HERBIE1

OK, so this guy clearly has cardiomyopathy, CHF, apparently gout, diabetes, HTN, GI bleeding issues, MI's- he has a pretty bad ticker. I'm not familiar with the units being used for the blood glucose level, so I'll just assume it's normal. I'd want a 12 lead EKG- he could easily be having another MI. Based on his vitals, he appears to be in cardiogenic shock. I'd consider Dopamine and some diesel therapy. He's a sick puppy. Ooops- just saw his BP, I retract my cardiogenic shock statement. I still think he is having a cardiac event, based on the vitals, and the fact that his ICD fired again.

Are there any polls showing that 70% of New Yorkers are opposed to building another Catholic church there?

Don't be afraid of mistakes. Be very afraid of repeating mistakes. Do the same things on every call ALL of the time. Even the BS ones. Cannot stress this enough. These 2 are gems. VERY true. The basics are vital, and vitals are basic.

Good one!

Do some digging and you will find that this Iman has made contradictory statements to Arabic media sources, in Arabic. Bottom line is that I read this organization only has about $20,000 in assets, which explains why the Iman is taking a taxpayer funded trip home to raise money. Sorry, but this whole thing stinks. We are NOT getting the whole story folks.

It may sound crass, but one of the most valuable piece of advice I received as a new guy was that YOU are not the one having the issues. You have the training, you have the knowledge, and eventually you will also have the experience. As was said above, you need to be confident and competent. People called YOU because they cannot handle whatever their problem happens to be. Trust yourself, trust your training, and always review to stay sharp- especially with issues you may not see very often. Focus on the basics- regardless of how messy a trauma is, or how complicated a very sick patient;s condition may be, you always start with your ABC's. You need to look beyond the blood and gore on a trauma, and beyond the fact that a person may be a diabetic, COPD, extensive cardiac history, and a dialysis patient. Airway, breathing, circulation, disability- establish the basic parameters, treat as appropriate, and move on from there. One step at a time keeps you focused and ensures you do not get tunnel vision and miss something. You will never completely lose that anxiety- and honestly, you never really want to. That twinge of anxiety keeps you focused, and the adrenaline rush is one of the best things about the job. Even after 30+ years, I occasionally see something "new" and have a momentary "Uh oh", moment. Most often, these moments happen when you get complacent- you assume a call will be routine and something strange happens, or a 20 year old with abdominal pain turns out to be multiple stab wounds with a sucking chest wound(actually happened to me.) You get over the momentary shock, and simply do your job. For most, the best part of the profession is you never know what to expect- most of us do not want to fly a desk in a routine 9-5 job.

I just found out about that Greek Church. I thought it was bigger news in NYC so I assumed you may have more information, because the story has been essentially ignored by the media. To me, it's utterly amazing that a church that was destroyed in the attack has yet to be rebuilt, yet a mosque, headed by an Iman who's opinions sound anything but tolerant, is being fast tracked. It's just plain wrong- on so many levels.

Maybe Richard can shed some light on this, but does this not prove that the push to build this mosque is nothing but a blatant attempt to appease the Muslims and show how PC this country has become under our apologist in chief? This Iman advocates things like the US becoming Sharia compliant. He thinks the US was complicit and/or responsible for what happened on 9/11. The mosque has been fast tracked, and everyone from the president to Bloomberg have given their approval on the project. But a Greek Orthodox church, that was crushed when WTC #2 collapsed, STILL cannot be built. Red tape, restrictions, politics, bureaucracy have stalled the project. They placed height restrictions on the church, were told it needed to be downsized(it could not be higher than the 9/11 memorial), yet no such restrictions were made for the mosque. WHY? Mosque moves forward, yet church in Limbo http://www.humanevents.com/article.php?print=yes&id=38462

I should have been more specific. This is not a FEDERAL government issue. If Bloomberg wants, he can claim eminent domain and ban the building of the mosque at that location. In other words, it will never happen. I'm not a New Yorker, but I'm guessing that even if Bloomberg received all types of blow back from the citizens, I don't think he's the typical politician. He doesn't need the job, he does not need the money, so unless he has aspirations of moving up in politics, he does not care what folks think. He is a business man, so this has to be about money. There is more to this story- guaranteed.

