HERBIE1

Good ideas from that preceptor. I've used many of those lines myself, but never thought much about it. Most of it just seems like common sense to me. I suppose it would be a good thing to have an established set of rules like that- especially if the preceptor is younger. It seems like a lot of those ideas came to me after a bit of life experience and time in the business. Too many times I have seen ego and control issues as the prime motivators for being a preceptor, which does nothing to help their student. I was fortunate- my preceptors were incredible. I learned tons from them- especially about the proper way to talk to patients and their families. The medical aspect is cook book. Knowing the proper way to treat people(not their illnesses) is the real art form here.

Wouldn't work for our "victims". We have the "lock up itis" where a mope fakes injury or illness, as if a trip to an ER will somehow get him released from custody. The police remind the perp that this will merely delay their processing and probably cost them another night in jail because of the delay. They don't care. It's not like most of them need to worry about losing time at work. LOL

Not simplistic at all, Richard. That's essentially all an ER will do anyway- except they will probably use a Morgan lens set up or some similar device. The only caveat I would have is if the patient was aggressive enough to warrant a pepper spray, I'd be cautious about a lot of close up contact with them. These days, with the advent of the Taser, we see far less pepper spray incidents than we used to- save for the occasional smart ass who sprays it in school.

LMAO Bellevue Sandwich??

Relax, enjoy the ride and be good to your patient. Give them what they need, not what your cookbook says.... Best advice I've heard in a long time. Too often we get caught up in using our toys, pushing meds, and in general justifying all that money, time, effort, and studying we did for school. Sometimes the very best thing we can do for a patient is to NOT do anything for that patient(other than observe and monitor, of course). Watch them, talk with them, and see how much of a difference a friendly ear can make. I have learned some amazing things from my patients and feel honored they were willing to share their thoughts with me.

In these cases, it's ALWAYS a training and management issue, in practice, and in the liability sense. If the victim's lawyer chooses to pursue the negligence angle(almost guaranteed), then one of the pillars of that is the notion of respondeat superior, which means management is responsible for the training and actions of their employees. If it can be proven that the employees were not provided adequate training on restraints and in the handling of a violent patient in custody, then management(the department/municipality, etc) is on the hook for big money.

This is just simple ABC's. Regardless of the reason you are called or the treatment you provide, your first job is to ensure the patient has an adequate airway. If they are combative, violent, unconscious- whatever- you still need to monitor that patient. Yes, your safety is always paramount, but if the person is properly restrained, they can attempt to fight, kick, scream all they want, as long as they are still able to breathe. This outcome will not be good for the EMT's.

Agreed with above. They may be warning signs or they may be completely benign. As was mentioned, treat the patient, not the monitor. Obviously in a patient with a cardiac condition you need to be far more suspicious of all the possibilities, but again, unless the PVC's increase, become multifocal, or the patient decompensates, don't be too worried.

Holy cripes, Lone Star. You are truly a lucky guy. I think you are right- someone up there thinks you have some unfinished business and more to offer this world. Glad you're still around to tell the story. Your story is eerily similar to an old friend of mine's. On his way home from work (a medic), apparently he didn't feel well- dizzy, extreme fatigue, and he called his wife, describing his symptoms. He said he was pulling over to take a quick nap because he was afraid of falling asleep behind the wheel. I guess he figured he was simply exhausted after a brutal shift. felt that way myself countless times, as we all have, I'm sure. After he didn't come home for a couple hours, the wife began calling him and got no answer. At some point, a passerby saw him parked on the side of a highway, slumped over the wheel, and called EMS. He was DOA- a brain aneurysm. Like you-apparently he had no real warning signs, no trauma, no underlying health problems. He was 35 years old, and a new dad. I thought the OP's question was in regards to proper AlS care in these cases, but it seems they are more interested in assigning blame. As you and others have noted, sometimes there is not a damn thing we can do to change an outcome, and we simply need to accept that. Sh-It happens.

You obviously must have missed the point here. With conditions such as this, there is nothing we can do prehospital. They need a neurosurgeon ASAP- period- if they have any chance of surviving and even then it's dicey. If that aneurysm is leaking or gawd forbid bursts, there is nothing we can do. Depending on where the problem is, the bleeding and pressure may not kill them immediately, but the prognosis is less than grim.

Our "norm" is supposed to be needless and preloads whenever possible, but every hospital has their own protocols. Needless tubing is pretty universal, but not every medication is compatible. Many will have a needle which can be unscrewed, but some is in vials, and some simply is not offered in needleless(luer-lock) form, which means you need to have adapters to accomodate. Pain in the arse- yep, and you never know when a medication may have only a needle- especially when there are multiple manufacturers of the same drug. I remember a recent cardiac arrest where we gave multiple epinephrines- and after someone opened a box, realized it had only a long cardiac needle. Instead of messing around and attaching an adapter, we simply grabbed another box with a luer lock. Some hospitals even hand out multi-use vials, which is generally useless for prehospital. About the only things we use multi-use vials for are things like morphine, valium, or other drugs that we routinely give serial doses for. Many piggy back drip meds still use needles, especially with some of the secondary tubing set ups, but we have rare occasion to use them- Dopamine and Lidocaine immediately come to mind.

