HERBIE1

Good topic. We are just starting with this protocol now. (Yeah, I know-our system isn't exactly on the cutting edge) I find it interesting that prior to roll out of the EZ IO, we saw a refresher DVD from the manufacturer that indicated the Lidocaine flush, but our protocols and initial training do NOT call for it- just the 10cc's of saline to create a space for the infusion. Maybe at some point we will adopt the Lidocaine flush, but we'll see. I've done a couple IO's the old fashioned way- always in peds arrests, and it was a brutal and barbaric process- manual insertion, so I'm happy for this new device. Our protocols are for patients in extremis- no specific glasgow-like impending arrest, unstable traumas, or anytime IV access is not only indicated but NEEDED, etc. I do know that the pressure bag/BP cuff is mandatory- gravity flow will NOT work-there is simply too much resistance. I'm not second guessing anyone here either(Monday morning QB's are a pain) but unless the patient is status epilepticus and decreasing O2 sats, if I needed to push Valium, I would probably go the IM route if IV access is not possible. Yes, it takes a bit longer to metabolize, but will still work, and as long as the patient is not critical, the delay won't be much of an issue. All you IO experts- keep those comments coming- I'm sucking all this info up like a sponge.

Welcome to the business and welcome to the board!

OK- I'll play: These are guesses since we have nearly 6K employees 1)- approx 30% 2) approx 40%- rest Hispanic, Asian, NAtive American, etc 3) approx 30% 4) 1- Bi-racial LIke in the story, every entrance exam and promotional exam is challenged herebecause not enough minorities score well enough. Even with quotas and tests designed by an expert in making race neutral exams- there is never enough minority representation. So- either racism is responsible, or there is something else going on. SO what does this prove? NOTHING. What is the racial makeup of your area? Nationwide, only about 13% of our population is black, which means there are large areas with NO minorities. That's just the way the numbers work out- sorry. Problem is, we have overarching, all encompassing things like affirmative action, quotas, and other set asides that apply across the board- regardless of the demographics in your area. A few years ago, we had a small manufacturing company here with 30-40 employees- which was 100% minority- all Hispanic. A black man wanted a job there, they had no openings, but he filed a suit saying the company discriminated against him. The courts agreed, told the owner he must comply and hire x number of blacks, but could not get enough applicants to fill out the quota. He closed his doors. So now instead of having 40 minorities in his business, he was told he didn't have the right "type" of minorities and everyone was out of a job. Is this the type of "equity" you are looking for? The beauty of the "slavery is responsible for the ills in the black community" idea is that it will never end. You cannot change the past- and even INTENTIONALLY using reverse discrimination to address these past wrongs, it's not enough to "even the score". Institutional racism can no longer be a valid excuse when the system provides things like set asides, affirmative action, and race neutral exams to combat this problem. There are even civil and financial penalties for NOT complying with these laws. There are activist groups, community groups, state, local, and federal organizations to monitor real and perceived breaches to these laws. So now what? What more should we do as a nation?

Not arguing that point, but I disagreed with the notion that just because a doctor isn't our medical control, his opinions are irrelevant. I said before, you don't want to get into these situations, but in our case, our "medical control" can be anyone from an RN to a 1st year resident. As such, we can get some outrageous "orders" from these residents- they may ask for treatment, drugs, or procedures that we do not have-often they are not familiar with our protocols, and I would be leery of having them handle an unusual case such as this. Point being, you still need to have your act together because for us, it is rare to ever have our actual medical directors on the radio. Just because someone is an MD, that does NOT mean their advice is always golden- you also need to have common sense and do what's proper and in the patient's best interests.

No offense intended. I'm not calling your age into question, your knowledge, nor your abilities. You are missing my point. What I was saying is that one's perceptions, attitudes, and ideas change as you progress throughout your career. The skills we practice are the easy part- they can be taught. Knowing the subtleties of the job, how to handle certain situations- that's what takes time. I'm not saying we make poor decisions early on, but when we are presented with one of those strange situations that make you scratch your head, the longer we've been doing this, the more likely we are to have been through something similar. It's also more likely that maturity and experience can make a difficult/unusual situation a bit easier. Again, as we progress through our careers, often times our attitudes, priorities, and ideas change, depending on who our mentors are and the experiences we have. That was my point.

