HERBIE1

Sounds like an updated version of Helen Keller's story. I'll look for it.

NO argument with you at all. What's wrong with making a good living? Most docs are hundreds of thousands in debt by the time they finish their residency. Simple economics dictate that they need to earn a certain income in order to make investing all that time, effort, and money into a career worthwhile. The struggles they have with reimbursement, as you noted, are a very real problem. Does that make them any less dedicated to their profession if they enjoy a higher standard of living than most? I have a friend who busted his arse for years, sacrificed, and put himself in about 300K in debt to become a doctor. He now has become partner in a surgical firm and is living the good life. He has several cars, a Harley. a huge house, is building a dream house by a lake, and even has a small plane. I don't begrudge him one bit- he earned everything he has. He is also one of the brightest and most dedicated doctors I have ever met.

There always has been, and always will be 2 sets of rules- one for John Q Public and one for the rich/elite/powerful. It applies in the case of the law as well as health care, and I agree that with the proposed health care reform, this "concierge" medicine will likely increase for those who can afford to pay for it. Fair? No, but it's also reality. Think about all the tax breaks someone who is wealthy can get vs the average citizen. Regular folks save receipts for charity donations to justify any write offs we want to take. The rich have a team of CPA's who find loopholes and tax dodges that allow them to skirt what we would think of as "paying their fair share". In a sense, many people have this concierge system now. You accept and construct an insurance plan that balances your out of pocket expenses like copays for treatment and medication vs the monthly premium you can afford to pay. On the high end, you pay top shelf premiums for an all inclusive plan that allows you freedom of choice for any doctor, at any hospital, and any treatment or medication your doctor decides. On the other hand, you can choose an HMO that limits your out of pocket expenses, but the plan dictates when and where you can seek care, who will provide that care, which hospitals you can be admitted to, and how long you can stay. Without derailing the thread, I agree we need to change the system, I just think that the proposed changes will not bring about the desired effect. There will always be a disparity between rich and poor. Think about the utopian type socialist countries and how the average citizen lives vs the powerful. I think human nature is such that despite good intentions, there will always be the "haves" and the "have not's". \\relinquishes soap box..

So, did you accept the invitation? Will you soon be rich beyond your wildest dreams?

LMAO On the plus side, I guess we won't have to worry about Heath Care Reform anymore...

The take home point I get from this story is that despite all our technology, we still know very little about the human brain. This patient was brought to multiple specialists- even here in the US- by the family because they simply did not accept that he was in a vegetative state. It appears that none of the specialists were able to confirm the family's suspicions(that he was aware of his surroundings)- which apparently turned out to be true. As was already noted, the next time you have a patient who appears to be in a persistent vegetative state, you never know what they can hear or see. It does bring an interesting point up- if we are so unsure of the actual level of functioning of a person, how should we treat advanced directive issues? It took 13 years, but this person is now capable of communicating. What if he is able to express his wish to be disconnected from his feeding and that he wants to die? Do we honor that wish? Although there are rare cases of people waking up from "comas" after years and assuming some level of functionality, the odds are astronomical that this person will ever be anything but totally dependent on others for their needs. Personally speaking, I would rather be dead.

Saw this too. Can you imagine the horror this guy went through for 23 years?

Welcome. It must be nice to live and work in Hawaii. Visited there about 20 years ago- beautiful place.

