WolfmanHarris

Agreed with HellsBells. It's just a check-box on a scenario. In reality, make sure you're building your clinical judgment to the extent you can justify the request for ALS. I don't mean justify in terms of being held to account my anyone else, but in making sure you understand why you've requested it and if the request makes sense. If you're not already, become familiar with the scope and interventions available to ALS in your area and in general the indication/contraindications. That way when you're requesting back-up you're doing it smartly and can do what you can to prep the patient for ALS. (i.e. if you're not able to acquire an ECG, then atleast expose the chest and towel them off prior to ALS. Roll up sleeves to expose sites for IV's. Have a recent set of vitals ready to go. Don't delay packaging unless required.) Remember, especially in the case of trauma, ALS interventions will be unlikely to have a significant impact on outcome. Get them packaged and ready to go so that ALS can start their lines, intubate or decompress on route.

Congrats! Now that you're on the road, don't lose sight of balance. When I was in school I spent so much time thinking and preparing for my career and being on the forums talking about it and learning more. When I started working I quickly found that I was spending to much time living EMS. I was studying as much as when I was in school, still on the forums and working full time. That's why I decided to take a step back from the online community and study a bit less. Enjoy every minute of work, but don't let it take over.

Leaving aside the protocol specific question, which is something of a non-starter, why don't we discuss the concept of orthostatic hypotension in a bit more depth? With the specificity and sensitivity of orthostatic hypotension being so limited, when would do you use it? What is your thinking here? Does it hold up under scrutiny? The only time I can think of that I've regularly checked orthostatics is in the context of the syncope patient. When presented with a syncope patient, with an unremarkable incident history, unremarkable cardiogram and normal blood sugar who is largely asymptomatic at time of assessment, I've been in the habit of taking my initial vitals in a supine or semi-sitting position, then sitting, then standing. My thinking here, what of it there is, is that I want to see how the Pt. compensates and that they can now maintain their pressure. Now, is my rationale here sound?

HBD is interesting, because during the days of the the provincial paper ACR there was a set list of approved acronyms and HBD wasn't one of them, so we used plain language. Now we use siren ePCR and have check boxes for most of our findings and on siren, "intoxication/HBD" is listed under chief complaints, history and a few other places. In terms of reporting objectively, we have a section under findings for alcohol/drug use which includes: "Pt. admits to alcohol use." "Alcoholic beverages on scene." "Alcohol use reported by other." Similar boxes for drugs. Under scene findings we can select "ETOH like odour." In terms of avoiding litigation though, say from a drunk driver call, these won't do very much, since those calls would mandate an incident report be completed which is entirely narrative.

HBD is so ubiquitous with EMS, ED and LEO's I thought it was in more common usage than that.

Mea culpa. HBD = Has Been Drinking.

Haven't had too many darwin award candidates or winners but a couple memorable ones: - 26 y/o M, emotionally upset, HBD. Called 911 for crisis, while on the phone took approximately 9 grams (not mg) of acetaminophen. When I informed him he had to go to the hospital because he'd had a toxic, potentially life threatening dose, he groaned and said "really?! Bummer." Nice enough guy otherwise who'd just let a really bad day get away from him. - 60 y/o M, HBD, hit playing hockey. In poor shape, heavy smoker, Hx of hypxn and high cholesterol but not being treated for either. C/O severe CP and SOB, probably sternal fracture. Pt. initially refused care. Then refused to go on the stretcher. Then feigned forgetting something to sneak back into the dressing room to down another drink. Then insisted on having a smoke outside the truck, which lead to a wicked coughing fit. Dx'ed with a cracked sternum and discharged. Called later that night due to pain. Hadn't bothered to fill his script yet.

Hobbies... taking care of my family at the moment. When there's time and inclination I play paintball (mil-sim woodsball, not inflatable stuff), camp when I can, read.

