HERBIE1

You may be right about IO fluids but I have never tried it. It is also counter intuitive to me. If I start a 14 gauge IV, I can administer an entire liter of fluid within a few minutes via gravity alone and I'm free to do other things while the bag is draining. IO's need a pressure bag or BP cuff to facilitate the infusion, which tend to need closer observation. In my experience, fluid resuscitation is also not the primary reason you need IV access in a code situation- it's simply a route to give medications. We've also gotten past the days of dumping gallons of fluid into trauma patients, so unless there is obvious frank blood loss, hypovolemia is a relative thing, and probably not our primary concern. I've seen many ICU patients who were fluid overloaded, dealing with ARDS and other issues thanks to 3rd spacing and fluid shifts. I look at this from a perspective where at most, our transport times are15 minutes or so- even to a Level 1 trauma center. If someone has data on this I would love to see it, but I am still going to be reluctant to do an IO on any patient who is not at the very least obtundant or completely unconscious.

Awesome story. That's just simple human kindness-we need more of that. It cost someone a couple bucks and like you said, made someone's final days a bit better. Shake that medic's hand for me.

Interesting. You say the cops will leave someone who is under arrest and come back later for them? Wow. Around here, if the person is in custody, the cops need to baby sit them until they are treated and discharged. If they get admitted to the floor- same thing. They need officers guarding the patient-regardless of the charges against them. Most cops are NOT happy about duty such as that.

I know a few people have mentioned about using IO's here, but to me it's my absolute last option. I have never used an IO except for extreme burns or a cardiac arrest situation. In the OP, the patient was supposed to be hypovolemic- no mention of vitals. That's fine, but unless this is an impending arrest, I don't think I would be using an IO. Depending on the BP and/or level of hypovolemia, IO would not be a very efficient way to infuse a lot of fluids. It would also depend on transport times. If the person needs IV medications, then obviously an IO would be more important. I have no problem telling an ER that I could not get a peripheral IV on a patient who has borderline or stable V/S's. My ego is not that fragile- sometimes we just have bad days. I figure I could either make a person a pin cushion and make it more difficult for blood draws and IV's in the ER, or I could admit defeat and do everything else I could.

Not sure of the make up of your crew- ie how much help you have and their certifications, but we also have short transport times in our system. There is nearly always time for an IV, but I would certainly not waste an undue amount of time. Start it enroute to the ER PRN, unless you need immediate access for medication or for fluid resuscitation. This is a good example of where communication between providers is critical. Who does which tasks when, what are the priorities, what is the patient's condition, etc- all things that need to be worked out.

My initial smart ass answer is- you get the IV WHEREVER you can, but for rapid fluid replacement, obviously you need something bigger than a 24 gauge in a finger, The foot is often overlooked- and certainly not ideal, but better than nothing. A couple of other often overlooked locations are the underside of the forearms and upper arms and in a contracted patient, they may actually be easier to get at than a traditional site. Obviously EJ and IO are other options if allowed in your system.

After reading that, I feel like I need to soak in a hot bath to cleanse myself. I feel dirty after just reading it. Everyone associated with this case should be fired, prosecuted, and then sent to prison to serve their time in general population. From the janitors who said nothing, to the grad assistant who witnessed the acts and did not report them to the police, to the coaching staff who were aware, to Paterno who never followed up on this, to the university administration who ignored this, to the university police who swept this under the rug- I am literally sick to my stomach.

My sincere condolences to you and your family on your loss. Unfortunately I know how you must feel.

Well, unfortunately I am too familiar with the EVIL Muslims, and it does directly relate to the topic at hand. One of those EVIL Muslims killed my nephew and another guy from his unit. Today is the one year anniversary of when we buried him. Like I said-taken at FACE VALUE, there is nothing in that statement that is derogatory or stereotypical to all Muslims. I do not deny this poster's inflammatory history, but looking back to some of the posts from crochity, I think he crossed the line many times too. Without that "evil" there as a qualifier, I would wholeheartedly agree with you. Maybe his intent was exactly as you infer, but in this case, I will give him the benefit of the doubt. I am well aware of my bias on this issue, but that being said, I still believe that sentence- taken as it was written, was not inappropriate, nor was it inflammatory. Regardless- it's your call, you are the moderator.

