systemet

* Ativan (lorazepam), Valium (diazepam), and Versed (midazolam) are all benzodiazepines; they all act at the GABA receptor, and share similar properties. This includes retrograde amnesia, which occurs with all benzodiazepines, including Rohypnol (flunitrazepam. * Midazolam IM is commonly used in many systems for seizure control when IV access can't be obtained. * Midazolam is more water-soluble, and doesn't need to be diluted before it's given, although you can if you prefer. * It's onset is more rapid, the drugs less potent, so you see lower dosing with Versed vs. Valium I'm suprised it's being used in preference to Ativan, as one system I worked in removed the valium and replaced it with ativan, as it was believed to be better for seizure control. I'll try and look for some studies if I have time. I wouldn't be concerned about potential legal exposure -- the same risks are there with any benzodiazepine, and seizure control is a valid indication. All the best,

Something to ponder - I believe that almost anyone can do this job, given the right training, the right mentors, the right coaching and support, and a decent system. I think we are way too quick in this field to tell people that they "don't have the right stuff." I know this is not what Dwayne is doing here -- I'm not suggesting that he is one of these people. I'm talking in generalities, rather than specifics. A lot of students, at every level, wonder if they have "what it takes". Personally, I believe the majority of them do. There's probably a very small percentage of people out there who have stress disorders or personality types that render them completely unsuitable. But I think most people can. It just comes, like every job / occupation / profession / trade / calling, at something of a cost. EMS can be incredibly rewarding. It can also be very difficult. I think what students should be asking themselves instead of "do I have what it takes to do EMS?", is "am I willing to live with the consequences of doing EMS?". A few people have raised the point that you might be incorrect in assuming the patient was at fault in this accident. Regardless, you're going to encounter similar situations again, and in some of them the patient will be the one at fault. You are going to see sick kids. And unfortunately a small percentage of them are going to be sick because of neglect or outright violence perpetrated against them. These are hard things to see. They will affect you for the rest of your life. Part of the challenge of doing this job is sometimes surviving it and not letting those experiences turn you into an angry, bitter person.

I think the problem with this relates to scale. Consider Alberta, Canada, where mobey's from -- population 3.7 million, with an area of around 650,000 km2 (255,000 square miles). This is larger than all European nation states except Russia or Kazakhstan. It's twice the area of Germany (~ 80 million). It's about the same size as Texas (pop. 25 million), and larger than every other US state, except Alaska. It has a similar population density to Wyoming, slightly less than New Zealand. And this is considered a relatively populated area within Canada. The large centers typically have some sort of MCI unit that can haul water and spine boards / supplies / O2 tanks, and then a bus fitted for stretchers for en masse transports of critical patients. But when you're looking at a region where the next nearest BLS ambulance might be an hour drive hot (if it's available), and the helicopter has to make a refuel stop there and on the way back, it's difficult to add resources. Some of these systems will do a call-in of all off-duty staff and use a mechanical spare, but this takes time and is subject to staff availability. Another factor that's often an issue in Canada / the US, is that ambulance service is often seen as a municipal service, and may be contracted to private entities, or run through a series of different fire departments or third-service providers. While they may have mutual aid agreements, often the resources end up where the tax dollars are. There have been many instances in such systems where "the last ALS unit in town" has refused to respond out of it's jurisdiction to assist at an MCI, in case a 911 call occurs in their service area. [As I understand it, this is no longer the case in Alberta. Although I may not be fully informed.] Government run systems tend to consider whether it might be strategic to place an ambulance in a low call volume (read: unprofitable) area, because there is no timely assistance. Private providers tend not to do this.

I read the ASTNA patient transport book on my Kindle. It was ok, but not great. https://kindle.amazon.com/work/astna-patient-transport-principles-practice/B002EX9BX8/0323057497

Just wanted to add: * U/S is the best way to dx tamponade, Beck's triad is pretty insensitive, even in the hands of physicians. * Most of us probably aren't that fantastic at deciding whether heart sounds are muffled.