I love the people I work with. I've had lots of different jobs before this, both great and bad, but the level at which staff support each other every day is the thing I love most about my job. If I have a bad shift, it's my partner and my platoon mates which make me get up and do it all over again the next day. And right now while I'm off work with family issues, the huge support I've had only reinforces that. I love the stability. I have good pay, good benefits and job security that ensures my family is taken care of. With all the other reasons why I love this job, I still wouldn't do it if I couldn't support my family comfortably. The intellectual challenge. Even sub-acute calls have so much to engage the mind. There's always something else to learn. When I talk about the excitement of this job, it refers to that challenge. I love the people we treat. Not all of them by any means, but there are so many interesting people out there with such different background, lives and stories. I've always been attracted to public service careers. I have a certain sense of duty to my community and enjoy serving it. I am entirely aware of how cheesy that sounds, but it's true. I like the shift rotation. Sure 12 hours can be long and nights aren't great, but the four day weekends and six days off each month are a good balance for home life. I like not having to think about what to wear to work? I hate my commute. To work for the fantastic, progressive, growing service I do and live in the great city with affordable housing I do, I have to drive 80 minutes each way to work. I hate standby's. We're station based but move around to other stations to cover. We can spend a huge chunk of our shift doing the stand-by shuffle which really wears me down. I hate doing non-emerg transfers. We don't do a lot of them, but they always seem to come just as you're getting some down time after getting slammed. It also doesn't help that policy hasn't caught up to deployment and only PCP (BLS) crews are supposed to do out of town transfers; except there's only two PCP trucks in my district now, so we get slammed with the 3am 4 hour round trips. I hate BS calls. Not calls where someone is scared, or doesn't know better, or doesn't know about more appropriate resources, but flat out abuse and entitlement. I hate pediatric calls. Of all the calls we do, I feel the most ill-equipped and overwhelmed. I know lots of people do too, but I still hate them. Love kids, hate kid calls.

Ya outfitting the fleet is a big line item on the budget. But it's the current goal of the service to transition to no-lift where possible. We have the tracked stair chairs. The power cots and power load are coming. We have bariatric units with ramps, winches, airbags. We also have a very open lift-assist policy.

Apparently we'll be phasing them in over 2012, 2013 (based on the 2012 capital budget). The budget just says "power tail lift" but given that this is the only one currently heading to market in Ontario...

We picked up a 40 y/o M who was worried because he hadn't had a BM in more than 24 hours and had low grade abdo pain. En route he remembered he had a BM that morning. Not really a call but still funny; dispatched for man on roof shooting. Cancelled two minutes later, "Umm... typo on PD's end. Man on roof, shouting."

As requested, the text of our Professional Commitment Statement. This was rolled out and placed on plaques in all our bases at the same time as the service issued wallet badges. It's part of a concerted effort lead by our Chief to build the image and traditions of the service both internally and externally. Professional Commitment Statement (plaque is headed by a copy of our badge) - I will advocate for all patients who require assistance; - I will act in a manner that recognizes my patients are persons deserving of respect and the preservation of their dignity and privacy; - I will ensure the safety of my patients, the safety of my colleagues and the safety of the public at all times; - I will act in a manner that retains public confidence in our collective health care efforts.

We don't. We have a professional commitment pledge on a plaque in every station. We also have a policy about general professionalism and conduct. Neither cover cell phones. Then again, no policy specifically forbids me from spitting on the floor of a patient's home. Professionalism is a big umbrella. I keep my phone on vibrate for the whole work day and don't touch it unless on downtime. My partner doesn't keep her phone on vibrate, but the soft ring tone she uses rings very infrequently and is hardly noticeable and she certainly never answers it during a call. If this is an issue that exists in a service, the service has far deeper problems and none of them will be solved with a single policy.

Morbidity and Mortality.

After every call, the cot is stripped. I wipe down the cot mattress and handles with virox wipes, wipe the monitor and cables and then make it up with one sheet and stack two folded sheets or a sheet and blanket (depending on the weather) at the end of the bed. A folded towel sits on the head of the bed (always know where your towel is at). Bags go on the cot buckled in with the monitor on it's pole. I then take a towel soak it in cleaning solution and use it and my foot like a mop and clean the floor of the truck (the mop's at the hospital garages just aren't swapped enough). Towel is then placed on the floor at the cot hook so that it wipes the wheels on the way in. That's after every regular call (well every other at least since the driving medic sets up the truck for the next call and my partner isn't always as anal as I am). Obviously messy calls get a deeper clean.

They're rebranding our service to "---- Region Paramedic Services" over the next year.

Reason one why our trauma bags have got about a dozen rolls in the top pouch. They disappear, tie themselves in knots, magically lose their adhesive properties or suddenly the roll is done all when you really need it.

The reason I wear a duty belt is so that the outer belt with my phone, radio clip and shears can get left on the mirror of the truck when I try to get some shut-eye. It's a comfort thing, the more I have on my belt, the less I have on my person when I'm resting.

