HERBIE1

If you don't mind me asking- what was your former career? Just curious...

Good post. I will say that WHERE a person is educated can give them an advantage. The reputation of a school- JR college, university, technical school, or trade school is important. It generally means there are some minimum standards- generally better than other places- that a student must meet in order to successfully complete their program. That said, the old adage of you can get a great education at a lousy school, and vice versa- is true. You get what you put into anything. I've had people swear that they love a certain hospital that has a lousy reputation, and I've seen things at supposedly top notch, world class facilities that would make your hair turn white. I agree about judging folks on their own merits. The school they attended is irrelevant to me- unless they demonstrate some deficiencies you need to correct, and then you need to go back and determine if the problem is with the student or the instruction they received at the school. In my experience with EMS providers, the school is not usually the problem. Agreed. We posted at the same time and said essentially the same things. Great minds, and all that...

Every city has their " bad" areas. DC proper is known for it''s violence and high crime rates. Correct me if I'm wrong here, but doesn't anyone who makes a decent living opt to live OUTSIDE of DC proper? NYC has Hell's Kitchen, Chicago has its ghettos, LA has East LA, etc, but there are also very pricey areas in each of these cities. You are right about the pay issue- "lousy pay" is a very relative description, especially when you consider other benefits like insurance, pensions, benefits, cost of living, and job security. For a brand new graduate, or a young person with limited job experience and/or education, this job is nothing to scoff at.

Like nearly everything else discussed here, looking for a universal answer is impossible in this business. We can't even agree on definitions of semester hours. To require anyone in EMS to be a paramedic is simply not practical. Think about the different systems all around the world. Some services operate with a doc on board, some or 2 medics, some are BLS, some are a combination of all of the above. Some areas simply do not have the resources to have an all ALS system. Isn't it better to at least have providers with SOME medical training vs having nothing at all? As we all know, despite national standards here, all EMS programs are NOT created equal. Some are medic or EMTB mills who's goal is to crank out as many folks as they can. Requiring a degree program is not the answer either. The quality of the instruction is not based on how many classroom hours you put in(although obviously more would probably be better), but the reputation, ability, and character of the instructors and program coordinators. Even medical schools vary- think about how a doctor who graduates from a Caribbean medical school is viewed by his peers. They could be a brilliant clinician, but will always have a stigma attached to their education. We could demand that a person must spend an unworldly amount of time in classroom and in training for EMS, and even require a college degree, but unless there is a payoff at the end- ie the person can make a decent wage once they are done, we won't be able to provide enough bodies to fill those spots.

Thanks for the info. I know a couple people who may be interested in this.

LOL Hangover? I cannot recall the last time I drank enough to qualify for one of those. Maybe that's the problem...

Yeah, I know. Problem is, there is no way in the world to prove or disprove that. Coincidence? Secondary to the vaccination? Sore muscles due to "old" age? All in my head? At this point, I'm leaning towards the last 2 options- I just talked to my partner and he's fine. In fact, he said he's getting ready to open a beer. Hmm... LOL

I know some places have been doing this for awhile. I wonder how much more money this really generate?

Well, so far... Talked to someone who had both the seasonal flu shot and the intranasal injection yesterday, and she is NOT doing well. She says she feels like crap, weak, achy, etc. As for me- pretty damn sore in the joints and not feeling up to snuff. Had a fairly rigorous medical day yesterday-including 2 intensive cardiac arrests and a patient in septic shock, but nothing really physical, and nothing that would explain why I'm so sore. The aching joints are also nothing I've ever felt before except when I first started working out. In other words, I guess this is what getting the flu must feel like. My regrets are beginning to stir...

Like I said, I really don't care if they show is realistic or not. It's a TV show, not a documentary. The old show biz adage is that there is no such thing as bad publicity, but in the case of something that some people assume is reality, I would question that claim. We do have bigger fish to fry- take the show for what it is- entertainment, and if it's really a bad show, it won't last long anyway- problem solved.