8 miles? Not quite the same as 2 blocks. *Sigh* This mosque will happen. Not because it SHOULD be built, and not because so many people support the idea of putting it there. It will be built because the new paradigm for this country is to bend over backwards to appear "tolerant" to the rest of the planet. The opinions of others are more important than the feelings of our own people. I'm surprised that we haven't yet apologized to Bin Laden and AQ for allowing such monstrously decadent symbols of capitalism to tempt them into an attack. Yes, it will happen- despite the fact that a CNN poll of New Yorkers said that 68% of them thought the building of this mosque at that location was WRONG. Then again, going against the will of the people seems to be the trend lately. This isn't a Constitutional law issue, this isn't a zoning issue- nothing legally prevents this from happening. That's what Obama can only say he supports the idea- the government has no real say in this.

First, welcome to the city. Second, the mutual respect thing is a problem when you have a fire department who grudgingly is forced to accept EMS into it's organization. The powers that be may understand(but still are not happy about) that often times, EMS is the only thing that stands between them and cuts to their budget, manning, and the closure of fire houses. Few in the rank and file see the big picture, and when they are forced to adopt EMS as part of their duties, many are not happy about it and openly express their hostility. Not a pleasant situation for someone in EMS to deal with. The respect is a 2 way street, but when the dominant entity feels they have been forced to do something they did not sign up for, they generally make their feelings known. EMS and fire suppression are 2 separate entities, but a good organization that has both trains their people to wear each hat, using whichever one is appropriate. Unfortunately for the hard core firemen, the EMS hat is much bigger these days.

I wish to introduce the term "Canadian Silver Six" I love it! I have never worked in such a remote area so I cannot say I have dealt with the challenges you face up there. That gives "rural" a whole new meaning. LOL

Doc- The problem with the IAFF is that in too many cases, it's about 150 years of tradition, unimpeded by progress. Yes, primarily it is a union, but it is also a huge lobbyist that has a lot of clout locally, as well as in Congress. Change is always difficult for any organization, but as you know, medicine is constantly evolving, so change is the "norm" for us. The very reasons why the fire service is good at what it does make it inherently resistant to change. Traditions run deep, and often times, things are done "because we always do things this way". I recall the old timers complaining about using things like SCBA's, hoods, forcing them to have rehab breaks, changing fireground tactics to make them safer, etc. Clearly the changes were for their own health, safety, and longevity, but too often it's not about logic. The organizational culture of a group like the fire service makes it very difficult to accept outside interference, and when they need to cede control to you- or anyone else- because medicine is not their strong suit, they often fight back. Like most groups, they need to know what's in it for them. The profession as a whole is also essentially self regulated. When was the last time you heard of a firefighter losing their job because of how they ventilated a roof, or how they directed a fire attack plan? In medicine, we have protocols that we follow, and layers of regulations, rules, and administration we must abide by. We have lawyers, medical control, state agencies, and other watchdog groups more than willing to point out if and when we make a mistake or deviate from a standard of care. Yes, in some areas, the fire service is very progressive and proactive in looking for the best possible solutions to provide public safety, care, and protection. But, ask almost anyone who works EMS in a large urban area. Chances are they know first hand the difficulties caused by the IAFF.

LMAO Funny stuff.

Is it a problem- yes. Is it the PRIMARY problem with illegals and the immigration issue- absolutely not. Actually, the bigger issue is folks coming here legally- by visa or becoming naturalized citizens with the intention of becoming active terrorists at some later date- sleeper cells. The Pakastani guy on the east coast a few months back is a perfect example. Educated here, got an advanced degree, had a job, a family, a home, etc. Assimilation into the society, fly under the radar, and then perpetrate whatever deed your Iman or terror group wants you to do. He was finally tracked down and caught after he made several tracks back to the Middle East to complete his training. Think also 9/11 and the hijackers. Trust me- I have some personal experience in this area- former in laws were involved with Hamas. No, not every member of the family was a "member", but many were, and yes, blood is thicker than any other loyalties they may have. This is nothing new folks- during the Cold War, the Soviets had similar families here, and we had folks living in the USSR, and elsewhere. Difference is, back then it was simply intel, being gathered and home grown attacks did not happen by them.

