HERBIE1

Does this mean that drinking light beer is now a waste of time? As was pointed out, all calories are not created equal. Eating 400 calories of fruit vs a cheeseburger will not yield the same results.

See what I mean, Brandon?

There will always be folks eager to show their expertise in a certain area. The thing about a diverse group as we have here is that everyone has their niche and will gladly share their sometimes extensive knowledge of a particular area. Nice to know- sure. Informative- absolutely. Practical and appropriate for this context? Not always. Just take what you need from the discussion, and if your question still isn't answered after all the sword rattling, ask it again. Threads frequently get side tracked.

To echo what tniugs- and I- said, lacking definitive evidence that supplemental O2 does any harm to the average prehospital patient, I think the placebo effect is HUGE. A person calls 911 for help, and assumes we can help them, or at least help ease their fears. Not every patient will have a dramatic turnaround like a narcotic OD, a reversal of hypoglycemia, or treatment for chest pain or pulmonary edema. Think about how often people ask how their BP is. Diagnostically it may have nothing to do with their situation, but it's something that most people understand. Think about how often people ask us what we think is going on with them. (No, we don't offer a diagnosis, but many times we can alleviate concerns with simple things like a kind word, a reassurance, or offer a possible, less serious reason for their symptoms.) If we tell them the O2 should help their nausea, anxiety, weakness, etc, then often times they accept it, calm down, and feel better. They arrive at the ER hopefully in a slightly better state physically and emotionally than when we arrived. The ER takes over and provides definitive care, but with all our fancy toys, medications, and training, I think too often we forget that the little things are what patients and their family remember about EMS. The end result is what counts, and the patient couldn't care less how many initials you have behind your name, that you just finished training on a new piece of equipment, or just reupped your ACLS certification. They simply want to feel better, and isn't that what this is all about? We are the first step of a continuum of care and I think that starting off on the right foot is an important part of feeling better. Several people have mentioned the mindset of a patient, and I agree that there are some people who are simply just too stubborn to die. We've all had the patients who defy all odds and should not be walking this earth- they conquer and recover from seemingly impossible situations time after time. We also have the people who succumb to illnesses and problems that are minor by comparison. I had a regular lady around 60 years old who had diabetes, CHF, MI's, CAD, one leg amputee- and on a drug store full of meds. Every several weeks she would call, and we would find her in the same situation- standing on one leg with her head in the freezer(she was convinced this made her feel better), with audible rales heard down the hall of her building, struggling to breathe. I intubated her 3 times(Did not have CPAP), and treated her with medications at least a dozen more. Most of the time she was breathing normally by the time we reached the ER and she always thanked us profusely. Her heart finally did give out, but from what I was told, it was actually sepsis that did her in. On several of her close calls, she did indeed tell us she was too ornery to die yet, and that she was simply not yet ready. We believed her.

Well, this goes back to evidence based medicine and as usual, we are at a disadvantage because our diagnostic options are limited. Without KNOWING what underlying problems are, in the case of supplemental O2, what harm could we do? Our routine medical care for an ALS patient has always included o2, monitor, TKO IV, and a glucose check. Over the years, thanks to real world concerns like costs of glucometer test strips, we are encouraged NOT to check a sugar on every patient unless there is a suspicion(or PMH suggests) an abnormally high or low reading may be likely. Our service is not exactly progressive, so discontinuing routine supplemental O2 because it MAY not be necessary is not likely to happen any time soon. Can things change- of course. Look at all the changes over the years we have seen in this business. It used to be many systems required permission from medical control to even start an IV. When I first started in this business, MAST suits were standard protocol on all cardiac arrests. We no longer use them, and the reasons have been well documented. We used to be encouraged to stabilize, splint, and work up trauma patients before transport. Then came the golden hour and everything possible is done enroute to definitive care at a trauma center. I think of all the medications that have come and gone over the years like Bretylium, and aminophylline. Remember when sodium bicarb was used very early in a cardiac arrest scenario, instead of for a renal patient or for an extended resuscitation? Some changes were because better treatments came available, some were because they were simply never used, and others caused side effects that were worse than the problems you were treating. Will the use of supplemental oxygen become less automatic? We'll see, but in the meantime, I still see no harm in it, and the potential to at the very least help alleviate a patient's fears and anxiety is reason enough to continue.

