HERBIE1

Basically true. Actually, on a cellular level, rigor occurs when the ATP(the compound muscles use to contract) is not released. You need energy to release that chemical bond and in death, that energy does not exist, thus rigor. A funeral director once told me the first muscles to begin to stiffen are actually the jaw muscles.

Unclear. Depends on the system since in some areas, the only transport crews are private providers, so they would be the only people LEOs would deal with. It's called professional courtesy. If- and it's a big IF- the driver actually flipped off the cop, the cop could have lodged a complaint with the company, confronted the person later, or both. This cop clearly got his feathers ruffled and he screwed up. BIG TIME. I wonder what the cop does for John Q Public that fails to yield to him if he has no problem pulling over and hassling an ambulance crew?

Transport the child- regardless. Hospitals have the required social services and clergy, etc to deal with a very difficult situation like this. Let them rule out any possible foul play- shaken baby syndrome, abuse, neglect, etc. The parents need to know that everything possible was done for their child and in most cases, merely transporting the child is better than leaving the baby in the home. Don't give the family false hope-explain the probable outcome, but make the effort. Unless it's clearly a crime scene, even with lividity and rigor, bring the child in, and notify the hospital of what you have. A deceased infant is a special circumstance which is not something you learn from a book. Emotions run high for the family and the rescuers in these cases.

Welcome!

The crew should be fired? How about letting the punishment fit the crime? They made a mistake. A stupid and totally unnecessary mistake, but that was all it was. Let it cost them time off, reeducation, and I promise they(and their coworkers) will get the message- it will never happen to this crew again.

LMAO Seems like he was harmless, but clearly the guy needs a stay at the laughing academy for awhile. As far as being threatening or menacing- that's a pretty subjective thing. I guess it depends on what the guy said to people. Simply sitting there, wearing that bathing suit is certainly weird, but it doesn't seem to rise to the level of criminal behavior. Gawd knows if we locked up all the people around here that are half a bubble off, the jails wouldn't have room for anyone else, (nor would there be anyone left to do prehospital care...)

Cool idea for a special student, spouse, friend, or a partner. I certainly wouldn't use it at work- been known to lose a few pens. Personally, I now prefer using the Gel-type pens because I like the way they write, and since we use a lap top for our PCR's I don't need to worry about bearing down to make 6 copies of the report. The smoothness and flow of the ink is like an expensive Cross pen, at a fraction of the cost.

LMAO That's one of the funniest videos I've seen in a long time. Thanks for the belly laugh.

I agree that the potential benefits would be more for a rural area and a long transport time. Problem is, I would hate to be the one who has to "decide" whether or not to transport to a Level 1 based on the findings of an US exam. I would think that like any skill, you would need to be pretty darn proficient in not only your technique to obtain a quality study, but your ability to interpret the results. Like was mentioned, that would mean using the device on multiple patients to keep you sharp. As you mentioned, by the time you could see fluid/air/blood on an US, wouldn't the person already be exhibiting signs of an internal injury and warrant a trip to a trauma center or you would already suspect such a problem based on MOI? I'm also am certainly no expert on US- I could barely make out pictures of my unborn kids much less an internal bleed. LOL

An inverted KED for a pelvic fx? Interesting. I never heard of that before. I have never actually used a KED in a strictly auto accident setting- the method I was trained for. I have used it to immobilize guys who fell into elevator shafts or holes- works great for that. I've used a KED/long board for immobilizing infants many times- akin to the "Papoose board" used to keep kids still in an ER. Works great- the kids don't move at all. Thanks for the tip- I'll need to consider the KED the next time we have a pelvic fx.