Just to add to what usalsfyre's and mobey have posted, this website is quite helpful in explaining the pathophysiology and management of TBI: http://www.trauma.or...euro/index.html

This is obviously a difficult situation. I've already thought about this longer than you would have time to in a real situation. I think this: * Patient 3 is dead, and gets a blanket. * Patient 1 gets RSI'd, goes ALS. * Patient 2 goes BLS, w/ a 20ml/kg crystalloid bolus (if physical exam reveals an absence of significant chest / abdo. trauma). BLS can give entonox in the absence of contraindications. * BLS gets instructions to call ALS if the patient becomes unconscious. In that situation we double up, and start thinking about airway and dopamine. Rationale: - We don't have enough hands to work a code in the presence of other criticals (reference: every triage system out there) - Initial therapy for patient 2 is a large fluid bolus and analgesia. BLS can take care of one of these, and attempt to address the other (analgesia) with entonox in the absence of contraindications. - Patient 3 needs to be intubated. They need to be sedated, therefore they can't go BLS. Observations: - In a real world situation you're unlikely to know vital signs prior to transport, unless the BLS unit is coming from a way out. - If you're a medic in a system this rural, it's likely that for the early part of this call you have triage responsibility, unless you have some very sharp EMTs, and aren't going to be doing anything ALS beyond a needle decompression or a 'cric. - The biggest impact you can probably make in this situation is picking up the phone / radio, calling the ER, convincing them to have an MD there when you get there, preferably one that's competent with trauma, then getting the MD's cell number, waking them up, and suggesting they call the critical care line and arrange 2 x fixed wing now instead of waiting for you to arrive. Depending on local politics this may not be possible. - You can motivate transporting either patient ALS. Especially in the fog of EMS at 0-dark.-30. Unfortunately whether you made the correct choice will likely be determined after the event by someone who has access to a lot of information that is unobtainable in the initial minutes of this call. They will have the benefit of hindsight, and may crucify you despite your best intentions.

That would suck. I can't imagine it being easy to put behind you. I think you're going to get a range of responses here, not all of them positive. I've been out of EMS for a couple of years, and am now looking at going back. I've had something approaching a 9 to 5 job for a couple of years. I can say that about a year out of EMS, I realised how much I'd endured, and what it was like to be part of the regular world, where you just don't see these things. I got used to sleeping in bed with my wife every night, and having stressful events being things like meetings and presentations. On the other hand, I've missed the sense of purpose that came with EMS. Knowing that I was helping people, and contributing to my community, and doing something I could be proud of. I also felt like I spent a little too much time just doing my job, and not enough working to improve EMS. We see a different side of society from the ambulance. I used to argue this point with my wife a lot. That her view of the world (coloured by being a research scientist) was of a bunch of educated people working in a university setting, arguing over who emptied the lunch room dishwasher last. I used to make the point that this set of experiences was very unrepresentative of the world as a whole. I think it's only now I've started to understand that so is the perspective of being a paramedic. We often see people at their worst, in terrible situations. It's easy to generalise this to the world around you. To think that this is representative. It's not. It's a warped view of society, it's not the truth about who we are as human beings. It seems to me, at least, that we're hard wired to take some responsibility for the events around us. You respond to a child killed by abusive parents, and you feel responsible for that somehow. Like just by being there, you're accountable for the event happening. But this is an illusion. I think it's important to realise that these things are external to you. You didn't make them happen, in fact, you turned up to try and make it better. As I'm growing older, I'm still learning that we chose to shape our own realities. Most of the things I've failed at in life have been because I've lacked the courage to tackle them, or placed some limitation on myself. I think the same can be true for being a paramedic. If you choose to only look at the negative around you, you can find yourself in a pit of despair, and it can be hard to climb out. You do get to choose what you focus on. If you look at the things you can change, the good you can do, instead of focusing on societal issues, and problems that someone else is responsible for, I think you end up making the choice to be happier and more optimistic. You might want to stay away from the cocaine and the alcohol. Both are good ways to become an asshole. Honestly, you want advice? Go see a doctor. Get set up with some sort of counselling. Consider taking an antidepressant. Get some exercise. See if you can get some sort of stress leave from work, or take some vacation time. Take up a hobby that has nothing to do with EMS, and just get some distance between yourself and the job for a bit, if it's at all possible. If you can't make peace with this, then you've got to start making some more positive moves towards changing careers than getting drunk and coked up. Not judging you, but it's pretty obvious neither of those activities are going to help. I think that a lot of people have probably felt that way at some point in time. For me, when EMS has been difficult, it's mostly been factors outside of work that have made it hard. Family, relationships, money problems, lack of time off, etc. When I've found it easier, those things have been taken care of first. And they should be, because they're the priority. It sounds like you need some help. Don't be too stupid or too stubborn to get it.