I can only speak directly from my own experiences, but the trends are indeed nationwide. Fires are down and around 80% of what a fire service responds to are medical calls. That's a fact we all know. We have firefighters here that can go through their entire probationary period and NEVER see a fire. As was mentioned, education, prevention and better building construction, fire retardants, sprinklers, etc, are a good thing. Problem is, like anything, drilling and simulations can only do so much, and like medical skills, if you don;t use it, you lose it. Then again, if you never get that experience, what are you supposed to do? We see older firefighters who may have the experience, but after years of inactivity and the toll those fires have taken on their bodies, when something DOES happen, they feel like they should be able to function at the same level as they did in their prime. Overexertion plus less than optimum conditioning means danger to their bodies. In most systems, EMS is constantly working- lifting patients and equipment all day. As was pointed out, even people who may be larger can still be physically fit, but are still in no less danger if they are not taking proper care of themselves. Can you imagine training for something for months, and then may wait months more or even years to use that training? Most people come out of training in the best shape of their lives. Some keep it up throughout their careers, but the vast majority do not. Even 15 years ago, fires were A LOT more prevalent, and members were far more physically fit because they worked hard nearly every day. Now, they can count their fires in the last year on one hand if they are lucky. Aerobic and weight training are tough, and to keep that up for an entire career takes dedication- especially when you aren't able to perform the skills you trained to do. Personally, I can honestly say that if after finishing paramedic school, I don't know how motivated I could remain to stay fit, stay current on my skills, etc, if I was never able to use what I had learned.

Mea culpa. Guilty of oversimplification. I was merely thinking of an undiagnosed or unknown(to us) hypoxic situation that would benefit from supplemental O2. My point was that without further diagnostics, someone COULD benefit from O2 even though they did not present with a typical hypoxia related complaint.

Let's put it this way- a couple liters of O2 via a cannula cannot hurt. Like you mentioned, the placebo effect is certainly possible. I've told people who were anxious, nauseated, upset, weak, tired, etc that it will help them, and often times, it does. It's also a subjective thing- the person has to believe it, so your attitude, demeanor, and bed side manner is important as well. If the patient THINKS it will help, often times it will- especially if there's an anxiety component. As for the clinical aspect- we never know- even ALS providers- what underlying issues they may have-ie their blood chemistry, metabolic issues, etc. Are they anemic but asymptomatic, and could benefit from the increased O2? As an ALS provider, many times we establish an IV/saline lock- just in case, and it's never needed by us. Many times it's simply a convenience for the ER. If the patient perceives we are doing something to address their problem, it tends to put them at ease just a bit. That also means lower BP and heart rate, lower O2 consumption, and anxiety is lessened just a bit, so clinically it is relevant.

90K? Pretty nice, but... Salaries are also relative. The cost of living in Orange County is a lot higher than in somewhere like rural Kansas or even other metro areas.

Clearly the Tridata report was ignored then. Nothing new. Well, TriData makes the recommendations but there is also no mandate to use the information or implement any of those ideas. A city spends 200K on a study that outlines needs and deficiencies, but the suggestions go unheeded. The problem is, in a fire based system, you need to change the emphasis from fire to EMS, and unless the changes benefit the majority(FS&R), they will not happen. You still need leaders to buy into the concepts before anything is changed, and for reasons well documented here, the old school attitudes are slow to change. We argue here over possible solutions, but I don't really know what the answer is. The upper level politics and mission statement stuff you refer to is what sets the tone- and the operational agenda for a department. If the leaders do not see providing quality EMS as a priority, then it sets the tone for all decisions made. There is no commitment to having a progressive, proactive EMS system, and that attitude is relayed to the providers when they do not have quality recruits, standards, or substandard equipment. Think about the name "Fire based EMS". Where do you think the emphasis is in a system like this? FSR came first, and EMS is an after thought or considered to be a necessary evil in too many places. Yes, there are progressive systems that buck that trend, but ask any single role who works in a big city about the dominant culture or paradigm where they work.

