Dustdevil

Good observation. This is why we also check for pulse changes, not just BP changes. Sometimes the body compensates so quickly that a drop in pressure is not noted, however a dramatic rise in pulse is noted, which was part of the compensatory response. Indeed, there are multiple factors at work in the body attempting to maintain homeostatic blood pressure. What you touched upon creates an interesting phenomenon that we run across in people with hypertension. They get diagnosed at stage III and get put on antihypertensives by their physician, who also recommends they watch their diet, get some exercise, and lose some weight. Of course, very few of those people actually do any of that, except for take the medicine. But those few people who get serious about getting in shape start losing weight and getting healthier. Then a few months down the line they come to me feeling weak and dizzy and having no energy. Problem is, their antihypertensive is still treating them as if they were still 250 pounds, not 200! Consequently, we have to back down, or even discontinue their medicine for them to have a normal pressure again.

quote]Bryan Who? Not bad for a first post, have you ever thought of publishing some of this information, you may be on to something here.

Yes. The alternative is to place my patient in jeopardy because I am too lazy to start a second IV. It's a no-brainer. I admire your technique, but if you could do better, why wouldn't you?

It seems pretty clear that a tourniquet was immediately indicated in this scenario, however it is certainly not a cut-and-dried situation. And, unfortunately, the limited training of EMTs doesn't provide enough time to really get into the educational foundation necessary to trust them with this decision. Think about all the things that poor providers do simply because "they can," or because "my protocols say...." without ever really doing any serious evaluation of this particular patient or his situation. Tourniquets would be another one of those over-utilised and mis-utilised "skills" if we were to open this can of worms in EMT school. There are, of course, damn few cases of bleeding that cannot be controlled with direct pressure. Even this one. But several factors come into play to prevent optimal management: 1. The EMTs were inadequately trained regarding tourniquets, although, probably rightly so. Consequently, they probably had neither the skills nor the equipment to properly do the job, not to mention the education to properly assess the situation and make the appropriate decision. 2. The EMTs were OVERtrained on bandaging, therefore giving them a "skill" to focus upon in lieu of thinking the problem through thoroughly and solving it more appropriately. Direct pressure isn't as sexy as piling 4x4s a foot deep on the wound, never removing them, as the mantra directs. Consequently, you end up with NO pressure at all being applied to the wound. But hey, at least it is covered, right? Out of sight, out of mind. 3. While direct pressure would most likely have been adequate while on the floor at the scene, it becomes almost impossible while moving, loading, and transporting the patient. Consequently, even this best choice becomes situationally inadequate. This is exactly why the tourniquet was created, to do the job of the medic, freeing the medic to perform other duties, like shooting back or moving the patient out of the line of fire, or simply putting oxygen on him and loading him into the ambo. Of course, there exist a lot of problems with teaching proper tourniquet utilisation in EMT school. It is rightly assumed that ninety-nine percent of the time, direct pressure is more than adequate for your patient. EMT school is about teaching you to deal with that ninety-ninth percentile, not the one-percenters. That is what paramedic school is for. And it is also feared, again rightly so, that wankers with a month of night school will often lack the educational foundation and intellectual tools necessary to properly implement tourniquet use. As a result, you end up with more people harmed by misuse than you have saved by proper use. As always, this is just another example of how and why every dilemma in EMS can and should be solved through education. I have solved at least one of the above problems through education. When I teach, I do not teach that nonsense about appying more dressings over the originial. I teach that if your first dressings soaked through, you need to fix the damn, problem, not just cover it up!

The difference is that you never read a headline that says, "Local Short Order Cook Held in Molestation," or "Air Conditioner Repair Man Arrested for Kiddie Porn." Yes, they are all reported. The difference, as Shane pointed out, is the sensationalism. The cook who molested dozens gets less of a headline than the fireman who just downloaded porn. Not that I give a rat's arse about firemen. Malicious systemic inequity just pisses me off.

Hey, glad you finally took the leap, Bryan! I told you this place rocked! And now it rocks even more! It is the only EMS board I have found that actually goes beyond the normal "rah-rah" cheerleading to hold intelligent and no-holds-barred discussions of relevant -- and sometimes controversial -- issues, while still fostering a supportive community atmosphere. No worries on the screen name. This is a pretty tight group here for the most part. A good many of us know who each other really are, behind the pseudonyms. And a few of us would have known it was you just by the content of your post anyhow! HEMS, like most of your pet issues, is commonly a hot topic of discussion here. Many of us fancy ourselves to be your mythbusting deputies, so your moral support is greatly appreciated.

