HERBIE1

Never done it, had it done to me, or even heard of this one before, BUT- I have to say, I'm 100% hetero, but this is DAMN FUNNY! LMAO

One question- are you guys serious about the alcohol in a tampon thing? I thought I had heard just about everything, but this is a new one on me. What is the point- just another way to get drunk? Better buzz? Kinky? My gawd- who thinks of these things?

Good luck on the job, and welcome. Detroit to Idaho? Talk about culture shock! LOL

In order to understand the fire service, you need to understand a bit about organizational culture, history, and how it relates to the fire service industry. Remember, the fire service was always a dirty and highly dangerous job that paid little and had few if any benefits, but over the years evolved to what it is today. First, as with any long standing profession or organization, certain established traditions and norms are passed down from one generation to the next. Some of it is functional- ie serves a purpose, and some of it is simply the way things have always been done. The hazing/indoctrination usually involved with new members, much like the military, is designed to reduce the person's identity and ensure they adapt to the group. New hires are called probies, candidates, rookies, FNG's-every department has their own vernacular, until these folks are deemed worthy of being accepted as part of the group. For obvious reasons, this bond and trust is needed- they depend on each other to keep them safe. Thus, the group must know they can trust the new member and that new person proves their worth by performing menial tasks, working hard, and keeping their eyes and ears open. Everyone participates in the shared duties, but a new guy/gal is expected to be the first to start working- polishing brass fittings, washing and waxing apparatus, maintaining tools, doing the dishes, etc- and the last one to stop. What they learn from their coworkers is just as important as what they learn in their formal firefighter training. Eventually, members feel a sense of pride in their career, their company, and the department they work for. They learn that everything they do reflects on not only themselves, but more importantly the reputations of everyone on their department- past and present. The fire service works as a team in everything they do-station chores, drills, training, and especially when fighting a fire. Once someone "passes muster" and is accepted into the group, the tradition is passed on to the next new guy. The longer any organization exists, the more culture it develops. Any company that has been around for a long time has an established and recognizable identity. Think of major corporations like IBM. It used to be known as "Big Blue", everyone dressed similarly. What about Wells Fargo- their traditions date back to the 1800's. Obviously things change, and some traditions are updated and discarded, mostly for financial expediency. Yes, much of this process is ritualistic, but it does have a purpose. Are there other ways to become a part of a group- sure, but barring any better ideas, this process will continue for the foreseeable future in the fire service. Can EMS learn from the fire service- yes, if we are willing, but we also need to stop making unnecessary comparisons to the fire service. Problem is, it will take time to develop the same history. In the grande scheme of things, EMS is still young. Traditions are developing, but as we know, it is a constant battle for pay, benefits, recognition, autonomy, and respect. I know it's not a popular opinion, but I don't know if we will ever develop to the point where we become the fully functional, independent entity we want to be. The trend is for EMS to be incorporated into another group- not the other way around. Many times I think we spend more time worrying about outside influences, and factors we cannot easily control, then we do developing our own sense of identity. In today's world, everyone is being told to do more with less, and since so many areas have already absorbed EMS into the fire service, it's pretty hard to go back from there. I suspect the changes we seek will have to be done from within such an overarching framework, which will not be an easy task. Optimally, we should continue to be proud of what we do, become the best professional we can, and do what we love to do. In many cases, we know that is a very difficult assignment, and fighting an uphill battle, but then again, nobody got into this business to get rich and retire early. LOL

Thank you for explaining what a "time out" is- it's been a few years since I have worked in a hospital. I had never heard the term before, but heard of the practice. I had no idea that JHACO had made this a requirement. Like you said though, in a busy ER setting, it doesn't always seem like it would be practical.

Probably a US Congressman. LOL:whistle:

When he said interview for a job, I assumed he was finished with schooling. No license yet, then I agree- you are absolutely correct. Don't beat yourself up too much- you were not in charge. Look at it as a learning experience as how NOT to handle a similar case in the future. Every one of us has been on many calls where we question our actions or inactions. You don't learn unless you ask questions, and anyone who claims to have never made a mistake on a call is either a liar or a fool. You are wise to be fearful of that crew leader- he/she sounds dangerous. It's one thing to not have essential or enough information to make an informed and accurate decision, but it seems like everything you needed to know was there. There should have been no question what needed to be done. Questioning, doing QA's and brainstorming only makes you a better provider. Here's a little tip-always assume that the incident you are involved with could be a potential lawsuit and act accordingly. As doc says, anyone can be sued for anything, and if you are in this business long enough, you WILL be involved in the legal process. If you do your job correctly, hopefully it's only as a witness, and not as a defendant. Bottom line- document every call as if a lawyer will be reviewing everything you do, because some day, it WILL happen.

