or auditory hallucinations etc.

Think of the political nominating conventions. Protesters had established areas, near, but also apart from the rest of the activities. They were allowed to exercise their 1st Amendment rights, folks were not subjected to anything inappropriate or disruptive. Neither side's rights were trampled on.

OK- I'll use Fred Phelps as an example. The left is so concerned with harming Phelp's right to free speech, but solutions I heard would address that. Limit WHERE and WHEN he can spew his venom- as in a couple blocks away, or 2 hrs before or after the ceremony. SO- with regards to the mosque- let the mosque be built- ON ANOTHER SITE. Problem solved.

There is MUCH more to this story. From what I understand, Intersections is a supporter of the Ground Zero mosque, so I do not understand why this guy identifies with them.

The problem with this issue- the attacks on 9/11,as well as our reaction to it- are very real and visceral. Logic has no place in this equation. We were attacked by a group of people who thought killing innocent men, women and children was a way to get their 72 virgins and an eternal place next to Allah. Their stated goal is to either convert or kill us. They hate us, they hate everything we stand for, they hate our religion, they hate our way of life. How can you possibly discuss this and look at it rationally? Patriotism, pride, anger, fear- these are subjective human emotions and feelings. We are being asked to embrace and accept a group associated with a horrible attack on our own soil. Most of us- especially those in this business- lost friends, coworkers, and brothers/sisters in a senseless and brutal attack. Few believe that all Muslims- or even most- agree with jihadists, but Muslims want to erect a symbol of a religion that represents these jihadists. That's a tough pill to swallow for many- myself included. It's not about Islamophobia (leave it to liberals to create a new buzzword), xenophobia, racism, or any other phobia. In my opinion, since those attacks, most moderate Muslims seemed more concerned with explaining why these people felt compelled to carry out their attacks vs vilifying them. Accurate or not, that is the prism I view this situation through.

Fascinating stuff. Thanks for sharing. Any idea what his situation will be post discharge? Any changes in the management of his situation- new meds, new Tx, etc?

Actually, "In God We trust" first appeared on coins during the Civil War, but you are correct, it did not become adopted as our national motto, nor did God appear in the pledge until the 1950's. Bending to influences is not the same as accepting that the founding fathers DID believe in some deity and that is the frame of reference they used when drafting the documents our society is based on. Obviously things have become hijacked by various groups to suit their own agendas, but such is the way of politics. Because these original documents are fairly vague in many areas, they are by design open to some interpretation- that is what the USSC is all about. Clearly, one of the dangers of "interpretation" is that we stray from what our founders envisioned. Our whole society was built on the notion of freedom OF religion, not freedom FROM religion. Our Declaration of Independence cites in the first paragraph the justification for dissolving the ties that bound us to England and assume the laws of Nature and "God's nature" as well as the fact men are "endowed by their Creator with certain unalienable rights". Is this an endorsement of religion? No, but it is also NOT a denial that a deity exists, nor is it a condemnation of those who believe in one. It is simply a tacit admission the founders believed in SOME type of higher power. I'm sure you are aware that the USSC ruled that the national motto is not an endorsement of any one religion, but does assume we were established under the belief of some "Supreme Being". They also ruled that such a motto does not mandate or even propose any type of state church. Everyone is entitled to their belief system, but you simply cannot deny the principles this country was founded on. As an atheist, you are entitled to your beliefs, but you also cannot dismiss our history, which IS tied to some form of deism.

Well, this country was founded on the belief that there is some type of deity. The framers believed it, but they did not mandate that everyone else believe in it. it was simply a frame of reference or starting point to propose their ideas. Nothing in our laws say we have to worship a "creator", that we will be punished if we do not accept that "creator", or that we need to follow a "creator's" laws.

The first question I would have is where you want to go with the program? Depending on how in depth you go with the background sciences, you could be pushing towards a more comprehensive, 4 year degree program. I would put together your proposed more advanced curriculum and pitch it to the higher ups. The problem with something like this(trying to elevate the education standards) is that in order to be successful beyond your classroom, you need a buy in from the powers that be, other instructors in the area, as well as medical control. You need to have the preceptors and FTO's to be on board and their training equivalent to what you are teaching didactic-wise. I would suggest making a pitch and putting out a plan- showing how and more importantly WHY- you feel the standards need to be elevated. I was asked by the dean of a public safety program to develop a new class for their fire science program- EMS Administration. I- along with 2 others- developed the curriculum, wrote the class, picked the text, etc. Luckily we were essentially given free reign because the dean was familiar with us from being in his Masters program. At first, we also received resistance when we began delving deeper into the leadership/management aspects, but at the end, we have received mostly positive reviews. As long as you lay out your plan, abide by any requirements/goals set forth by those in charge, and justify and demonstrate how your plan will achieve those goals, I think you will be in good shape. Good luck.