Judging by your listed age, you are relatively new to the business. It seems that right or wrong, many people go through phases in their careers. You start out eager, full of energy and ready to save the world. Depending on your mentors, you will eventually learn to either be a good provider or a bad one. You may go through a disillusioned phase when you learn about the realities of prehospital care- the abusers, how many times we are little more than taxi cabs, the pay, the lack of respect, etc. You may develop bad habits, you may become burned out- it's usually a difficult time. At some point, most come to terms with the what the job is all about- helping as many as you can- and that can mean anything from holding a little old lady's hand, making a balloon from a rubber glove for a sick kid, or dumping the drug box into someone who is doing their best to die on you. You realize that it's silly to make the job more stressful than it already is and that. You also realize the "old timers" have paved the way for the next generation and while you might not agree with everything they did, you understand how things have changed over the years- for good and bad. Pick up the good things from folks, and resolve not to repeat their mistakes. You also eventually realize that this is a profession that is the hardest job you'll ever love.

So here it is in a nutshell. This is about paybacks, with no endpoint in sight. When will we be "punished" enough for what our ancestors did? When will this score be settled? So by your definition of intelligence, anyone in a third world country or with an inferior educational system, these people must be less intelligent than everyone else? You are confusing education with intelligence. These are NOT mutually exclusive concepts. As you said, this is proof of prejudice, not racism. Sadly, this will ALWAYS be a problem with human beings. We don't trust people who are unlike us and we tend to gravitate towards people with similar backgrounds and interests. Cities have ethnic neighborhoods, entire towns and counties can be predominantly one religion or another. Is that racism, or just people expressing a preference? As for the lack of black coaches in sports- well, what are the backgrounds of these coaches? Educational backgrounds? Did they have the skills necessary to do the job? Again, nobody is denying that horrible things were done to blacks in the past. Jews have a similar issue, as do most every other ethnic group. Many immigrants in the early days of this country even came here as indentured servants. Point is, where do we go from here? Do we continue to punish people who's only commonality to their their ancestors and their actions is the color of their skin. Sound familiar? We will not move on unless we stop living in the past.

Totally agree. Any MD worth his salt should also understand the predicament you were in and hopefully he can understand the potential for liability to you. A doctor has a higher medical authority than you, and a patient's PMD his certainly far more familiar with the patient than anyone else-including your medical control, so certainly his opinion is VERY RELEVANT.

The opportunities are there for EVERYONE, it's a matter of taking advantage of them. Problem is, those opportunities are NOT promises and for most people, it takes a lot of work to take advantage of them. The issue is, when you give someone something solely based on a "payback" idea, it's no longer an opportunity, it becomes an entitlement that requires no effort on their part. That helps NOBODY and merely perpetuates the cycle. Agreed. The problem is, we need to address the fundamental mindset of entitlement, and it's not PC to say that giving someone something for nothing does NOT empower them in any way. It sends the message that we feel a group is inferior and that they cannot succeed without these set asides. It has become a self fulfilling prophecy for too many- if you are essentially telling me that I can't do it without help and I can get what I need/want without trying, then why should I even put forth the effort? My wife is in higher education at a university and despite all the outreach programs they try specifically targeted at minorities, their numbers still lag behind every other group. She deals with athletes who have been catered to their whole lives, class "valedictorians" who can barely write their own names, and people who have never been told by their families/friends that an education and hard work are worthwhile pursuits. They can address the academic shortcomings if the person is willing to put forth the effort, but how do you address an entitlement mindset that is the polar opposite of a strong work ethic? She fights a subtle but constant battle with advocacy groups on campus who push for things simply based on race, (or to a lesser degree, ethnic origin, gender, or sexual preference,) not achievement or merit. This is a mentality that needs to be changed- a lot of people(activists, community organizers, race baiters, etc- who would be out of a job if we as a nation ever decided to push for success based on merit and achievement, so clearly this is an uphill battle. This has to start with kids, who need to be taught the value of hard work, self reliance, achievement, and it will move forward to successive generations, and no, it will not happen overnight. Clearly, until we have a fundamental shift in our emphasis- to one of advancement, not payback or retribution, nothing will change. We now have a Democratic Congress with a Democratic POTUS, so don't expect that attitude to change any time soon. Although our POTUS is a prime example of what is possible for anyone, there are too many people and groups with a vested interest in keeping the status quo.