Huge events, and rightly so. Tons of media coverage, reporters, TV, etc. Just like any family, all the squabbles, politics, and bickering take a back seat. Very somber, very dignified, and the amazing thing to me is how many civilians want to pay their respects and attend the wake, funeral, and the processions. These processions alone can tie up traffic for miles and screw up entire neighborhoods, but few people seem to be really bothered by it. It's also a process that drags on probably longer than a "traditional" death, since it takes time to organize everything involved in putting on one of these events. As for details, there is a department liaison that works with the family and with their wishes. The family dictates their and the member's wishes, and the department abides by them. Insurance issues, death benefits, counseling, financial help, logistics with the actual wake and burial, etc- all are discussed and assisted with. Some families want a hearse, others opt for the member's assigned apparatus to carry the coffin. Of course an honor guard is arranged, bagpipers, etc. Rides for the family are arranged, taking a kid to school, help with things like shopping, making phone calls, notifications of appropriate agencies, and much more. Essentially, anything the family needs is taken care of. It's on overwhelming time for them and I think most of them they have no idea what is in store for them. They are always amazed at how many people and law enforcement, fire, military, and EMS agency representatives show up-from all over the country, and how many may have never met the person. It's a show of respect for them, their families, the member who died, and for the whole organization. Additionally, coworkers step up and do whatever is needed- shovel snow, mow grass, do household chores, pick up elderly relatives, provide meals, run errands- whatever is necessary. This process goes on long after the member is buried- the family is not forgotten. These things are obviously difficult- even if you may not know the member personally- because we are indeed a family. Lots of tears, lots of laughs and plenty of stories. At the most recent wake I attended- not line of duty- but an active member- who died suddenly, I briefly spoke with the family after paying my respects, and even though it was only an hour or so into the wake, they were stunned at the turn out, and they finally understood exactly what it means to have a second family. The line of mourners had already stretched out the door and down the block and they said that all the love and respect shown really helps them get through the process. There have been many times I've spent as much as 3 hours just standing in line, waiting to pay my respects. These things are physically and emotionally draining for all involved. You hug your kids and your family a little tighter, and appreciate them even more. Obviously, LODD's vary depending on available resources, size of the agencies involved, and the area you work in, but a show of respect is also not about numbers.

I give the guy credit for manning up and addressing the concerns that were expressed to him. Still haven't watched the show though,

OK, after repeatedly saying that I probably would not get the vaccine, I changed my mind. After weighing all the factors, and learning a few things, I took the intranasal inoculation today, although I did refuse the seasonal flu vaccine. The tipping points- Although you will shed the virus for several days after the dose, because it is an attenuated version, it is too weak to spread the disease, but it may actually impart immunity to anyone who is exposed to it. Concern about bringing home the virus to my family if exposed, even if I am OK. I have an at-risk child and wife-they both have asthma. Let's just say this: If this is another false alarm like the avian flu, I will not be happy since I NEVER get the flu. All the hysterics and warnings from the avian flue and now H1N1 will desensitize the general public for the next expected "epidemic". Even if there is a real threat in the future, I think a lot of people will simply ignore those warnings. Edit: Mods, please move this post to the appropriate forum. Sorry-

Blank staring eyes on someone who is deceased- not a problem- unless they start blinking. Just wait until that supposedly very deceased person noisily "exhales" residual air when you move them. That will get your attention. LOL

The only "compensation" we receive is Con-ed hours- no extra pay. As for how students are assigned, a more experienced preceptor may be given a "problem child" or someone who needs a strong influence. The program coordinators are generally familiar with the personalities and try to match up people based on that. The newer preceptors are often given stronger students until they become more developed as teachers. As I alluded to before, sometimes personality conflicts arise that cannot be resolved, and the student may be given to another preceptor. This is not optimum in my opinion because as we all know, we will not always like our partners, but need to make the situation work at least for that day. I do give the personality situation with a student a little slack in this regard, since it's hard enough to learn the job, and adding personality issues on top of that may be an undue hardship. They can work on the interpersonal issues later, especially since they will have to figure these things out on their own anyway. The way our program works, each student splits their time between 2 preceptors, and then returns to the original one for a final evaluation. I think this is a pretty good system- the student sees different styles of teaching, different ways of handling patients, and different personalities and hopefully picks up the best of both instructors. If one preceptor has a clash with a student, you can compare the experiences with the 2nd preceptor and see if it's the student or the instructor who needs the help.

That's what I thought about pain management. Thanks. Too bad so many areas still adhere to the old school ideas- mine certainly does. It's funny, one of the first things nurses ask these days- regardless of the chief complaint- "Are you in any pain", and then ask them to rate it. Clearly it has become a priority in an ER, but has not translated yet to the prehospital setting. As for consults, I've been out of ER's for about 10 years now, but even back then, the consult always seemed to be a formality. Then again, don't the residents need to come down anyway to evaluate if you are admitting them to their service or under their attending? Maybe it depends on the particular hospital. Then again, I worked in a busy Level 1 Trauma center so it seemed every time you turned around, there were docs of all flavors standing there. LOL

Wow. A core temp of 56 degrees and she survived? Incredible. Thus, the old adage- they are never dead until they are warm and dead.