Beat me to it, P. This allows you to introduce another variable- potential radio problems. Static, weak signal, background noise, etc. Here's another situation. How about a multivictim scenario where a doc would need to coordinate multiple resources, with multiple hospitals? Ambulance 1 to University with a multivictim trauma- --Go ahead- We are on the scene of a motor vehicle collision at State and Main, car vs SUV, approx 40MPH, we have a total of 8 victims- 6 adults, 2 peds. Patient conditions as follows: 3 adult red traumas, 2 red peds, 3 yellows. One red adult is still being extricated from vehicle. Closest comprehensive ER's are... , closest and regional trauma centers are... Please advise on ER and trauma center bed availability.. --Stand by Ambo 1... Ambo 2 will take 1 adult red to X hospital, Ambo 2 will take 1 adult red to X hospital, Ambo 3 will take 1 adult red once extricated to Y hosp, Ambo's 4 and 5 will take 1 peds red each to Children X, Ambo AA will take 2 yellows to X ER, Ambo BB with 1 yellow adult to Y hosp. *************** Depending on the system, you may or may not include more details, but on multivictims here, we stick with triage colors, and maybe include if the red is classified via mechanism or patient condition, stable, unstable, ETA's to hospitals, etc . Add another wrinkle- have one of the vehicles carrying a hazardous substance, which means a decon station would need to be set up, possible antidotes to a poisoning, etc. A scenario such as this would force the student to coordinate with other hospitals as to bed availability, any resource limitations, etc. You can have the student ask for more details and realize that the telemetry officer on scene may not be have all details of patient conditions, vitals, etc. YOu can even include air transport if available and pertinent to your locale, etc.

Chicago. It's a cadaver lab offered by Rush University/Hospital.

I was feeling somewhat jealous of you guys but strangely enough, I just found out we are being offered the same thing through a local university hospital here. Very limited enrollment, class size of 20. Should be fun.

They could always use a good EMS provider in Israel. The carnage and insanity they see in some of those areas makes the ghettos of NYC, LA, and Chicago seem like a walk in the park. I met a couple medics from Israel years ago and the stories they told me of what they deal with were incredible. I imagine it's only gotten worse there. Good luck in your career, Josh. The suggestions made above will help you.

Thanks. Obviously scene time varies with the type of call-on traumas I spend as little time on scene as possible. I have this little clock in my head that starts ticking as soon as we get our patient, and it kicks me into 2nd gear. Example: The other day we had a GSW to the chest, hypotensive. Distance to scene was about 2 miles, distance to a level one was about 4 miles from there. Time from dispatch to arrival at ER- 16 minutes- on scene time was about 4- 5 minutes. We had 1- 14 gauge IV, O2, monitor, EKG, and dressing done while on scene. I got another 14 gauge IV enroute and monitored his vitals. Oxygenation was fine- somehow the bullet seemed to have missed the lungs. Best case scenario, of course, and if I didn't see the official times on the computer, I would have never believed it. LOL (It also helps to have an experienced and great partner who is also a veteran of the ghetto) We "stay and play" when appropriate-ie on complicated cardiac calls, but our transport times are also short(my area is on average about 10 minutes, which is at the high end of overall transport times here) The longest transport time here is maybe 15-20 minutes for a level one trauma, with heavy traffic. If we are longer than 30 minutes at the ER we must also notify dispatch and explain why- no ER beds(common lately), extensive clean up/decon, awaiting supplies,. complicated documentation, multiple patients, etc. There is usually another call- or 10- waiting, so turn around times are constantly being monitored. The only reference I have to long transports is 25 years ago when I was on the privates. I used to go out of my mind when we had 30-45 minute routine transports/transfers. I take my hat off to the guys in the rural areas where these extended times are common- especially where air transport is not available.

Wow- you guys spend a lot of time on scene. How long does your average run take, doc?

They teach firefighter II AND the paramedic program?

Absolutely true. And for many of us, that informal debriefing is all we need, but we all are different. Sometimes you may not feel close enough to your coworkers to share your feelings- you work part time, you are new, or even the folks you work with are not receptive to this idea(that would be a shame). In that case, a CISD would be invaluable to a person who has no one else to talk to. We all decompress in different ways- talk about what went wrong, what went well, what we could have done better, and the projected outcomes of our patients. This usually happens in one way or another after most calls of any significance. As I said before, even the most routine call can push someone "over the edge", meaning their usual coping mechanisms may not be enough. We need to be vigilant, keep an eye on each other, and note when someone does not seem to be handling a particular situation very well. Nobody understands what our job entails better than our coworkers, and for all we know, someday that person who needs a little extra help may be us.

Horrible about that plane crash, Richard. Must have been a nightmare. Most everyone has issues with bad calls involving kids- myself included. Responding to a friend's home and finding their little baby girl when she died of SIDS was my worst. That one shook me up for awhile.