Sorry you're in a touch patch right now, Ruff. The problem with moving is the local economies in most places are probably no better than where you are now, not to mention cost of living is ridiculous in many places- especially to the north. Couple that with starting pay at many companies would make it tough to make ends meet. I'd hate to be starting out in this business now, knowing what entry level pay is and the cost of living. Yes, jobs with municipalities pay well, but even those are not hiring these days. Keep hunting- something will turn up.

Maybe someone saw the POTUS's claim to address the don't ask, don't tell policy in the military, which dragged out this thread again? Anyway... EVERYONE has a bias of some type. Some are worse/more destructive/vulgar/strange than others. The question is, how do you ACT on those biases? Do you treat that person differently? Do you think less of them in terms of their competency based on that bias? Do you think they should be given special considerations- good or bad- vs the rest of the population? I am prejudiced against stupid people. Problem is I am conflicted about that since their mere existence guarantees we all have jobs. In one of the ER's I worked at, most of the male RN's were gay. Some were more flamboyant than others. One in particular was Indian, who came from a wealthy family back in Southern India. One of the funniest guys I have ever met. Witty, razor sharp tongue, and did not tolerate idiocy. Our area had a huge gay population and he was constantly laughing at how some would act like queens, or butch. He is also one of the best nurses I have ever met. He would make comments like "well, you know how us fags are..." when someone acted particularly stupid. One of my favorite pass times was when the new crop of residents would make their rounds and I'd point out a potential love interest for him. He would initially blush(a funny thing to see a dark skinned guy do), and say in jest something like- "Well he's clearly not a fag but I bet I could turn him!" During some of the rare serious conversations we had, he talked about what it was like growing up in India, being gay. He denied it for years and even was married for a brief time to a woman- it didn't work. He said he loves going home to visit but attitudes in his family and his caste are pretty old fashioned. Point is, unless the person is militant about their issue- whether it's race, gender, feminism, sexual orientation, politics- I have no problem with them. To my knowledge, I have never worked with a gay man, but with several lesbians and I have to admit, it's a bit strange when a female and I are checking out the same woman's rear end. LOL I've worked with a couple lesbians who were extremely militant and always looking for a confrontation. They would see a perceived slight in damn near any comment someone made to them. I had it out with one of them and said their sexual preference wasn't the problem for me, it was their piss poor attitude. They of course assumed I was a homophobe- much easier to throw out a label like that than to admit you have a lousy personality.

As anyone familiar with numbers knows, polls and stats can be made to say whatever you want them to say. Obama is still very popular here in very specific areas and among certain demographics. Still, his overall approval ratings are low- regardless of which poll you see. Obviously that would mean there are some areas/groups that are VERY unhappy with him so far to offset those who are still wildly enthusiastic. Some in Canada may very well support the guy, and as far as I'm concerned, they can have him. I'll even pay for the plane ticket. He's no different than anyone else- except he talks a good game and can enthrall people with his rhetoric. That makes him a good politician, not necessarily a good leader.

Fascinating read- especially since the date on the article was 1991. I wonder if he would amend any of this today.

LMAO Yeah, but the clinical trials would really suck. I don't care how much money you offer someone, I highly doubt the lure of a few bucks would be enough to get someone to willingly be stung dozens of times by bees. It seems that it takes near fatal doses of that venom to offer the relief, so I'm thinking there would also be a very slim margin for error and more than a few "oops" cases. Poor college students are only willing to put up with so much in the name of beer money... Great. Does this mean I need to look for a place on my rig for yet another piece of equipment? \\\ Wonders where on earth I would put that bee hive...

I never thought about the pacemaker thing. As for bee venom, there have been studies that say people who have experienced multiple stings have enjoyed various health benefits. I seem to also recall reading about people who intentionally get stung to get relief from things like arthritis. As a matter of fact, I just saw a recent story about a woman who was in anaphylactic shock and nearly died after multiple stings. She spent time in the ICU and when she woke up and fully recovered, she realized that her joints that were stiff, sore, and achy (knees, ankles, hands, etc) were free of arthritis. I don't know if it's some inherent properties of the venom itself or the result of some immune system changes, but it's pretty interesting stuff.

LMAO I like that one Lone Star.

Not dumb at all. I found that with augmentation, the breasts are more dense and rigid which makes moving them out of the way more difficult. In these patients, the women aren't generally as self conscious(they're usually proud of their assets), and they are more than happy to help move them out of the way, especially if they are large.