John Lennon. I would guess there to be two factors that contributed to his rapid exsanguination. First, the proximity of the arterial transection. Bigger hose = bigger leak. Second, the clean nature of the clean, incisional nature of the injury. Stands to reason that the reflexive contraction/retraction of the artery would be more typical for a more traumatic injury such as a tearing laceration like a gsw or shrapnel. The lesser trauma = a lesser protective reflex = greater haemorrhagic control. I see them out here. Especially the femoral, which is damn hard to reach or control. I am a little surprised the EMTs in your case didn't TK the injury right away. It does seem that schools tend to scare the hell out of people about tourniquets these days though.

I sure hope not. I like to think we have a little more intelligent and enlightened crowd here than the average fire department.

Hehehe... You read my mind (again)! Certainly, anything with "devil" in the name must be a winner! But maybe you were just saying I suck?

Not until you actually leap, you're not. :wink:

Plus 5 for taking that to heart. You will certainly hear it from many more people than myself here. Truth is embraced by the masses. Darn. Just when I was beginning to have faith in you. For the last time.... . And I do mean LEARNING assessment, not just memorising checklists and having no understanding of the process or the findings. Until you master this skill, every other skill in medicine is completely useless to you and your patients. If you take this one point to heart and make it your personal educational philosophy, you will be light years above your peers in short order. And you will have the respect of those who really matter. Like me. EDIT: Plus 5 to Ozzy for his last post. Great minds think alike! :wink:

Somebody actually sells paediatric spine boards? :? Somebody actually buys paediatric spine boards? :shock: I can't remember ever having so much spare compartment room on an ambulance that I could afford to stuff pointless crap like that in there. Now spine boards for fat people... there is something you might actually find occasionally useful! Are you carrying those?

Don't you wish you had thought of that before you came to Dallas? :wink: P.S. I got my Apple!!

Seen it? I've never even heard of it. I don't even know what a "citation bar" is. In fact, I am outright accusing you of making this all up. And minus 5 for posting in the wrong forum. :wink:

Excellent point, Shane. Plus 5. :thumbright:

And when it's under your MDs orders and supervision, it is not out of your scope of practice. Somebody's been Googling too much.

Wake up! You're dreaming! Work is easy to find for paramedics ONLY if you count non-emergency ambulance driver work. Otherwise, real EMS work is difficult at best, and very rarely pays a decent wage. Especially in the big cities where things are dominated by the firemonkeys and volunteers.

It's been thirty-two years now, and I have yet to burn out of EMS. I did, however, burn out in EMS after thirteen years. It passes.

PCPs are advanced providers, in comparison to an EMT. They can provide IV therapy, which takes half of the workload off of the ACP. In the US, the medic has to do it all because the EMT has no advanced skills. I think that is where your confusion stems from. Differences between US and Canadian systems.

I have seen Texas grant foreign medics a clearance to test for NR, so that is worth checking out. It is best if you can hook up with a service who has a Training Officer or Administrator who is intimately familiar with the State EMS office, who can navigate the minefield for you though.

That quite possibly could have been the end of the friendship for me. Chiche is right. I just lost all respect for him. Ask him exactly what business we are in. I submit that we are in the CARE business. And he obviously does not care, so he has no business in our business. Caring isn't a selective duty that you can turn on and off at your personal convenience or whim. You must care totally and at all times. I'd have fired him on the spot for that statement. Although, now with his info posted here on this board it may be a little late, EMT City might be good for him. Being surrounded by professionals from all across the spectrum of providers here has been a very positive influence on me and many others. This place forces you to wake up and realise that EMS is a total profession with standards, and is not confined to just what the small bunch of burnout losers you happen to have worked with in that awesome three months of experience happen to do. If that isn't enough to make somebody step-up, then they most likely are not suited to the profession.

Busted and convicted are two very different things. And if his wife is a million years old, who could blame him? :twisted:

Acquiring the equipment is not a problem. The problem is choosing which equipment I want to buy. That is why I am asking for y'alls help. And, although I have not yet tried, I have a feeling that the Government purchasing people would balk at the idea of buying anything from eBay.

Ooops, I should have clarified. I am very definitely looking for a powered suction unit. Must be portable, but will likely be used in the aid station just as often, if not more, than it is used in the field. Must have good suction, good battery life, and a battery that doesn't crap out if it doesn't get used much. Cost is not a consideration (I LOVE saying that! ). I currently have the V-Vacs, and while I have not used them for anything more than experimenting with water and soup, I can say for sure that I hope I never have to use them in a real emergency. That's why I am ordering a couple of real suction units! Gotta run. Back soon. Thanks!