As to the "tricks" to determine responsiveness-I've seen hard core regulars who could pass any of those noxious stimuli tests- the arm drop, no reaction to ammonia inhalants, sternal rubs- the works. At that point, treat them as if they are really unresponsive and let the hospital sort it out. Gawd only knows why people play these games, but it takes far more effort to "prove" they are faking it then to simply play their game and bring them in. Same with getting a refusal of service- people waste so much time and energy justifying/documenting why someone was not transported- it's far easier to transport them. No amount of rationalization, reasoning, or badgering will change their minds or their behaviors. Abusers will be abusers.

They must be updating their info at the CDC web site- it says the document is currently not available. As for the PSA- interesting. Question for you: What would be your recommendations if a provider comes across several patients on a train or plane, for example, who have flu like symptoms but don't necessarily want treatment or transport? It's a confined space, breathing the same air, and we could have a lot of potential carriers who could wreak havoc on an area. Is a quarantine indicated, or must this come from a CDC or Health Department directive? From what I was told, in this area at least, we do NOT have the authority to do this. It seems to me that we are propagating a potential epidemic if we see clusters of patients like this and simply allow them to go on their way. I see many legal and ethical problems here. What would you do?

Many variations on that phrase- "Aye" tach(as in aye, aye, aye...), is another. I know of a few more, far more unPC that I will omit. It's just a crude way to describe someone, most often a female of Hispanic origin, who becomes so upset they can no longer be reasoned with and discussion with them is no longer possible. I've seen similar reactions in people of Arab descent too. Similar to this is the idea of "running amok", which is actually a recognized psychiatric issue common in the Malaysian culture: ( As an EMTB student nearly 30 years ago, doing clinical time, I first heard this explanation from an ER doctor when we were confronted with a hysterical Malaysian patient) <h1 id="firstHeading" class="firstHeading">Running amok</h1> <h3 id=siteSub">From Wikipedia, the free encyclopedia</h3> Jump to: navigation, search This article is about the amok behaviour and state of mind. For other potential meanings, see Amok (disambiguation). Running amok, sometimes referred to as simply amok (also spelled amuck or amuk), is derived from the Malay/Indonesian/Filipino word amuk, meaning "mad with rage" (uncontrollable rage). The word was in use in India during the British Empire, originally to describe an elephant gone mad, separated from its herd, running wild and causing devastation. The word was made popular by the colonial tales of Rudyard Kipling. Although commonly used in a colloquial and less-violent sense, the phrase is particularly associated with a specific sociopathic culture-bound syndrome in Malaysian culture. In a typical case of running amok, a male who has shown no previous sign of anger or any inclination to violence will acquire a weapon and, in a sudden frenzy, will attempt to kill or seriously injure anyone he encounters. Amok episodes of this kind normally end with the attacker being killed by bystanders, or committing suicide. The syndrome of "Amok" is found in the DSM-IV TR: "[1]"

Well put, Doc. One needs to look no further than our current POTUS to see what is possible for anyone in this country. There are no legal barriers for anyone NOT to succeed and thrive. Yes, for some-(of any color or ethnic group) those barriers will be formidable, but a person or group's past does NOT predetermine their future unless they allow it to happen. Think of the immigrants who come to this country who do not know the language, culture, and are not even citizens. They come from places with oppressive governments, live in squalor, amid war, and were subjected to tortures, abuses, and hardships we can't even imagine. Their hardships are not the stuff of history, they happened to them every day. Somehow they arrive here, adapt, survive, and thrive, despite having far more obstacles in their paths and NO legal protections or the rights of citizenship versus people who are born and raised here.