Sounds like maybe I'm not familiar enough with the "occupy" movement to be commenting here. I would agree that if they're claiming to represent 99% of the population, and that anyone who disagrees is part of the 1%, then it's also fallacious. Maybe that's the point, and I missed it. Agreed. But there's also a world of difference in my mind between someone making minimum wage, supporting kids, who gets a net tax rebate, and someone worth a couple of million not paying tax. I'm pretty left wing. I don't mind paying taxes to provide social services. I like having them there when I need them. I don't think this mentality is as common in the states.

I didn't realise they were that cheap. They've been going for twice that here, but a lot of things are very expensive. Any loss of charge over time? I haven't noticed any with the Kindle. Shows how much I know! I thought they had a back-lit screen. I broke my first kindle dropping it from waist height onto a hard floor. Amazon replaced it free of charge, because it was still under warranty. It wasn't too inconvenient. I read my Kindle on the subway. I figure if someone wants it, they can have it. For $150, I'd rather not get dental work. I'm not sure if I'd feel the same way about an iPad. Sounds like a ringing endorsement of the iPad. If I can find one that cheap, I might have to try it out. I'd always thought these were two separate markets, i.e. Kindle = reading books, iPad = laptop replacement, surfing. I still like my Kindle, it's fantastic for reading plain text books. I just wouldn't expect it to do much else.

I have a Kindle. I love it. But it's mostly good for plain text. I've saved a ton of money unethically downloading .mobi format books off the net. I've downloaded some textbooks on it, but the diagrams don't reproduce well, and aren't in colour. It's an almighty pain to move around images and zoom in and out. And the cost difference on most texts is around 5-10%. It's also very difficult to read .pdf documents on. Great screen, great battery life (weeks), very light. Refreshes reasonably quickly. But it's not really functional for browsing, beyond maybe checking your email. The technology doesn't allow for video / animation. But it does a great job of replacing the average paper back book, and takes up a lot less space. I can read for hours without eye strain. It's not back-lit though, so if you're reading in low light environments you need a light source. Works fine in bright sun. I wouldn't use it for textbooks though. I'd get a paper copy. I have no experience with the iPad, but the things I'd be concerned about are (i) cost, (ii) battery life, (iii) eye strain when reading, (iv) whether I'd feel happy pulling out something that expensive to read in a public place, or throwing it around in a work bag.

Nice! I wonder where that is?

I'm not sure if I understand all the motivations behind the "occupy" movement, but I think this article presents a false dichotomy. It seems to suggest that either you're one of the 53% of Americans that pay federal income tax, or you're a member of an "Occupy!" group. My impression (albeit from afar), has been that there are plenty of people who pay federal income tax that are dissatisfied with the current situation, and have been protesting. It seems like one of the many (and often confusing) issues has been that some of the richest Americans aren't contributing income tax, due to various tax loopholes. I have respect for anyone who manages to educate themselves and move out of poverty. I think when you've done that, it's tempting to feel like "you did it yourself", and as if no one else had a hand in your success. I don't think that's really often the case. And even if it is, and you manage to succeed, does it mean that the system doesn't need changing? Or that it's fair? I have a hard time, as an outsider, hearing about discussions on the federal deficits and national debt where one side is drawing a line in the sand and saying "no new taxes", even to the ultra-wealthy. Choosing to have low taxes, is choosing not to take in revenue. It's still ultimately spending. Instead of spending on schools, or the military, or health care, it's general spending on the population of people with taxable incomes. It seems like any approach to deficit management that focuses on either taxation, or social programs, is overly simplistic and doomed to failure. I'd also question the 53% number. It seems hard to believe that 53% of eligible Americans are paying federal income tax if the current unemployment rate is 9%. I suspect that these numbers are being counted differently, and that it's not that 38% of Americans are employed but somehow committing tax evasion. I wonder if the 53% number being reported include people who pay income tax, but get a net tax rebate? Or children, retirees, chronically disabled, and people in general who aren't included in unemployment figures.