YOu have a point about job duties, Richard. I am amused when people actually see what we are capable of doing, the type of equipment we carry, etc- generally when they have had no prior experience with EMS. We had a call in a doctor's office for a hypotensive and bradycardic cardiac patient who we proceeded to evaluate and eventually pace. The doctor: I had no idea you guys were capable of doing this". Of course, you still get the occasional old school doc who simply wants a taxi ride for his patient having a massive MI, but thankfully those guys are far fewer these days.

Agree with everyone. The fact that he admitted to taking 20 ASA, that is well beyond anything therapeutic, and even though it may have only been a suicidal "gesture", the end result could be the real deal. Couple that with the ETOH and he is NOT a competent patient to refuse. I agree with getting supervisors involved- both PD and your own. Advise medical control, and make it clear the patient is going one way or another. Years ago I had a young woman who "only" took a bunch of Tylenols-thinking they were harmless because they were OTC. Her OD was aimed at getting back at her cheating boyfriend, and she claimed she didn't really want to hurt herself. We transported her and I later heard her liver was failing and she would probably need a transplant. Pretty severe consequences for someone who didn't really mean to hurt herself. If the situation was clearly explained to the LEO's- as in, as the doc stated, the problems with ASA OD's that will crop up later, AND the fact that you have no idea what else this guy took- recreational drugs or RX's, this is a lawsuit waiting to happen, I'm guessing they might have felt differently about taking him into protective custody. Emphasize that he is NOT legally capable of refusing. I realize that being a rider puts you in a tough spot but God forbid if this guy decides to finish the job by some other method , you are on the hook as much as the people who were getting paid to be there. One question- Any idea who made the original call for help for EMS and/or PD?

"3. After treatment was administered, the patient would refuse." There are tons of reasons why we do what we do, when we do them and how we do them- all perfectly legit and within the boundaries that are set for us. We make judgment calls all day long- some bigger than others. When we triage multiple victims, are we not making moral as well as medical judgments- all well within the parameters set forth by medical control? I think you are parsing words here and isolating a particular phrase out of context. If a person's primary issue is an altered mental status, and they are otherwise stable( not pulesless and apneic), then I submit that the slight delay is not a significant risk considering the benefits that could be gained by getting this person to definitive care- beyond the medical interventions they need. This is not delaying treatment on a cardiac arrest until you are sure of their DNR status. He assumed the patient would refuse based on previous encounters. That is by no means a 100% guarantee, and it didn't happen yet. As for a delay in treatment, what type of delay are we talking about here- 30 seconds, a minute? What if the patient was combative and you needed to restrain them before attempting interventions- there would also be a "delay" in treatment, wouldn't there? We all know that a lawyer can make a mountain out of a molehill, but if what you are doing is erring on the side of a patient, I honestly see no problem here and that is a "risk" I'll take every time. If you are delaying treatment because you are too lazy, or it's too inconvenient to transport, that is a whole different ballgame.

I disagree. The original scenario said that this person's home life was such that he had no support system at home. I don't know the specifics of his other medical issues, but for many people- especially the elderly and infirm, managing their illnesses involves more than just themselves. What if this person had trouble getting to the store to purchase adequate and appropriate food and medical supplies to manage their condition? Does that make them incompetent, negligent, or incapable of caring for themselves, or does it mean that his support system is either incapable or refuses to provide that assistance to help the patient? Is it inappropriate to get this person a helper, for example, to assist them in managing their daily tasks? If this prevents them from repeated hypoglycemic episodes with all the problems that creates, and trips to the hospital, isn't that a good thing? It sounds like the only way this could happen would be from an external push from a social service agency, facilitated by a worker in the hospital. You are putting the cart before the horse here. How do you know for certain that this person WILL refuse transport, even though this is their pattern of behaviuor in the past? Nobody is clairvoyant, although we may have a good idea what will probably happen, but the only assumption we can legally make is to provide treatment and transport for the incompetent or minor patients. Any other assumptions are the result of a personal bias or opinion, and that is a dangerous route to take. What about the chronic alcoholic who "ALWAYS" gets released from the ER with instructions to stop drinking, and with referrals to substance abuse counseling? Does the hospital stop giving him those discharge instructions because they "KNOW" the person will never comply? What if the one time this person is NOT provided with these referrals is finally the time they decide to stop drinking, yet the prospect of finding that help is too much effort, so they simply decide it's easier to go back to the store and buy another bottle? Trust me, I'm no bleeding heart, but in this case, I think Dwayne did an honorable thing and in reality, it was nothing more than a minor adjustment of what he was supposed to do anyway. In the end, nothing may change for that patient, but at least Dwayne took the extra step and was an advocate for his patient. I see no moral, ethical, or legal conflict here and I cannot imagine anyone in a position of authority(medical or legal) would fault him for his actions.