Congrats to you and the Mrs. I have 2 girls and a boy. Let me put it this way- say good bye to your sanity, and if you manage to keep any of your hair, I promise it will soon be grey. Girls are TOUGH. LOL Seriously- Just wait until she's born- you will be instantly wrapped around that little finger. There's nothing like daddy's little girl and you will immediately feel a love deeper than anything else on earth- (and be scared to death at the same time. My first thought was- Oh gawd, I hope I don't screw this up!)

I call it irrelevant. So if Chris Rock said it, then it must be true. Actually, I find him damn funny most of the time, but if he is your social barometer or philosophy yard stick, that's a problem. He's a comedian who gets paid to say outrageous things and to make people laugh. There is something fundamentally wrong with a person who wants to be someone else. The issue is not of racism, it's a matter of knowing who and what you are and if you aren't happy, then it's YOUR RESPONSIBILITY to change. I am not responsible for your problems or that of someone else's race. Assuming we agree that education is key to getting ahead; without it it's almost certain you will struggle your whole life. There is NO VALID REASON why someone cannot stay in school and get an education. NONE. Unfortunately, there is also no promise of success FOR ANYONE in this world unless you are born with a silver spoon. That leaves out about 90% of the people, so that means we ALL need to work to get ahead. Everything else is a personal choice- deciding whether or not to join a gang, deciding whether or not to break the law, do or sell drugs, deciding to have a baby with no job and no education. Unless you are saying that black people can't compete on a level playing field, your argument is flawed.

Interesting topic. My take- The autonomy issue is very relative. Are you operating in a remote village where there is no other medical care for miles around? Is your "medical control" in the next room, on the other end of a radio, or phone? We've all been taught that only a doctor makes a diagnosis. We have "impressions". I agree that for all intents and purposes, we DO make a diagnosis every time we treat someone but ultimately, the MD is the one who is left holding the bag. We take someone to a hospital, they receive definitive care by a doc, and hopefully confirm our "impression". The difference, the doc is responsible for their diagnosis, we defer ours to our medical control and/or the physician at the receiving ER. For years, I worked in a very busy Level 1 trauma center. Although we performed many of the skills that we did in the field, we also were taught many others. I learned how to insert Foley's, sutures, 12 leads, NG tubes, gastric lavages, order simple Xrays, do ortho work such as posterior molds- and assisted in many other procedures- chest tubes, thoracotomies- quite a learning experience. Most of the time we started a triage note on a patient and generally would establish an IV and do required bloodwork. Obviously if there were questions, we would ask the doc, but for routine issues, most of the time this stuff was done even before the doc would see the patient. We learned which labs were required for whch complaints. Clearly, the docs needed to be able to trust you and be confident in your skills, and without their blessing, you would NOT be allowed to do all these things. Were we making a definitive diagnosis-of course not, but we did know which tools the doc would need to come up with that diagnosis. Autonomous in this case meant you did not need to always wait for a doctor's order, but the only way this could work is that you must know your limitations. Even doctors have resources to call in when they are stumped-ie an anesthesiologist to help with a tough tube, or help in any specialty they need. Many times I presented a funky looking EKG to an ER attending and they told me that a cardilogist would need to make the definitive call on that rhythm- they were not sure either. In the prehospital setting, all we have is a radio and our partner for backup. With out level of training, that can be a scary proposition with a medically complicated patient. Personally, I think that the more you learn, the more you learn just how much you don't know.