No doubt about some of those vollie departments. I've seen guys with more lights and antennas on their personal vehicles than on my work rig. Sweet ride nonetheless, but IMO ruined by all that crap on it. LOL

OK- AAA is an easy guess. Could he have been dissecting and finally ruptured? I saw someone die from a AAA right before my eyes. Scariest thing I have ever seen. A 50 year old priest walked into the ER c/o back pain. Unequal pedal pulses, hypotensive- no mass. Quickly confirmed the AAA and a surgeon was called in- approximately 45 minute ETA. In the meantime, the ER doc wanted to apply the MAST suit, and I was the only one who knew how to put them on-even though I was actually still a paramedic student. Talk about pressure. LOL I stuck like glue to this patient, realizing he was in big trouble. He knew it was serious, he knew his life was on the line. We made small talk, and I kept looking at the ER door, hoping the surgeon was there. About 30 minutes goes by, the man's eyes got real big, the color drained from his body top to bottom like someone pulled the plug on a drain, and he went apneic. I called for the doctor, and within 30 seconds he was gone. The surgeon showed up just as we were zipping him into a morgue bag.

I did not see the original post, so this is all I know: "Also pray that the evil muslims in the world do not do anything stupid today." Guess what? I am going to defend flaming. The operative words here are "evil muslims". Unless there is more to it, I agree with that statement. Nowhere does it say ALL muslims are evil. Nowhere does it say that ALL muslims should die. I will take that sentence at face value, assuming there was no other intent, nor was there more to the deleted post that changed the context of that statement. Flame away, folks.

Look at the names- "Ms Smugbottom"? Come on- this was a satire piece, folks. Pitchforks and torches, Frankenstein?? Pretty damn funny, if you ask me. Maybe the guy did indeed purchase this as his own personal vehicle which he responds to fires with. Silly? Sure, but I'd love to have a 1978 Vette. I've seen many souped up Camaros, Mustangs, Trans Am's, etc as law enforcement cars, generally with lots of notations on them saying it was confiscated during a drug raid. So what?

The name of the hospital where you transported your patient is not PHI, but it becomes up to a witness or a victim to cooperate with the police once they are tracked down. Unless a law mandates reporting of a crime- ie abuse, neglect, injury on public property, GSW's, etc- then it's up to the victim/patient to determine if they want police involvement- not us. We certainly can make the notification for them if they want, but that's the extent of our responsibility.

Occasionally we take someone back home- but as was mentioned- under very special circumstances. Is it against policy? Of course. The other day, for example- little old lady fall down, go boom on sidewalk. Tripped on a crack. Sustained SMALL- 1/4 lac to her eyebrow thanks to her glasses frames- MAYBE needed a suture, steri-strip, or Dermabond. Shook up and upset more than anything. Vitals fine, no significant PMH, no loss of consciousness- absolutely refused. Couldn't afford the ride or the ER bill. Cleaned her up, called her grandson who she lives with- just a couple blocks away, and explained what happened. We said we would take her home if grandson would take her to her family doctor for at least a tetanus and follow up. He agreed, and both were very appreciative of our extra effort. Documented everything- except the part where we took her home. It was just a routine refusal of transport- except for the taxi ride home. Not too concerned if someone wants to nail me for what we did. I'll gladly take the punishment- and would do it again in a heartbeat. I would hope someone would do the same for my mom in a similar situation.