Didn't say I agreed with the policy. Like everything else in medicine, this is all about fear of litigation. Think of the issues OB/Gyn's have- many will no longer deliver kids because their malpractice is through the roof. Ideally, to mitigate those lawsuits, a woman who is pregnant could be put on light duty/assigned to a desk job/training if possible in their agency. Problem is, in many areas, light duty is not an option- either you are fully functional to work with no restrictions, or you are not.

Nice job on the paper. What grade did you get? LOL As evidenced by the various responses, there is no "right" way of handling tough situations. As you noted, I think that CISD should ALWAYS be voluntary, and the facilitators need to understand that it's perfectly normal and OK for someone may not want to participate. Something that is horrendous for one person does not even register for another. A simple, nontraumatic call can also be a trigger that reminds a person of another incident that WAS a problem. Everyone has their own time frame to deal with tragedies, and I think the onus is on a supervisors and coworkers to keep an eye on someone after a bad situation- a delayed response is not uncommon- whether or not they went through CISD. A simple cardiac arrest may remind someone of a recently deceased family member and the person could suddenly have trouble coping. (Happened to a former partner-she fell apart after a 85 year old nursing home arrest. Nothing unusually sad or tragic- she's dealt with tons of similar calls, but apparently a beloved grandfather recently died in a nursing home and the emotions came flooding back to her. ) Need for CISD-no, but she just needed to talk out her problem and felt better. Those who are "old school" were taught that thing like CISD shows signs of weakness, but now we know better. Some people have better coping mechanisms than others, while some need a little extra help. Nothing wrong with that- or with someone who does not want a formal debriefing. I do know that good supervisors can incorporate a debriefing of a significant event with CISD. As the details of the call are rehashed, the supervisor looks for signs that someone may not be coping well and takes action as needed, but it's still not a formal CISD.

I don't know about training, but around here, as soon as a woman finds out she's pregnant, she's off work, even though most OB's say that they have no problem with a woman working into her 1st or 2nd trimester. The biggest issue I have been told is balance ans safety issues associated with that, when the woman starts getting big. I do see potential issues with training if the woman is large and needs to work on lifting techniques. It may be a liability issue for the school

Again, early morning usually means there is downtime- even in a busy system. Yes, you can still get a call 5 minutes after you walk in, and in that case, you need to hope everything is OK and in proper working order until you can verify that for yourself. What else can you do? As for paperwork, many times members have a checklist to complete for a particular compartment, area, or set of tools. One guy needs to start the saws, and Hurst tools. Another verifies fittings That list is then forwarded to an officer to complete a master check out form. The driver needs to verify fuel in apparatus and tools, fluid levels, tank levels, emergency lights/siren, etc. Individual members need to sign and be accountable for their own equipment like SCBA's. It's a team effort. Each person needs to rely on the other that they have properly executed whatever their responsibilities are for that day. As for serious maintenance issues, well, the apparatus would be out of service until those problems were fixed, wouldn't it? There are plenty of things that occur in public safety simply because of tradition and there is no good rationale for doing it. Teasing, titles like probie or candidate, the expectation that the new guy is first to do menial labor or unpleasant tasks, and the last to finish. Certain informal rules like respecting veterans favorite seats at the dinner table, etc all can happen. As for lack of sleep- if you come in at the same time every day and are relieved at the same time, you don't work any longer than the next guy. This lack of sleep is part of the job. You can't decide that you are too tired to take in a fire or medical call at 3AM. You can literally be up for 24 hours with no rest. Done it countless times in my career, as have many folks in this business. Is it optimal? Of course not, but if someone cannot handle this schedule, they need to find a new career, a place that does not work 24 hour shifts, or a locale that is simply not very busy. Will the 24 hour schedule be disregarded, as the residency schedule was changed? Maybe, but the logistics of changing an entire fire crew 2-3x's a day could be a logistical nightmare in a busy system, not to mention you would need to hire more personnel. Not an easy solution, especially in these times.