Back to the article, and a different take on this: Sources of bias included that the written section measured memorization rather than actual skills needed for the jobs; giving too much weight to the written section; and lack of testing for leadership in emergency conditions, according to a brief filed by officers of the Society for Industrial and Organizational Psychology. So now the reasons for the supposed bias is because too much emphasis is on the written portion of the exam. Ahem- how on earth do you test knowledge of fireground tactics, department rules and regulations, and knowledge WITHOUT a written test? The test was made race neutral under federal guidelines. OK, since the 60's laws have been in place that prohibit discrimination in voting, hiring, and damn near everything. We have entire government agencies whose sole purpose is to monitor these things, investigate claims of bias, and assign penalties for such. We have watchdog/neighborhood/civil rights groups that jump at any real or perceived instance of bias. Since this time, man has gone to the moon and back multiple times, we have explored our entire solar system and beyond, computers have gone from being the size of a warehouse to fitting in the palm of your hand. We have cars that can parallel park on their own and even brake on their own before you rear end someone. Are we honestly supposed to think that we still need to have punitive rules to address something that current laws prohibit? Is racism STILL the reason why there is such a disparity in educational performance? Do we still need to punish people today for laws on the books, enacted by our ancestors who have been dead for generations? If this is only about punishment/retribution/reparations/paybacks(since for a half century, you cannot legally discriminate) when will the punishment be served? Hell, we have convicted murderers who get out of jail in 10 years- when will justice be served? It's clear these laws do not address the problem or the disparity would no longer exist, so when will people start asking the tough questions- like what is the REAL reason for the problem? Could it be that these set asides and entitlements are now actually doing more harm than good? (Don't worry, we know you can't compete on a level playing field so we'll dumb down a test/ have set asides/ give you a job or promotion, etc solely based on the color of your skin or your heritage) If someone has been told for generations that they CANNOT compete, that their failures, problems, and social problems are NOT their fault, wouldn't the logical response for many be to eventually accept that and agree with it?

Rules and regulations are fine and obviously we need to always do what's best for our patients and CYA. Problem is, as anyone who's been in this business for more than a day or 2, they KNOW not everything is black and white. My issue here is with those ignoring the neuro doc on the phone. Yes, there is nothing to ensure that he was really the patient's doctor or even a doctor at all but I'm the most paranoid, cynical guy around. If I am speaking with someone who sounds like a doctor, is familiar with the patient, and is giving appropriate advice, I am NOT going to dismiss his counsel out of hand. Get your medical control involved, explain the convsersation you had with the neuro guy, explain the patient's condition, and leave it up to them. I will never forget a lecture I had years ago by the medical director of our local epilepsy foundation who emphasized many times that most patients who have seizures, with a known history of same-do NOT need to be transported. This went against everything our system preaches and we tried to explain this problem to the guy. We agrued with the guy- about level of consciousness, etc. He didn't change his stance, nor did we. Again, it sounds great on paper, but you need to balance what's best for the patient, what is proper protocol, and the details of each particular situation. If this kid has a complicated medical history, I would be far more likely to simply take the patient, but I was not there. Problem is, now we have a pissing contest between the family, the doctor, and your medical control. In my experience, most times medical control will not go against the wishes of the attending physician- regardless of what our protocol says. Yes, we've all been taught that unless the doc takes over treatment, signs your form to take responsibility, AND accompanies the patient, they can't assume responsibility. Has anyone provided treatment, directed by medical control, that is NOT part of our protocol? Many times, I have given Benadryl for a dystonic reaction yet we have no established protocols for such a problem. In reality, this neurologist is an MD, with far more training than we have, they have personal knowledge of the patient and their history, and if they "suggest" a course of treatment, we would be hard pressed to disagree with that and have it hold up in a court of law- even with medical control. Politics and turf wars complicate our jobs. Tough situation- and unfortunately, unless you plan on leaving the business, it won't be the last judgment call you will be forced to make. Isn't medicine fun??