Very interesting take. I agree with your assessment about folks who want black and white answers not necessarily being right for this profession. I guess you never really know how an employee will fare in this business. Sometimes you make the right call, sometimes not. I think I related this story before but it bears repeating. When I was in management, I remember getting an application from a guy who had served time in prison for robbery. He had all the right credentials, glowing references, went to a good EMT school, etc, and I put his application aside for further consideration. Meantime, the guy called to follow up with me- did I get the application, is it complete, did I need anything else from him, etc? I even received a call from one of his references who was very supportive of this guy. I liked his persistence, professionalism, and diligence and I decided to bring him in for an interview. He was up front about his prison time, I expressed my concerns about it and he understood. The interview went very well. I went to the owner of the company, and to make a long story short, we fought for several weeks before I was finally allowed to hire him. Turned out he was one of the best employees I could have ever asked for. I gloated on a regular basis to my boss about my "wisdom" in pushing for the guy. LOL I think the interview process makes a big difference too- you also need to have a 6th sense about people to gauge their personality, their motivation, and any potential pitfalls you may see. Sometimes you are right, sometimes you are dead wrong, but you would hope that before someone invests the time, money, and effort into a career- especially a new one- they fully check out what they are getting into, and if it's a good fit for them. As we all know, that does not always happen and many people wash out very early on in their careers.

I recall a study years ago that stated any more than 13 calls in a shift is too many. Mental acuity suffers, mistakes become more common, and it's simply not good for your health. That said, as several people have mentioned, it depends HEAVILY on your situation. Urban or rural? Long transport times or less than 10 minutes? What type of assistance do you get? 2 man crews or 3? All paramedic providers, all BLS, or EMTB with EMTP? Except when I first started years ago as an EMTB, I've only worked 24 hour shifts, with various amounts of time off in between shift days. As anyone in a busy urban system can attest, your run totals can easily be 20-30 calls in 24 hours. This call volume can and will take a toll on your body over time-even if you get used to the platoon schedule, and it is certainly not optimal for your patients. Yes, the vast majority of calls are nothing that taxes your skills or your brain, but what happens with that complicated cardiac call at 3AM, when you are on call number 22 for the day? Is your patient getting the best care possible? Even doctors during their residency have had their schedules cut back for fear of medical mistakes. It is long past the time when we need to do the same for EMS, but as always, this is about money, politics, and now, a bad economy. Everyone is being asked to do more with less, so the notion of easing some of the workload is probably still a pipe dream at this point.

I'm with you here. Our protocols don't specifically address living conditions as a contraindication to a refusal, but they are addressed as part of our elderly abuse/neglect guidelines. We are required to make proper notifications- even if the person does not wish to be transported and are competent- regardless of the reason we were called. I know that I- and several others here- have been chastised for not taking the extra step for our patients. Recall threads on abuse of the system by the homeless, chronic ETOH'ers, and how some feel we should be doing more than simply picking them up and dropping them off at an ER countless times. Now it seems some are accusing Dwayne of overstepping his authority and "assuming" his patient would be better served by delaying his treatment until they were transporting him after his hypoglycemic episode. This act of compassion requires no extra phone calls, no notifications to external organizations, other than a notification to the ER of this patient's social issues at home. Seems like a win/win to me- patient gets required care AND at the very least, a chance to change the problems at home that surely contribute to their inability to manage, regulate and monitor their medical condition.