Again- I'm not debating the merits of what these medics are asking for. The issue is, if the area has been doing without adequate EMS coverage for this long, for the standpoint of "management", I'm guessing their opinion is they can do without it at all. Who is picking up the slack and providing care- ie nonunion providers, and if so, how many are there? Obviously I'm playing devils advocate here- that's all I can do without knowing a lot more details. This is a classic labor/management issue, and it's up to each provider to decide what's best for them. It's great to take a stand on something but if you have a family, they must come first and do what's best for them. If someone chooses to pick up and leave, that's their business. I'm not equating sports with medical care, but some years ago, we had a football strike here and the owners simply hired replacement players to play for them. From a management standpoint, if they can hire "scabs" and not meet the demands of the strikers, that is exactly what they will do. Unless the medics can generate enough public sympathy- and in our business, PR is not our strong suit-I'm afraid that management has the upper hand here. I wish them luck, but I think they also need to be realistic as to their expectations.

Well, after being on both sides of the labor/management issue, I think I am qualified to make a couple observations. First, I will not debate the specifics of the issues- it's not my fight, but I will always advocate for more money. Too many in this profession make a pittance, compared to what their job responsibilities are. The problem with any job action is you need to know what is at stake BEFORE you make a move. If there has been no movement in 2 months on this, then clearly the providers are not in a very strong bargaining position. In a nutshell, I think the providers need to reassess their goals or they can very easily need to find a new career. Strikes may be necessary in some cases, but there are very real consequences. The hard feelings, animosity, distrust, and angst never really go away and do a great deal of harm to the organizations involved.

I think you need to provide more information. What is the number of employees and their level of certification? What are the manning requirements- ie-1 EMTP/1EMTB? Are there contractual issues that mandate work schedules, vacations, time off, comp time, etc. I don't know if a pat formula would be the best idea- maybe I'm wrong.

Based on the abstract, I am inferring that because the patient received the steroids sooner, they did not decompensate as much as if the treatment was administered in the ER, they stabilized quicker, and their rates of admission were less. Intuitively, this makes sense-more aggressive treatment would mean a better outcome for the patient. Although the study excluded COPD'ers and smokers, in my system we have more than enough patients who merely have asthma with no other complicating diseases so I would like to see this implemented here. To me, this seems like the current trend- more prehospital care vs waiting until the patient arrives in the ER. Because of the inherent intertia of providing most ER care, for example, we can provide analegesics to a patient sooner- vs getting triaged, registered, seen by a nurse, seen by an MD, awaiting orders and administering the pain medication. On a slight tangent, a few years ago we began using a combination of atrovent and albuterol in COPD patients, knowing that unless we have an extended transport time, the benefits of the atrovent will generally be seen after the patient arrives at the emergency room. Thus, my question is- is the wave of the future providing treatment that is more beneficial to the patient in the long term vs simply emergency mitigation and stabilization? If so, that means that our scope of practice will rapidly expand whether we like it or not. I have no problem with that, as our roles have been evolving at an exponential rate over recent years anyway.

LMAO Talk about full circle. Funeral homes are where many ambulance services got their start.

We have no specific guidelines but have given the Benadryl many times in such cases. I simply describe the symptoms and ask for the Benadryl. Works every time. Luckily, the worst that can happen if it does not work is a sleepy patient.

Either you work in a progressive system that allows you to make that determination, or you are playing with fire. I'm thinking the former. The skills needed to clinically clear a C-spine aren't difficult to learn, but then again, we work under someone else's license so if we make a mistake, they will need to answer for it as well as the provider.

I've been a member here for years, lurked occasionally, but never posted until recently. I am impressed by the breadth of talent, the far flung locations people hail from, and the range of education, ages, and provider levels. We have everything from volunteers to MD's here and everyone brings something different and valuable to the table. I like the idea of getting unique perspectives on problems many of us face. I think too often we get wrapped up in our own little worlds and fail to see the commonalities of what we do. Are there differences in how we operate, how we provide care, and the trials we face- absolutely, but it seems most here are generally fixed on helping each other and the people we respond to for care. Here's a hearty golf clap for the site admins and all those who make this place happen.

Again-if you are a student, ask your instructor or preceptor. If not, check with your state regulatory agency- Department of Public Health?