Triage is only a part of the overall response to mitigating an incident, and in a smaller scale incident, it's usually done on a limited basis. It's also simply not practical to adopt a full blown START triage system all the time. Training is key and everyone(police, fire, and EMS) needs to know their roles and must practice them. The biggest problem on ANY MCI- and even on a smaller scale- communications and interoperability between agencies. If you can't talk to other agencies, at any level-things go south quickly. In every MCI I have been involved with, in the after action critiques, by far the single most common problem stated by everyone involved is communications. The problem is, too often these things turn into turf wars- who's in charge, who is making decisions, and who is notified when these decisions are made. Everyone wants to protect their own little domain and is more worried about looking bad than in working together. In large scale incidents, each agency establishes their own command center and although there may be a central command location, too often the decisions are made outside this command center. NIMS, if properly implemented- is an ideal way provide a format for everyone to work together and get on the same page. It starts at the top- the providers will do exactly what they are told if the powers that be adopt the command structure. Unfortunately, the only way to improve is to have more incidents, and each time, use NIMS type command structures in every possible situation. Training is fine, but we all know that 2 incidents never unfold in the same way and our response is never exactly the same. Practically, there is not enough time to establish a unified command structure in anything but large scale, longer term incidents, but the more they are implemented, the more they become second nature. In the end, I think the most important issue is the establishment of a unified command structure and the communications needed to make an MCI efficient. The nuts and bolts of triage, treatment, transport, etc- mitigation- will all occur more smoothly as long as the command framework is in place.

Tough call. If someone has pneumonia, you may actually thicken up their secretions with albuterol, as you would with a diuretic and make things worse. CPAP would be a good idea if available. The tachycardia could be from hypoxemia or from the infectious process. Unless you are working with the patient long term, I wouldn't worry about knocking out their respiratory drive- that generally takes far longer than we ever spend with a patient. Crank up the o2 and like you said, it was helping.

Agreed. Well, in this case, the guy was not exactly an angel but in this particular case, he was NOT the intended target. There was alot of shooting in the area and he was hit by a bullet fired a long way away- which explained why it never penetrated his skull. Had another guy shot 5 times- abdomen and legs- bleeding like a stuck pig and left quite a trail of blood. He ran about 6 blocks AFTER he was shot before he finally collapsed from hypovolemia. By the time we started 2 large bore IV's, the guy was bleeding out blood tinged saline from his wounds. Turns out this was pay back for a previous shooting he was responsible for. Gotta love street justice. He did not survive.

Most paramedic schools "require" experience- around here it's usually one year but too often that is waved. Sorry, but I disagree with the notion that experience is not necessary. I am curious to hear why you feel this way. New doctors spend a year internship right out of medical school and then progress to their residencies. They are evaluated by veterans, their skills are verified and honed. Same with nurses. Most shadow veterans for awhile before they are turned loose to work on their own. Why should the transition from EMTB to paramedic be any different?

I think the technical term for that feeling is the "Aw Sh*t!" response with an increased sphincter tone. LOL

I had a guy who was shot in the back of the head- small caliber, lodged just under the skin. Initially passed the guy up because the police were interviewing him as a witness until we noticed blood on the back of his shirt. Spent 10 minutes arguing with the guy. Absolutely refused to believe he was shot- right up to the time when the doc pulled the bullet out of his scalp and dropped it into an emesis basin. His reaction- he was mad as hell and couldn't wait to get even with the guy who shot him. BTW- bullet never went deeper than the scalp- no fracture. Nothing surprises me anymore.

The professionals? I have news for you-we're all supposed to be professionals. Last time I checked, people in this business- even students- are supposed to be adults. You are supposed to be a preceptor, not a babysitter and if a student has difficulty paying attention to where his preceptor and his/her partner are, that's not a good sign. If they aren't responsible enough to simply pay attention to what's going on, much less the patient care aspect of the job, I suggest they might be in the wrong career. A preceptor's job is to teach, monitor, mentor, and be a resource for their student, How attentive is a student if they can't even keep track of their preceptor? They should be watching every move made, monitoring a patient, grabbing patient belongings, helping carry equipment or the patient- whatever needs to be done. A student should not be disappearing. I can promise you this- if you as a student are left behind, it will never happen again. Of course things happen, but we aren't talking about leaving a 2 year old child, this is supposed to be an adult. I agree a student shouldn't be left at a residence but if they are left on a scene or at an ER?... BFD They shouldn't be wandering around aimlessly. They are supposed to be students, there to learn by observing and by doing- they are NOT helpless infants.