It doesn't matter what the patient's mental status becomes AFTER treatment, it's what you see when you arrive, so like all patients, you assume they want to be treated as well as transported. Even on diabetics, I never look at them as a potential refusal, even though it may be quite likely. If they are unresponsive/incompetent when you arrive, you do what's in the best interests of the patient. You cannot presume to KNOW what they will want later. I've had patients surprise me AND their family who SWEAR the person will refuse when we wake them up and they decide to go to the ER. Yes, their glucose level may be back to normal, but who knows how they will feel after they wake up? Will they wake up with chest pain, abdominal pain, or some other complaint? Yes, multiple incidents with the same patient in the same situation and chances are you are right on target with your assumptions, but there are no guarantees. Part of the reason we allow patients to refuse is that they have a support system, and will comply with your instructions. In the case of a patient in poor living conditions and poor support, there is a good chance they will not or cannot comply with your directions. Is it wrong then to transport them to a place that may be able to get them the social services they need to be able to take proper care of themselves? Treating the medical part is easy- getting them the social service assistance is far more difficult- even in the hospital. Ensuring they receive those services at home is even harder. Getting them to accept that help may be another issue too, but you do the best you can. I see nothing unethical in what Dwayne did. In fact, I see the opposite- he went the extra mile for his patient.

I agree that when a patient survives to discharge without deficits, it is the ultimate indication of a save, but it is NOT the only positive outcome. Let's say we get a person back, they survive long enough for the family to maybe come in from out of town to say their good byes. Hugely important for some people to be able to properly start their grieving process. Also, organ donation is a possibility-even just corneas and bone grafts.

Does that also apply to a doc that needs to do a cut down on a patient with poor peripheral veins? So if a person provided you with a perfectly rational reason for why their glucose level dropped(ie they fell asleep early because they were tired and missed their dinner or late night snack), you simply dismiss what they are telling you? Remember, when this person's levels return to normal, they are fully alert, oriented, and competent to sign a release if they so choose,provided there are no other factors involved. You give them options, explain potential problems, advise them to eat, and let THEM make the decision. I'm more than happy to take someone, but I also don't feel compelled to strong arm someone- especially a life long diabetic- to be transported. They KNOW what to do and have heard it all before. The most logical person they need to see is their endocrinologist or GP- they are most familiar with their patient, their diet, any compliance issues, and any trends the patient has with the management of their disease. In the case of a new diabetic, someone who is very brittle, or I suspect is not telling us the whole story, I always urge them to allow transport and do my best to scare them into it, if necessary.

I'll echo that comment about missing the same parts of a show or movie multiple times- especially before we could so easily record things we want to see. These days, thankfully we have TIVO or a similar device so we can go back and watch them at our leisure. I guess that's one of the major benefits of being a fireman- they generally have plenty of time to see entire movies, entire ball games, and take incredibly long and uninterrupted naps.

The issues I have here are with femoral pulse check and "CPR adequacy". If you define this "adequacy" as simply a ROSC or oxygenation, then stats and studies would be appropriate. Prehospitally, if you are looking to see if the compressions being done are effectively-as in depth and rate, then anecdotal evidence is essentially all you can expect. I am well aware about the efficiency of CPR, but again, I look at this from a practical standpoint. In a code room in an ER(with respiratory techs, docs, students, nurses, etc- it's pretty crowded. People are pushing meds from peripheral IV ports, doing ventilations, checking BP's, doing compressions- all on the upper half of the patient. Thus, the least crowded location is the lower half of the patient, thus the femoral area is a good place to verify compressions. Same with prehospital- it gets pretty crowded in the back of a rig. I tend to take a pragmatic approach to prehospital care. We improvise, adapt, and do what needs to be done since much of what we see and do is not in the books or any table of stats. Learning the skills in this business is the easy part- knowing the proper place to apply them takes time. I'll leave the discussion relating to a in-hospital, critical care setting to someone else. As for background- 30 years in EMS. Worked in ER's and level 1 trauma centers for 15 years. Volunteered, did disaster assessment, special events, Worked as a preceptor, management, administration. Masters degree, teach university level classes, teach EMT's and paramedics. All star credentials- nope, but adequate to make a few observations.

Yeah doc, more room would be nice- I can't tell you how many times the heart lung bypass machine gets in the way. It simply takes up too much room. I'm all for technology when appropriate but prehospital, I think sometimes we rely too heavily on what a machine or electronic device tells us. Look at the patient- simple assessments can tell us so much- skin parameters, lungs, V/S, cap refill- all can paint a better overall picture and are fast and easy to obtain. It's akin to one of the first things we are taught in cardiology- when the "machine" tells you the patient is in V-fib but they are awake and talking to you, your first treatment is checking leads and not grabbing for the paddles. I see it in many of my students- they are so infatuated with their new skills that they sometimes forget about the basics, but I think we've all been there. For one "nonbeliever", he was so anxious to intubate, that he didn't even realize that our cardiac arrest had a ROSC and was waking up.