Trust me-there are PLENTY where I work. There are physical fitness standards to get the job, but they only become suggestions once you finish your probationary period. It's a shame, because you would think we know better. As a result of the demands of the job, people fall into the trap of lousy sleep patterns, stress, poor stress coping mechanisms(booze and smoking), poor eating habits, poor physical fitness, and their health- and longevity suffers. I am amazed at how many people I work with who are in their 40's that are walking around with significant CAD, HTN, DM, and stents. We have to do a better job of taking care of ourselves.

I would like to see info on WHY US citizens would go to the UK, Canada, or Mexico for care. I don't know, but can a noncitizen get free care in these other places? As for people coming from other countries to the US, I suspect much of the time, it is for specialty or state of the art care they cannot receive in their own countries. I do know we had the recent push in trying to import drugs from places like Canada and Mexico because they are so much cheaper there. I do know US citizens travel to other places for things like controversial treatments who's efficacy may be questionable. I know places like Germany and Mexico offer various therapies like hormone and herbal treatments that are not sanctioned or covered by insurance here. If able, I would imagine people who are desperate enough and have the means to do it, will try anything, but I assume those are all out of pocket expenses.

My sincerest condolences to you and your family, Mobey.

The original post was about lawsuits as a result of line of duty care. I wouldn't worry too much about the criminal side. Very unlikely to be charged with a criminal complaint as a result of providing approrpiate care. CIVIL, on the other hand is a different story. You can sue someone for nearly any reason but like I said, at least malpractice or negligence is a very tough nut to crack. I too have been to court and given depositions MANY times as a witness, and also never as a defendant. BS lawsuits will be directed at those with deep pockets- city, county, department, etc. Most slip and fall lawyers(my general term to describe these types of attorneys) know this and won't waste their time unless big money is involved. Most municipalities frequently deal with all types of nuisance lawsuits and they used to throw a couple grand at a complainant just to make it go away. These days, because most larger departments and municipalities already have lawyers on staff that they realize that agreeing to go to trial on a BS case usually scares off the con artists and they are soon dropped. As you said, most of the time they are indeed fishing expeditions, looking to see if a settlement is possible. Mass transit cases are perfect examples of this. A "horrific" bus accident like a broken side view mirror, and suddenly everyone on the bus(including the driver) has neck and back pain, requiring months of therapy and medication, lost wages, etc. The old story-only 3 people on the bus at the time of the accident, yet suddenly 40 people are on scene, complaining of injuries. Trains are the worst- too many doors to guard. LOL

While researching for medical/legal issues classes, I came across very few such cases. Negligence is the most common problem, but as was noted, it is very rare. Think about the thousands of patient contacts every day- it just doesn't happen. There is also a very high hurdle that must be proven in order to be charged with negligence: A provider's actions must be willful and wanton and several questions must be answered in order to prove such a claim. Did the provider have a duty to provide care? Did the provider breach that duty by failing to provide care according to an established standard? DId harm come to the patient as a result of that failure? Was that harm due to failing to provide care according to established standards? Additionally, the plaintiff must provide the burden of proof to answer all these questions. In other words, a simple mistake will not automatically mean litigation- although you certainly will receive sanctions/discipline from your state and local systems. You must intentionally cause harm or deviate from acceptable standards.

I would agree that an undergrad degree in ANYTHING is almost a necessity these days. My point was that because of the expense of higher ed, one needs to be very careful about where to spend their education dollars and get the biggest bang for their buck. I realize that people's plans and goals change over time, but you need to position yourself to be able to make the best possible use out of whatever education you choose to pursue.