As anyone who works in a ghetto can attest, there are similar examples of stellar parenting everywhere you look. 2AM in the ghetto looks like high noon in downtown Manhattan- toddlers just hanging out while their parents party their arses off. We call it GST(Ghetto Standard Time)- Ghost towns until at least noon.

At your next class, ask your instructor.

Unless it's an obvious DOA-decomposition, decapitation, lividity/rigor, etc, our protocol says you must use a monitor to confirm DOA. As for multiple victims in a trauma situation, then obviously impending death is treated as a black. Clearly, if you are the only crew on scene, and the next available units are nowhere close, then 2 critical patients could overwhelm your resources. Point is, everyone's situation is different, and your actions depend on your specific resources. I am in a high volume urban area with plenty of resources available in all but the largest incidents, and I have never left a "nearly dead" patient(ie agonal resps) without attempting treatment. Futile most of the time- yes, but that is our protocol. If they show signs of life, they are worked. Obviously, in a trauma scenario, a cardiac rythm is not the first thing you worry about, but if you want to confirm DOA, that is the only way to prevent pronouncing someone who is not yet deceased. Do I hook up every traumatic arrest? Only if I am working them up and transporting.

I can understand all the portable devices, but I am still amazed at the complicated devices- like the VAD- that are used at home now. Good point about the presentation of a seemingly "normal" patient. Thanks to modern medicine, kids routinely survive conditions that would have been fatal just a few years ago. A child could easily present with a bundle branch block or other abnormality usually seen in older folks. To the point of not adequately assessing someone... I've almost been fooled by patients who I thought were dead- especially those at crime scenes. We had a drug deal/ robbery gone bad where victim #1 was on his hands and knees, bound- hands and feet- and had his neck sliced from ear to ear, getting each carotid in the process. Messy. We confirmed he was DOA, (pulse, auscultation, and EKG) and then found another victim- a female with the same injury, only she was sitting up, propped against a door. She also had that ghastly shade of pale/grey that means she probably lost most of her blood volume. As I approached to check her carotid, she opened her eyes, picked up her head, and attempted to speak. We had a nice anatomy lesson as we could see all the internal structures of her anterior neck. I nearly had an MI myself and think I wet myself a little. After working her, the best we could get was a 60 systolic BP after nearly 3 liters of LR(before we were using .9% saline). She made it to surgery but I read in the paper that she died in the OR. Point is, it takes no time to confirm the DOA with a monitor. I also find that in all but the most obvious cases of severe decomposition, placing the leads on someone and showing the family Asystole, I think it demystifies and confirms your claim that there is nothing you can do for the person, and helps the family start their grieving process. Most people know that "flatline" is NOT a good thing. Also, it keeps "mistakes" like missing a bradycardic rate- from occurring.