No argument with what you say. I have noticed a "know it all" trend for many- but not all- new students over recent years, probably for the reasons you cite, and more. I don't know the answer, but as a preceptor we have no choice but to stick to our guns. Like you, I will go out of my way to ensure my students grasp what I am teaching them. I "what if" them to death- even on routine calls. "What if" the BP drops, what if their respiratory rate increases, "what if" the patient's mentation changes, etc. You can make any situation into a teaching moment if you are creative enough. I would drive the students crazy- I'd create a scenario where a simply snotty nose turned into a PE or a pneumo, but they learned. LOL I bowed out of being a preceptor for awhile because a local program was cranking out students who clearly should not have passed their didactic studies. I would give these students poor evaluations after I realized they did not have the required book knowledge and received a bunch of static for it. I would suggest the students get refreshers in their deficient areas, if they were bad enough. The program's solution: simply shift the student to another preceptor who they knew would give them a pass. They were already finished with their didactic portion of the program, took and passed their finals, and would be doing an internship with me when I realized many didn't know basic cardiology concepts, medications, or even basic pharmacology. I voiced my concerns about potential liabilities, and was essentially told this was a numbers game- if these students had a pulse, they graduated. I honestly don't know how some of them ever passed their finals, much less their state exams. (Actually, I DO know, but let's just say that politics and racial issues were involved.) Eventually enough preceptors complained to the right people, and things finally changed. I parted company with that program and refused to take on students for quite some time. Eventually they changed program directors who instilled and ENFORCED minimum standards to enter and remain in the program, and the caliber of students improved dramatically. The new directors were people I admired and trusted, and I knew they were not going to cut corners or bend to outside pressures. I was then asked to resume being a preceptor, and I gladly agreed. My bottom line before I sign off on a student- as with most preceptors, I would assume: Would I trust this person to be my partner, or to work on a family member? Until I can answer that question affirmatively, I will not pass a student.

This is a pet peeve of mine. If a BLS crew is calling for an upgrade to ALS, then clearly they are not comfortable with the patient. If it turns out after the ALS crew evaluates the patient that ALS care is truly not needed, then this is a teaching moment. Explain what is going on, ask why the crew was uncomfortable, and address their concerns. We all had to learn sometime, and nothing changes unless you take the time to teach. If the BLS crew isn't interested in learning, well that's another story, but in my experience, that is rare. Many times, a BLS crew is less experienced than their ALS counterparts, but even if they are veterans, they know less pathophysiology, have less training, and certainly have fewer options should the patient's condition deteriorate. Any ALS crew that berates a basic for calling for an upgrade needs at least an attitude adjustment, if not reeducation themselves. Think about when you were brand new- ALS or BLS- and were presented with a patient who's S&'S's were nothing like you were taught in the books. Not a pleasant situation to be in.

I'd like the doc's input on this, but I think I already know the answer. Would the fact that a patient received prehospital analgesia for unspecified abdominal pain change how that patient would be worked up? Wouldn't he still get a a full set of blood work, a UA, surgical consult, a CT, ultrasound, Xray, etc, as dictated by the patient's chief complaint? In years past, who had the biggest complaint about prehospital pain management of abdominal issues- the ER doc, or the surgeon called for the consult?

One point that is worth mentioning. As any educator knows, people learn in different ways. Some are visual learners, some learn by doing, others need notes, memorization, etc. A good preceptor needs to be aware of this and should adjust their teaching style accordingly. Yes, field training is more about clinical skills, but didactic education is part of the process as well. If you have a student that is having a tough time grasping a concept or applying what he/she has learned to a patient, then it is the responsibility of the preceptor to change tactics. Ask the student how they study- do they take copious notes, do they use mnemonics or other memory tricks, do they rewrite their notes, do they listen to a taped lecture, do they draw pictures or flow charts, etc- and adapt your teaching style to what works best for your student. Just because you learned by drinking gallons of coffee and rereading your text 10 x's it does not mean that method works for your student. I have no data to back this up, but I think these days kids are probably more visually oriented than in the past. They are bombarded with multimedia everything, and that's probably a good thing to keep in mind. They learned with flashy power point presentations complete with sounds, video clips, as well as the raw data. Anyone else agree with this, or am I out in left field here?

The only thing I would add is that if you ask for analgesic orders and are denied, make certain you ask for a reason, and verify that denial. Depending on your system, you can also voice your objection later and request that someone review that run. If it's an attending on the radio, there's probably not much you can do, but often times it may be a nurse or a resident who may need reeducation as to proper protocols for analgesics.

We were all taught that anyone with abdominal pain should not get analgesics, but I have seen a few exceptions. I've had a couple instances when it was clear someone had a kidney stone- classic symptoms, PMH of same, and we were authorized to give something for pain. Rare, but it has happened. As for other instances, we usually administer the medication per standing orders and then notify the hospital- never had a problem. Again, after moving the patient and a probably bumpy transport, pain relief is the decent thing to do. Ortho injuries are no fun. What doc said is spot on. A significant period of time can elapse from when you deliver the patient at the ER to when they finally get a bed, are registered, triaged by the nurse, had vitals taken, and been seen by maybe a med student, a resident, and then the attending. There is no reason why we can't take the edge off until the patient can get "the good stuff" in the ER. I've even administered a second dose (per orders) just before we unload the patient, in the ER bay for this very reason. If we have the means to provide this help, then why wouldn't we do it? Last week we had a 10 year old boy with 40% burns, 2nd degree, due to spilled oil. No respiratory involvement, thank gawd. I was on the radio getting the proper morphine dose from our pediatric center even before we had the IV established. This poor kid was tough but clearly hurting, and scared to death. Dad- and the patient- appreciated the relief we provided.(BTW- the transport time was only about 7-8 minutes.)