I will not do a quid pro quo here with examples of Muslim terror around the globe. Pick up any newspaper and see what has happened in the last 6 months in Gaza or Africa. The BIG difference between the Bible and the Koran and Sharia law (Which this NYC Iman is trying to expand here) is if you do not agree with the bible, NOBODY is forcing you to accept it. Sharia law dictates your entire life, and failure to comply results in severe penalties in the here and now, not in the afterlife. The bible is filled with parables but few accept it verbatum. The ones who do take the bible literally are seen to be extreme, radical nut jobs and nobody takes them seriously. Same with the radical Muslims, except now we are not only supposed to be tolerant of them, but allow them to build a monument to their intolerance 2 blocks from Ground zero. No way.

How many instances of terror attacks on innocent men, women, and children have been perpetrated by Christians in the last 50 years or so? Now, shall we list how many attacks Muslims have been responsible for in that same time period? Pretending something did not happen does not make it go away, nor does it make the acts any less egregious. Read the requirements, ideals, and values in the Koran and tell me again about how Muslims feel about tolerance, and what they require of those who follow that religion. BTW- bad example- Saudi Arabia follows Sharia law, which by definition is INTOLERANT. It mandates standards of behavior, morals, and makes criminal penalties for those who do not follow it. NO other religion dictates so much of someone's life.

I will agree with the idea that you should not broadcast that your partner is new. You need to step in and correct when warranted, and if I sense the patient is nervous about that, I usually make a joke and say yes, this person is new but has been well trained, but I have more than enough experience for the both of us. I'll make a joke about my grey hairs(I earned every one of them) and usually the patient calms down. If the person picks a less than optimal IV site, for example, (unless its location, size, etc is vital for pushing certain meds) I let it go and address it after the call. As was mentioned, there is a proper time and place to go over details of a call and the actions of a student or newbie. I usually ask THEM how they think the call went, what went well, what they could have done different or better, and more importantly, WHY. It's most effective if a student discovers/realizes mistakes on their own- the lesson tends to sink in much quicker. To me, that says they know what to do, it's just a matter of putting it all together in the proper context.

I know it sounds counterintuitive, but I actually had my medical director tell me to push fluids on a cardiogenic shock patient- Hypotensive, pink frothy sputum, tachycardia. I certainly would not do it without a doctor's authority. I cannot recall the details, but for some reason there was a good possibility the person was hypovolemic. I questioned the doc about pushing fluids(supposedly a no-no with a person in failure) but he explained later that 200cc's or so will make essentially no difference to the patient in terms of fluid overload, but if they are fluid deprived, it can help stabilize their BP. In my case, it did work. In field, we cannot be certain if it's a pump failure issue or hypovolemia, so I would go with pressors unless told otherwise.. Based on the patient's history in this scenario, his heart was clearly in bad shape, so pump failure would be a good bet, although hypovolemia is still a possibility. Obviously we do not have the benefit of Hg, Hematacrit, or other blood values. I reiterate my thinking that this person is probably a good candidate for an LVAD- probably permanent- since it does not sound like he's a good candidate for a transplant..

The only fear involved is that this mosque will incite horrible problems if it is built. It will further divide an already far too divided country and cause further resentment from people who were harmed because of the events of that day. I understand political differences, but on something like this, there should be no disagreement.

All I have to say is that this country is truly FUBAR. I simply cannot believe we are debating the relative merits and values of putting a mosque near ground zero. Like with many things in this country(as in sleazy politicians who get reelected for decades), some of us have incredibly short memories. For the sake of this country's future, I do not think November can come soon enough.

Welcome to the city. Kudos to you for having a back up plan- you are already ahead of the game: Expect the unexpected, and plan accordingly. Good luck in school, and by all means, utilize this site as a resource. As was noted, plenty of experience here, diverse backgrounds and areas, so if someone does not know the answer to a question, they will find out.

Welcome to the city! Couple questions. How long have you been an instructor/trainer/FTO? I suggest trying another tactic when issuing advice/criticism. Are you responsible for an official evaluation of this person- ie filling out paperwork, preparing a report, etc? If so, then remind him/her that YOU are the one this student needs to come to, NOT anyone else. If you are already having conflicts after only 4 shifts, that is not a good sign. It's always a delicate balance when you are working with a partner who is also someone who needs training- there needs to be clearly defined boundaries and responsibilities. Explain that they are no longer a student, but they are brand new to the field, and as such, need guidance and someone to show them the ropes. It might be that this person is simply immature- especially if they are a recent HS grad. It might be there is a personality conflict. It might be the person is unclear, they do not understand their role, the hierarchy/reporting chain of your organization. You need to have a sit down with the student and explain the facts of life. That document from above is definitely golden. Add to it that this business is no game, that you are dealing with people's lives, and a certain level of maturity is necessary. That maturity means there is a time to listen, to absorb, and to learn.

Couple more questions. What is his ejection fraction like? I still think it's his ticker. I think he might be a candidate for an LVAD- his heart simply cannot adequately pump anymore.