This study was done in 2008 by the Mayo clinic and published this year: http://www.pubmedcentral.nih.gov/articlere...i?artid=2672978 This is the conclusion of this study: This spinal immobilization guideline demonstrates efficacy in identifying those at risk for spinal fractures. The guideline accurately identified all cervical fractures found in this study. The use of an age-extreme criterion may enhance this already effective guideline. Further analysis of compliance failures may add to the guideline's ability to predict fractures.More than 20% (9/42) of patients who had spinal fractures found in this study had indications for immobilization, but it was not performed by ambulance staff. Continual training and regular case review with quality assurance programs should frequently evaluate spinal clearance guidelines. Quality assurance, patient follow-up, and audit systems may improve compliance. It is imperative that ambulance systems monitor and continually review this guideline and train for its application. This is another study, published in the Journal of Trauma, Injury, Infection, and Critical Care in 2005... I have the full study, but no longer have online access to the complete article. Sorry, but my scanner is down or I would scan this article for you guys This is a citation for the study and abstract: BACKGROUND: To evaluate the practices and outcomes associated with a statewide, emergency medical services (EMS) protocol for trauma patient spine assessment and selective patient immobilization. METHODS: An EMS spine assessment protocol was instituted on July 1, 2002 for all EMS providers in the state of Maine. Spine immobilization decisions were prospectively collected with EMS encounter data. Prehospital patient data were linked to a statewide hospital database that included all patients treated for spine fracture during the 12-month period following the spine assessment protocol implementation. Incidence of spine fractures among EMS-assessed trauma patients and the correlation between EMS spine immobilization decisions and the presence of spine fractures-stable and unstable-were the primary investigational outcomes. RESULTS: There were 207,545 EMS encounters during the study period, including 31,885 transports to an emergency department for acute trauma-related illness. For this cohort, there were 12,988 (41%) patients transported with EMS spine immobilization. Linkage of EMS and hospital data revealed 154 acute spine fracture patients; 20 (13.0%) transported without EMS-reported spine immobilization interventions. This nonimmobilized group included 19 stable spine fractures and one unstable thoracic spine injury. The protocol sensitivity for immobilization of any acute spine fracture was 87.0% (95% confidence interval [CI], 81.7-92.3) with a negative predictive value of 99.9% (95% CI, 99.8-100). CONCLUSIONS: The use of this statewide EMS spine assessment protocol resulted in one nonimmobilized, unstable spine fracture patient in approximately 32,000 trauma encounters. Presence of the protocol affected a decision not to immobilize greater than half of all EMS-assessed trauma patients. Burton JH, Dunn MG, Harmon NR, Hermanson TA, and Bradshaw JR The Journal of trauma 61(1):161-7, 2006 Jul - Who cited this? | PubMed ID: 16832265 | Fulltext This is the final paragraph of the discussion, from the full study: In summary, the use of prehospital EMS spine assessment protocol affected a decision not to immobilize greater than half of all trauma patients in this predominantly rural state. The presence and accuracy of this EMS protocol did not appear to place trauma patients at substantial risk of adverse neurological outcome as a direct consequence of the selective patient spine immobilization decision. Thus, it seems the selective use of full C-spine precautions is a safe and valid idea -as long as proper protocols and training are provided. To me, and to any provider that's been doing this for awhile, I think we know when there is a potential for a serious spinal injury based on MOI, exam, or PMH. I can count exactly ONE patient in 30 years who had a C-spine injury that I did not suspect based on his exam or MOI. It was a 60ish man who tripped and fell, sustaining a small head lac. He was ambulatory, with no other complaints or injuries. He simply wanted a bandaid and to go home. For some reason, I chose to fully immobilize this guy(listen to that inner voice, folks)-much to the amazement of my partner and a nurse bystander- and delivered him to the closest ER (BLS)- which happened to be a Level 1 Trauma center. Later that day, the attending trauma surgeon(who I know very well) pulled me over to an Xray viewing box to see something. Of course, being paranoid, I wondered what we had done wrong. LOL She showed me a nasty looking dislocation/fx of C2-C3 I think- and said it was from my little old man. After I picked up my jaw from the floor, I asked how he was doing. No deficits, he would probably get a halo and would be fine. She gave us an "atta boy" and asked why we had initially immobilized him, based on his MOI and exam. I said I honestly did not know, but am certainly glad we did. Bottom line- I think we can all agree that a complaint of neck pain after being rear ended at 5MPH should not mandate a full immobilization, and we are finally seeing data to back that up. Experience, education and training(along with a solid protocol) and applying that to patient care is what this business is all about.

We were just notified of someone in our area who has a VAD, and that they should have trained personnel with them at all times who are aware of it's function. It's a private residence, and it seems they are in pretty fragile health, so we may need to deal with them. We received brief instructions as to where we should defib PRN, the fact that we will feel no peripheral pulses with the device, etc, but a few of us are requesting more info on this. I don't know how common these devices will become- at least in the prehospital setting- but I am truly amazed at the technology/equipment that used to be reserved for ICU's is being used at home. Internal defibrillators, PIC lines, home dialysis machines- just a few years ago we would have never seen these things in the field. What's next- a home heart/lung bypass machine?