You need numbers to back up your position. Averages over a set period of time. How many patients are transported? How many were extrications? How many needed to be airlifted? Transport times? Outcomes of patients- could transport delays have contributed to M&M of the victims? See if you can generate some stats to justify your claims. I agree that this is about a cost/benefit ratio, so you need to be able to justify that benefit to the powers that be. Good luck.

I would say that showing up early because someone else wants the job is only a small part of the reason. It's also a matter of pride and practicality. You already made through training, now you need to show your bosses and coworkers you are up to the challenge. You need to PROVE yourself to be a productive member of a team. I don't care what anyone tells me about the condition of the apparatus, any potential issues with supplies, maintenance issues, etc, I check everything out. It's not a matter of not trusting what someone tells me, it's a matter of accountability. As soon as you relieve the prior crew and start work, YOU are responsible for that apparatus, and anything the off going crew misses or forgets to tell you is still YOUR responsibility. If you find a discrepancy, then yes, the onus is on your to address it with the previous shift, and/or rectify the problem yourself. If something is missed, YOU are the one who will need to be accountable for it, and if you do not check for yourself, it will become YOUR problem. As for paper work, there is plenty to do when your arrive. Attendance records, documentation of the apparatus and supplies, citing any personnel problems, training schedules, maintenance logs, citing members on vacation, ill, traded tours of duty, ensuring equipment is functional, batteries charged, SCBA's are in working order, saws start up and are fueled- tons of things to do. Once you walk in the door, you may get a call immediately, and the sooner you know that everthing is OK, the sooner you are ready to work. Circadian rhythms? This is the wrong business to be in if you are concerned about your sleep cycles- especially in a busy system. I realize there is a wide variety in the types of services people work for- busy urban systems, slower rural areas, etc. If call volume is low, you may be drilling all day, cleaning/polishing equipment, studying, etc, or you may only have time for a quick check out and you are busy all shift long. Typically, even in a busy system, early AM is slower, and is the only time you would be able to do a good inventory, so it only makes sense to get there early to accomplish your responsibilities. Preparing for drills- or a call- means that you better be damn sure your equipment is ready when you need it. What if someone puts a piece of equipment back in the wrong place? What if they were cleaning it, servicing it, or training with it and they forget to put it back on the apparatus? It happens, and in the middle of a fire or EMS run is NOT the time to find out. How would you know everything is OK unless you do a proper check of these items? The first thing you do is go over the most important items- the ones that you cannot do without. SCBA's, masks, saws, Thermal imaging cameras, monitors, vital medications, O2 levels, ensuring the main ladder is operational, ensuring the engine is able to pump, the booster tank is filled, etc- whatever your particular role is, you ensure you can function properly in that role. Maybe a new piece of equipment or a new model was issued? You had better be familiar with it's operation. What if you are detailed to a different apparatus than usual, or have a different job responsibility for the day? Your team/partner/public depends on you to be ready and that means knowing you have what you need and it is present and in proper working order. The rest of the details and a more comprehensive inventory comes later, but a 5 minute check out? No way. Not if you are serious about your job.

In terms of preparations, med school and the fire department or EMS are apples and Buicks. Med school is an individual effort(except for labs) Your results arise directly from your efforts and are not dependent on anyone else. Your preparation/study time can also happen nearly anywhere- at home the prior night, at the library, that AM while eating breakfast, on a train to school,- whenever. When you arrive at the firehouse or EMS station, you need to check out your apparatus, your supplies, clean, restock PRN, do any required paperwork, prepare for any drills, receive a report from the crew you are relieving, check out your SCBA, etc. Fire or EMS, you need to work as a team, and that team is only as effective as it's weakest link. As with the military, you need to understand you are part of a bigger picture and when training, the instructors instill that team approach- especially with FSR- your life depends on how well you work together as a team. Anyone who has dealt with a problem child in their station understands how disruptive such a person can be to the unit as a whole. Resentment, anger, mistrust- not good things to have for a team to be effective.

Nasal? NRB. Thiamine and Dextrose, PRN too... Or so I am told...