How about realistic? LOL I know what you're saying about the rural or "slower" ER's. Years ago- when there actually WERE slower ER's, I worked in one of them. Slower, smaller, but it was still urban. It would often go from zero to insanity in about 2 minutes. As a "tech", I learned a lot from the docs there. Much of it was by necessity- they needed all the help they could get since staffing was generally minimal as I always worked 11p-7a. I learned how to drop NG's, Ewalds, Foleys,12 leads, administer meds, put on posterior molds of all shapes and sizes, even assist with suturing and other minor procedures. I used to love watching how the docs handled things when all hell broke loose, and would apply what I saw- good and bad- in the field. The one thing I did learn was how often the docs would verify a diagnosis, do some quick research on a drug or disease- throughout the course of their shifts. This was before the internet, which meant lots of reference books. Obviously the majority of patients were routine, but this was also back in the 80's when HIV and AIDS were first appearing, the ER was in a gay area, so we were seeing all those bizarre cancers and respiratory problems. Fascinating stuff.

Addressed to Doc- I know that sometimes even altruistic physicians get fed up with the BS. Some years ago an ER doc in a BUSY urban hospital here was working shorthanded, impossibly backed up with patients, and a full ER. He began going through charts that were triaged, pulling out the clearly nonemergent patients. He had the nurse call them into a room, the doctor came in, and in about 15 minutes had "treated" and released about 20 people. The vast majority were URI's or uncomplicated cases "fixed" by Ibuprofen or Nyquil I think. This doc was treated as a hero by the staff that night, but I see the obvious danger in what he did. This guy was pretty high strung and burned out, but I understood his frustration. The myriad of BS cases were taking time, staff, and bed space away from a bunch of seriously ill patients. Unfortunately this was before they had a Fast Track/Immediate care area. I believe he soon left for a sleepy little rural ER shortly after that.

I could fill up volumes with BS calls- and YES, there are BS calls. When there is no penalty for abusing the system, when it costs you YOU nothing for the ride or the ER visit, there will be BS calls- and it will be a chronic problem. Sorry, but that altruistic stuff about our purpose does not apply here. The E in EMS stands for something, and I defy anyone to explain how any of the patients below could be classified as an emergency. Let's see off the top of my head: -I ran out of bandaids and I need one for my finger -I had a bad dream -I'm upset and angry at my son because he won't do his homework - I need a ride to the ER because I need my prescription refilled I could go on for hours...

I'm not sure what you are referring to, but I agree with HLPP here at least about the survival rates for traumatic arrests in the field being essentially zero. Maybe that system is required to work traumatic arrests, which means the patient was not pronounced until the ER, but was in full arrest the entire time. We are also required to transport traumatic arrests- unless they meet certain criteria, or it's declared a crime scene by the police. Do I agree that an hour is far too long? Of course.

LOL Damn funny...

LMAO I have to say this is one of the best- and funniest- derailments of a thread I have ever seen! Thanks so much for the belly laughs, guys- I really need it this week. \\\Now if you will excuse me, I will be looking for an Aussie/NZ/English translator to figure out what the hell you guys are talking about...

I have no problem with confidence- even a lot of it. I think it's a vital trait to have in this profession. You damn well better be confident in your abilities to handle any situation- or, if necessary, how to get the help you need to mitigate it. Folks call us because something is happening they simply cannot handle on their own. Problem is, when you are brand new or worse yet- a student- you know just enough to potentially get yourself and your patient in big trouble. When that confidence morphs into arrogance, it is a very dangerous thing for a student or someone new. It's funny-EMS has a way of knocking you down a peg- even after 30 years in the business. Every so often, patients will throw you a curve ball you never see coming, just to keep you honest. Some people never catch on to this idea until it's too late.

Welcome, and jump right in.

So she already knows everything as a STUDENT? I would LOVE to get this girl as my partner- she would be in for a very rude awakening.

There are pros and cons to busy systems. Pros- generally you see an incredible variety of stuff, and your skills are sharper. Cons- Lots of BS calls, and it takes a toll on your body- physically and mentally. I guess the grass is always greener...