To me the key point is that the Facebook page was run by his Deputy Chief. My Chief is a fantastic leader, friendly, approachable and has a been known to accept invites to get togethers held by various members of the service. I'd gladly have a drink with him at a social occasion, but he is still first and foremost, my boss. That is how my relationship (such as it is in such a large service) began and that's what defines it. I cannot expect him to look the other way if I conduct myself in an unprofessional way, in public, in front of him; at work or not. That could show a tacit approval. Facebook isn't private, no matter what people think. Sure it has privacy settings, but it's not private. The more you allow your work life and your home life and all the random acquaintances you have to meld together on a social networking site, the more you allow your posts to be considered "public," and potentially open yourself up to complaints. If you have two thousand "friends" and have your privacy settings set to allow all of them and all there friends to see what you say, how private is it really? If you got up in front of two thousand people who were physically present, would you still consider it private? Of course not. People just need to use their heads more.

Fairly straightforward call that left me with one problem. Called at ~0500 for a 36 y/o F, 4 days post-partum, c/o abdo pain. Upon Pt. contract presented with a 36 y/o F, semi-prone in bed, nursing, in obvious distress, though somewhat stoic. Pt. reports 8/10 suprapubic pain radiating through legs and back; intermittent increase in pain to 10/10, described as similar to contractions though "much worse." Symptoms onset during pregnancy, though much less severe and prenatal investigation found no clear diagnosis (told "normal" at that time.) Symptoms have been worsening since delivery and have become unbearable today. Pt. is gravada 4, parity 4. No complications during pregnancy or delivery. No complications with previous pregnancies. All children delivered by vaginal birth. Pt. is a smoker, unclear how much. No medications, NKDA. Pt. diagnosed with kidney and gall stones prior to pregnancy, though she neglected to mention that until transport. Physical assessment inconclusive; Pt. in such pain that everything appears tender and all movement or palpation aggravates pain. Patient is on a third floor of a townhouse and required stair chair wheeling down a long path to reach vehicle. EVERY, movement, bump, change in position or vibration induced further pain to the point of screaming, writhing and shortness of breath. I can't recall exact vitals. Pt. was slightly tachycardic, hypertense, tachypnic, satting at 96-99% on room air. Monitor showed sinus tachycardia. Pt. afebrile, though husband reports her being warm to the touch previous day. Pt. has taken nothing to control symptoms. My working diagnosis is renal colic, but I'll admit I'm basing that more on history than my assessment findings. I'm curious what others may have as a differential. My other question is that we offered to call ACP back-up for pain management. In discussion with the patient see declined when I informed her that she may not be able to nurse immediately after being given the fentanyl. Pt. unwilling to even temporairly switch to formula. Unfortunately, I couldn't tell her how long that would be for, since I have no idea. I respect her decision to not feed formula at all, I do take issue with some of the taboos that have now surrounded this and the pressure it creates on a new mom (dealing with this a bit with my pregnant wife and her own anxiety regarding breastfeeding); but I feel I wasn't able to fully inform my patient and guide her decision. Certainly the half-life and therapeutic window are easy to find, but I'm having a heck of a time finding resources on the interaction of medications and breastfeeding. Thoughts on this? Cheer, - Matt

Agreed. What an interesting place to practice! (Hopefully not in the Chinese curse sense of the word.)

I hope I didn't come across as trashing those who carry gear, because aside from some of the exceptions we've discussed previously (the Zombie guy with the STOMP pack) I don't have an issue. My point was coming mainly as someone who's only been on the road for 2.5 years and who recently went through the surf the galls site phase. It's just part of the enthusiastic, keener new period of the profession. Heck I'm still regarded as a keener at work, but thankfully now because I'm the guy to go to if you want to know about the latest research, the newest standard or the CME package that was just released; rather than the stuff on my belt (minus my bigshears, those are a conversation starter). I'm glad I didn't blow the money I considered spending two years ago on stuff I'd never use and don't regret for a second spending the money on a good stethoscope, my big shears, some new textbooks and a subscription to Prehospital Emergency Care. Now if I see cool "gee whiz" gear, I forward it to the equipment committee at work and hope for the best. It'll get used on the truck, it won't in my car. Definitely worth buying if your work doesn't issue them personally. Not just for if you stop and help, but if you need to change a tire. With me not bothering to take my gear bag out of my car between shifts, I do always have this handy and I keep the one I bought as a student in my wife's car for her.