Thanks. I'll take a good hard look at this tomorrow. Bed time for this cowboy- have a good one.

It was alluded to here- for years they've been playing around with the idea of artificial blood, but cannot seem to get it to work. I'm not sure what the problems are, but isn't it amazing- with all our technology, we still cannot beat mother nature when it comes to something like blood?

I think the point with the blood transfusion was that in some cases, trauma patients have lost so much blood that even though we may be able to keep a decent BP with massive fluids, the person has nothing left to carry oxygen. I agree- unless you fix what's bleeding, pumping more blood won't help, but it might buy us time prehospital. I can't tell you how many times we would have a massive bleed- multiple GSW's, multiple trauma, stab wounds, etc, and by the time we get to the ER, the person's bleeding pink fluids from their wounds- they are just circulating blood tinged saline- or LR in the old days. Never a good outcome from that.

First- MP- thank you for your service. Second, welcome to the city!

Did you express your reservations to the FTO's? What advice did they give you? They should have options that could help you- more time with an FTO, clinical time, etc. Again- relax as much as you can, trust your knowledge, and always do what's right for the patient. You'll never go wrong if you keep that in mind. Being "scared" is a good thing. The adrenaline rush keeps you sharp, you just need to focus that rush in the right direction. As was mentioned, even us old farts that have been doing this a long time still have those "Uh-oh" moments. A bizarre rhythm you aren't sure about, conflicting signs, symptoms, and presentations of your patients- just take it step by step. Ask questions every chance you get. Most docs- especially students and residents- are more than happy to explain something to you- it reinforces their skills. There's an old adage in medical training of new docs- SEE a procedure, DO a procedure, TEACH a procedure. If you can adequately and accurately explain something to someone, then clearly you have a firm grasp of the material. I recall years ago seeing a funky EKG strip we simply could not identify. We treated the patient appropriately and transported. I asked the ER doc(who I knew and respected a lot) to identify the strip for me- I wanted to know what I was missing. The doc looked at it, shrugged his shoulders and said- "Beats the hell out of me. That's what cardiologists are for." I sat there with my mouth hanging open, but that's when I also realized- NOBODY knows it all. Don't ever let pride get in the way. If I don''t know something, I have no problem saying- I have no idea what's going on here. Doctors call in specialists when they are in over their heads or beyond their area of expertise- why can't we? That's what your partner or medical control is for. The vast majority of our calls are pretty straight forward, but occasionally we get those puzzlers that really make you think. That's why keeping current and reviewing your knowledge base is so important- regardless if you are brand new or an old fogey. You need to have a firm grasp of the things we are supposed to know, and be familiar with as much as possible. I LOVE those mysteries. I love the challenge of trying to figure out a complicated medical/cardiac presentation- even if the treatment is beyond our scope, I always try to guess what the hospital will do to fix the problem. It keeps me fresh. I also suggest working in an ER- you learn an incredible amount just by witnessing and being a part of the care. You learn about normal/abnormal lab values, reading Xrays, CT's, ultra sound exams. You see what tests are ordered based on the patient's complaints. You will be amazed at the amount of knowledge you absorb, and it helps you explain to family and patients what will happen once they hit the hospital doors.

I've seen the mention countless times about folks not objecting to the mosque, but WHERE they want to build it. I've said the same thing dozens of times since I first heard about the plans. Let them build a dozen mosques- just not in the shadow of the former WTC's. Couple that with this Iman's stated views of that day(ie he thinks the US government was complicit in the attack), the fact that they want the grand opening on 9/11, that the guy wrote a book that claimed that day was essentially a call to a jihad for Muslims- and this is just plain wrong. It's not about being intolerant of a religion, it's about the US bending over backwards to appear PC and tolerant. It's morally and ethically wrong. Look for huge trouble in NYC- and possibly elsewhere- if this project ever gets off the ground.

tniuqs- Good post. Well thought out advice.