Ours was adapted from "Safety Pad", but like vehicle specs, those who are tasked with doing it are not the ones who use it in the field. It does not autogenerate a narrative, but after clicking on all the required fields, the information is present in the report, although you need to hunt for it. You do have the option of putting a narrative in each section- physical exam, vitals, treatment, etc, I choose to write one integrated summary that covers the entire call. It's more fluid, it tells the entire story and paints the proper picture of what happened with that patient. The specifics and details like times, dosages, etc are included elsewhere in the report, under their respective headings. When appropriate, I repeat the treatments in my comments when for example, the patient improves or decompensates after an intervention because the program does not allow for that type of documentation. I understand the benefit of using an e-report- quicker billing, easier tracking of data, QA and QI purposes, etc, but certain things simply cannot be adequately expressed via a software aided program.

The EKG tech that taught me told me exactly that- move the breast. I was told it's lazy and poor technique not to use the chest wall whenever possible.

All good answers, letmesleep. I would also emphasize that you need to document any issues that cause you to alter your care or delays you may encounter- access to patient, extrication issues, patient's refusals to treatments, differences between patient statements and what you see, etc. Everyone develops their own routine and how you document also depends on whether or not you have an electronic PCR. These electronic programs often have drop down menus that offer choices to document a delay to the scene- heavy traffic, road conditions, wrong address, etc. Be VERY careful when using these predetermined, computer generated options. As an example of potential pitfalls- the software we use has several different places and methods to determine the patient's GCS and level of consciousness and you need to ensure each section is in agreement, although they do not completely match up in content. It's simply a software glitch that everyone complains about and we are told because it is a proprietary product, they can no longer change the software without paying a huge fee. An example of documentation issues- I had to testify in a personal injury care case where the person had a head injury. As I said, the various level of consciousness sections of the report differed slightly, and there was a discrepancy between them. The lawyers were arguing whether the person was intoxicated or his agitation and actions were the result of the head injury and asked me about the variations. I explained to them about the computer issues, and at the time this software was also new. I also pointed out my VERY detailed comments that fully explained the patient's condition that left no doubt about his mental status. I said that I stand by my words, and any discrepancies with those mandatory computer generated options was the fault of the software designer, not me. The defense attorney and the judge understood and accepted my explanation. Another- A couple weeks ago we had a nasty roll over- highway speed. Guy was out of his car before we got there, sitting in a state trooper's cruiser. He got out as we arrived, and stepped into our rig. Our treatment was standard, turned out he had a tiny lac to his forehead, nothing more, but he went to a trauma center for evaluation. The pertinent point here was in the documentation. Because this was a DUI case(the other driver was a fatality) police investigators caught up with us a few days later. We went over what happened, I reviewed my report, and noted a glaring error. I had correctly documented that the guy was ambulatory to our rig, but it also said that he was sitting on the squad bench as he rode to the ER, and walked into the ER when we arrived at the hospital. Obviously the guy was on a backboard and collar, on the cot, so there was no way he could have been seated in the rig, nor did he walk into the trauma center. I pointed this out to the investigators and complained bitterly about the computer program, and the officers said they have similar issues with their report writing software. I ALWAYS review my runs for accuracy before closing them out and printing them, but I somehow missed the mode of transportation section. I inadvertently hit the wrong options and did not notice. It happens, but ultimately it is YOUR responsibility to ensure that report is a complete and accurate portrayal of the patient, his condition, and your treatment. Learn your own method of report writing and use a cheat sheet if necessary until it becomes ingrained in your head. I am known for my very detailed personal comments- even if they may repeat information elsewhere in the report because I know I can defend my own words. The story, in your own words, may also just save your butt and your reputation in court.

Just like a trauma patient, you have to expose. I don't see how you can get optimal placement of leads- especially the chest leads- without removing the bra. I don't know for sure, but wouldn't a bra with a metal wire also cause interference and artifact? Obviously you need to preserve dignity and the use of a towel or sheet is mandatory. As for using the back of the hand and/or forearm to move the breast, that was something I learned early on when working in an ER. Initially it was uncomfortable for me to do a 12 lead on a woman-especially one that was younger- so I can only imagine the discomfort and anxiety of the woman. Yes, a woman with large breasts can be a challenge, but lead placement is no different. I actually saw someone try to place the leads on top of the breast because she was too nervous to move it. I corrected her, and said that like any other procedure, getting a poor result is no better than not doing the exam at all.

The only reason we went to saline locks was pure economics. A few cc's of flush an angiocatheter, and a J-loop are still a lot cheaper than a bag of saline and tubing. Unless someone needs fluid replacement, having IV access via a lock is all we need. If for some reason things change, hanging a bag is no big deal.

Why would a saline lock prevent pushing fluids?