I don't think we disagree. In a perfect world with unlimited resources($$) and time, it would be great to go as far in EMS education as possible and then move on to other areas like management. I was just pointing out that without knowing the poster's aspirations, I would suggest a more holistic, well rounded approach to make yourself more marketable. I would also point out that to be of any value, an advanced degree in management (grad school) is probably what you really need anyway.

Here lies the fundamental problem. Fire based EMS is run by FIRE CHIEFS, who treat EMS work like fire duty. Fire service is a static deployment system, and depending on the area, it may also work for EMS, but often times it does not. A fire chief will provide a fire service solution to address an EMS problem, and often times it does nothing to address the actual problem. Call volumes, resources, type of system, size of response area all are key to proper utilization of assets within a system, but a fire chief's first choice will be to protect fire service jobs.

I agree that it depends highly on where you plan to work AND what your future plans are for the profession. I would argue that getting a degree in management(as in public safety administration) or business would make you the most marketable if you plan to move up in the ranks.

Why do you think it has such a poor execution? What are the specific problems associated with that system? I've heard that EMS runs a high call volume with not enough rigs. Is that still the case? Didn't TriData do a study of that system some years back? DId they actually address the problems the report brought up, or correct any deficiencies? I'm not arguing, just trying to compare problems. I would bet the HFD's problems are not unique to that city either.

I will put up with a certain amount of BS. When I reach my limit, I respond in the same manner I am addressed. As for obnoxious- "you ain't seen nothin yet". Believe it or not, I am being restrained. Not worth getting worked up about this. Childish? Maybe, but I never claimed to have the patience of Jobe. The system is NOT fine, but BS patients are not the problem- the system is. The only way someone can take advantage of a situation is if they are allowed to do it. The rules are made to protect a patient, but in doing so, loopholes remain, and are exploited by some. That's life, but I won't pretend to like it, nor will I idly take abuse when I comment on it. I've been in this business for a long time- in multiple capacities- management, supervisory, and street work. I teach, I attend classes for personal enrichment as well as improving my knowledge and skills. You need to find your niche and exert your time, energy, and skills in a way most appropriate for you and your circumstances, which may be quite different than mine, or someone else's. "Right" can also be a very subjective thing. Keep the idealism as long as you can, Kaisu. I hope your situation- call volume, work environment, personal and professional life, and mother nature allow you to remain that way. It's not easy to do.

I appreciate the reasoned response, Dwayne. My problem is- and it's nothing new- I too am a realist as well as being pragmatic, which means I do my job, follow the rules, but also understand how the process really works. When I hear an idea, program, or initiative that sounds too good to be true, I know that it usually is. My political views reflect a similar sensibility. In many ways, I am jealous of idealistic people- of how they can remain true to their views, despite a mountain of evidence that may contradict the wisdom of such a stance. The frustration would drive me insane. We need both types of people in the world, but I think for many in this business, idealistic is a tough route to take. I do my job, I've been doing it well for 30 years, and I still do whatever I can, within reason, to help people- patients and family members alike. When accused of being burnt out, apathetic, or somehow falling short of some utopian ideal, I will fight back.

Clearly I have dared to step on a senior poster's toes here. As with most forums, this one has a hierarchy, and most folks seem to defer to this person's expertise on every subject. I violated that protocol. As was noted, too many threads have dissolved into personal attacks and I sincerely apologize for my part in them, but when someone makes implications or inferences about my character or professionalism, I will not ignore them. This is a good place to learn and exchange ideas, but the drama and BS isn't worth it.

Wow. Coma? I'm liking my original thoughts- some type of poisoning or drug ingestion. Like aussie said, I'm liking huffing here. It's legal to purchase, and nearly every home probably has a can of compressed air to clean their electronics. Easy access. Depending on the propellant and chemicals involved it could certainly explain what happened and why it seems the tox screens apparently did not show anything. I hope they figure it out. Bad news.

Have yet to see a case of even suspected H1N1, but our protocols are N95 mask, mask for PT, BSI and normal PPE. Disinfect as for any viral agent.