Well, we have a couple municipalities around here that are Public Safety- they are trained as police officers, FF's AND medics. They are also small, and not high volume areas. Not common, but it seems to be happening more lately. From a personnel standpoint, cross training saves money, and that is the bottom line for them. If they can pay someone to wear multiple hats, vs establishing multiple departments, they see it as a positive. The potential for liability seems so remote to them it's just not on their radar. I don't know what the answer is, Richard, but us old timers have seen a lot of changes in the business- from Cadillac ambulances that were converted hearses to state of the art MICU's. The trend is certainly towards cross training and fire services absorbing EMS. We may not like it, and could recite a million reasons why it's a bad idea, but I honestly do not see the trend changing.

While it's normal to feel anxious when you first start out, the fact that you didn't have any time as an EMTB makes it more difficult. I don't know what your situation is- 3rd service, fire department, etc, but hopefully they put you with a veteran medic. I would say trust your instincts and your knowledge. Assuming you did well in school, paid attention, and retained what you were taught, you should be OK. Remember, you are there for the patient, and if you focus on that it will help. It takes awhile to be comfortable- there's simply no substitute(or short cut) for experience. Years ago, I worked with a girl who was in exactly your situation. Because she was a single mom, she needed to finish school quickly, so she went straight from EMTB training to paramedic school- which was also an accelerated program. Very bright girl- booksmart, she knew her stuff, but completely green- zero experience on the street. She literally didn't even know how to attatch a regulator to an oxygen bottle. It was like training a brand new rookie EMTB. It took time, a lot of patience, but she ended up being a pretty good medic(she had other issues that hampered her progress, but that's another story). I kept telling her to remember her training and what she learned. It can be done, you can be successful, but because you have no street experience as an EMTB, you certainly put yourself behind the curve. You will need to learn the basics of simply talking to people, taking histories, etc, PLUS all the advanced skills you learned in paramedic school. If you can, express your concerns with a supervisor so they can put you with someone who can help you- that is key. It will be tough, but don't give up. Remember why you got into this business, work hard, and see if you can get extra clinical help from your medical director. Bottom line is that you were hired, so clearly someone believes in you, so now you need to believe in yourself. Good luck, and shoot me a message if I can be of further assistance.

I think the concept of prehospital care in general- and specifically in this case, critical trauma patients- is still a work in progress. Great- with all the advancements in medicine and technology, many people are "saved" that used to either die on the scene, or be declared DOA at an ER. As was noted, "saving" people is just the first step- the complications that arise AFTER their vitals are stabilized and immediate life threats are treated are a whole different story. Days, weeks, and months in an ICU or extended care facility with devastating deficits might not be everyone's definition of a "positive" outcome. That's also a topic for another discussion. The golden hour was a direct response to the advancement of prehospital care. Like you say, it was about understanding that someone with multisystem trauma needed a surgeon, not an ER doc and quick identification, notification, and transport was critical, vs running a mega code in the back of the ambulance. We CAN and DO make a difference with many medical and cardiac patients- we have enough toys and medications to at least mitigate the immediate life threat until we can get them to a hospital. Not so for trauma patients. Unless we can surgically repair a transected aorta, remove a spleen, or repair the damage done by a projectile lodged in some internal organ, these folks are beyond our scope to "fix". So in the end, we still need to practice good assessment skills, understand that sometimes our best treatment is diesel therapy, and let someone else decide the ramifications of whether or not the system is doing more harm than good. The "golden hour" shouldn't be some iron clad barrier, but a general rule that dictates what course of action and/or the best facility is for our patient. When I started in this business, the concept of trauma centers was nonexistant. Critically injured- but still salvageable patients- simply did not make it. Later, when I worked on the side in a busy Level 1 trauma center, I saw more thoracotomies than you could shake a stick at- sometimes one or 2 a day. Gradually the data showed that the survival rate of these folks was virtually zero, and the cost of such futile interventions was prohibitive. It was soon understood that top notch trauma care is incredibly expensive, and they sought ways to minimize costs whenever possible. Now, it is rare if you see a "cracked chest"- essentially it only happens if the trauma patient arrests in the ER, then MAYBE they decide to open their chests. Trauma(and prehospital) care IS still evolving, and in many cases, folks that used to be rushed to an ER in a futile attempt to save them, are simply declared dead on the scene(based on proper criteria, of course). Who knows what the next evolution of care will be, but you alluded to it- the concept of the "golden hour" should be a guideline, not something etched in stone.