Tons of smart alec responses come to mind, but... Depends heavily on the type of service you work for. Volunteer- you may be at home, at another job and respond when on call. Paid- you may drill, check out the rig, study, clean, etc. You may be assigned to hold an area- sit in your rig in a fixed location until you are needed. If you are fire based you may return to the fire house. Private- you may hold an area, have a HQ or garage. You also may be hospital based and function as a tech in that hospital's ER until you are needed. In busier areas, you may run back to back calls your entire shift-there is essentially no down time. You need to do some homework as to what types of services are in your area, or the location you intend to work in. Good luck.

I'll echo the comments about keeping a strong core and strong abdominals. HUGELY important. You could have the strongest back in the world, but unless your core is solid, you will be in trouble. As anyone in the business can attest, back problems are almost a given if you do this for any length of time or frequency. As for sleep schedules, it can be tough to get used to, and some people never really adjust. It also depends on the length of your shift- 8, 10, 12, or 24 hours, as well as the time off between shifts. Does your area stay with permanent shifts or do you rotate days, to PM's to nights? Ask around in your area, check on the volume of calls, how much help, and what type you get if you need it. Good luck- but be careful- this business gets in your blood like a drug.

Pretty interesting- and arrogant- assumption, isn't it? Based on the responses here, it would seem that many folks have training far beyond the "average 911 paramedic" provider. Problem is, unless I'm wrong, the original poster seemed to be asking what we can do PREHOSPITAL to assess the efficacy of CPR. Quantitatively we are limited in our measurements and methods, but there are also qualitative methods to gauge how the patient is responding. Things like ABG's, arterial pressures, and ICP's are nice, but I seem to have misplaced the triple lumen kits in the rig...

New or not to the business, you already have the right attitude. NOBODY is too old to learn, and the only way you do learn is by asking questions when you don't know something. It's much better to say "I' don't know", than to do something wrong because you are too proud to ask a question. QA- and any post call analysis- is crucial-even on an informal basis. Obviously you need to be up to speed on your basic knowledge and skills but as you will soon learn, if you already haven't, as soon as you think you've seen it all, something throws you for a loop. Good luck.

The cultural component is huge. Obviously in some religions there are very strict taboos about what a person can and cannot do. The muslim head wear is a huge issue in some circles, and unless the person's complaint is related to the head, I see no reason why we need to force them to unveil. I recently had a muslim woman who was in early labor, and we were simply providing routine care. As I went to apply the nasal cannula, I realized her ears were not exposed because of her scarf. I was going to put a mask on her or tape down the cannula, when she saw my issue. Before I could say anything she ripped off her head scarf and allowed me access to her ears. I told her she didn't need to do that but she said- "Do what you need to do- it's OK, I know you are trying to help me." I'm not sure how pleased the husband was after he saw her at the ER, but the patient is the one you are legally bound to listen to and treat. Another situation I had was also an OB who was actually crowning as we arrived. Delivering a baby with your eyes closed is probably not a good idea, so as I was checking the patient, I realized the family was clearly Muslim, as evidenced by an Arabic TV show in the background, the language the family was speaking and the traditional dress of everyone except our patient, who was in her PJ's. By this time the woman already was in bed with her legs up and I was grabbing the OB kit. I saw the husband and thought that if I involved him in some way, I could avert any potential problems. I had him grab a couple pillows and blankets, and as the baby was born, I asked if he wanted to cut the cord. His eyes got real big, but he agreed. Everything went fine, the baby delivered, and I clamped the cord for him. I handed him the scalpel, and showed him where to cut. He was so happy to have a healthy baby, he never seemed at all upset, and he thanked us profusely. Every situation is different and you need to feel out the attitudes of the patient and the family as soon as you arrive on the scene. Experience will guide you as to how you need to proceed. If you run into a problem, I would clearly explain why you need to expose something or do what you need to do, have a member of their family present, and if they or the family still refuse, advise your medical control, document this fact and have them sign off on it. The argument or problem is NOT worth the hassle, and in the vast majority of cases, it won't really affect a patient's condition.