I think you have a great attitude, but I just want to discuss one of the points you've made here. I think the benefit of intervention by EMS has to be balanced against the benefit of getting the patient to definitive care. I've personally seen crews trying to do RSIs on multi-traumas within 5 minutes of a trauma center, on patients' whose airways were maintainable, and could be BVM ventilated to >90%. The vast majority of these patients are probably better waiting the 5-10 minutes to have their airways managed by an ED physician. I've also seen people try to intubate in the ambulance bay at the receiving hospital when there's far more skilled people a hundred meters away. Neither of these make sense to me. I'm not saying there aren't instances where it's better to sit down and take some time, e.g. an MI patient, while organising a cathlab activation or doing thrombolysis, patients who need airway management who are a fair distance from a trauma center or are going to be transported to a minor hospital pending medevac. I just think we have to be careful to make sure that what we're doing in the field is always in the best interest of the patient.

Let me start by saying that I don't have recent experience in this system. I don't want to post my identity on the forum, but if anyone wants to pm me, I'll be happy to chat more candidly. I agree with squint that there's an element of "divide and conquer" here. As long as providers are fighting each other, they're not organising for the common good. Whatever inequities exist in the system, they won't be solved by one rural line medic and one city line medic arguing over who's got the better skills. Just as the various FD and EMS system clashes in the past were never fixed by two front-line providers getting in each other's way on a call. I think that the rural providers have been historically underpaid. It's good to see their wages brought up to par. If this has had to happen at the cost of stagnation in the bigger centers, then that's a shame, and obviously undesirable. I imagine a positive with this change is that it must now be possible to leave the city after 10 years, go to a quieter rural service, and not have to take a huge pay cut. In the past a lot of the senior guys would have had to take a huge hit to do this. I'm a little biased towards the urban providers, I have to admit. I also agree with squint where he suggests that there's a lack of a real critical care level in AB. It seems a little silly to have AOCPs including Swan-Ganz monitoring, ABG analysis and x-ray interpretation when very very few providers have had more than a few hours of training in these areas, have more than a cursory understanding, and are unlikely to be exposed to them on anything approaching a regular basis. Is running a transfer to the city with an intubated patient and a pressor running critical care? Maybe. But then, is doing a 12-lead, and giving tenecteplase, plavix and enoxaparin critical care? Perhaps. Because that's been done in the big city for 10 years now. My experience has been that any system has it's five percenters. This even includes STARS. I can't argue if the average rural medic is better, or the average city medic (I could accept the argument that the average STARS medic might be). They're different roles. I can understand the frustration of flexing all over Planet Earth, doing hallway nursing and running inner city calls. I can also see how working rural, doing LDTs for patients with antibiotics hung, and being on call when you get home can be pretty tiring too. It will be interesting to see how AHS manages to attract providers to the less desirable services / positions, now that they can't simply raise the wage for a given region. I'm woefully out of touch with the current situation, however my suggestion would be that the best thing for EMS in AB would be to increase educational hours, and extend the training for both EMTs and paramedics. Move to a Bachelor's degree program, as the RNs did, and provide a more solid basis for clinical practice. If I recall, paramedic training has been 2 years since the early 80s. And despite all the scope of practice changes, and increasing responsibility, it hasn't been extended a day since. This would seem to be a critical issue to address. As an aside, regarding the skills argument. Obviously competency is a range. It's not a binary outcome. Some people are more competent than others, and will find themselves at different places within that continuum. There's been studies suggesting that cardiac arrest survival is higher when patients are intubated by providers with > 25 ETIs in the last 5 years [1]. This is obviously subject to a lot of confounders, and some of the odds ratios are a little sketchy There data showing that paramedic students success rate improves as they intubate more patients, and they suggest a minimum number of ETIs for initial training is ~ 25 intubations / student [2]. This is probably fairly intuitive. It's also been shown that paramedics that intubate more frequently have higher success rates [3]. There have also been many reported studies discussing the effects of restricting intubations for paramedics who perform less than 6-12/year [4][5]. A decay in intubation skills following paramedic training has also been described [6]. It's not like this hasn't been investigated, although obviously it could use some further study. Without straying too far off topic, skill decay and retention may be a particular problem for the rural paramedic [7], but is also an issue in the urban setting. I'm sure there are city medics who aren't intubating 6 times a year (and six times a year might not be enough, especially if the success rate is 0%, or the patients are traumatised / subject to excessive hypoxia / hypercapnia, etc.). This is why there should be a good quality control and continuing education program in place to meet the needs of providers that aren't getting sufficient exposure to skill practice. All the best. [1] Wang HE, Balasubramani GK, Cook LJ, Lave JR, Yealy DM.Out-of-hospital endotracheal intubation experience and patient outcomes. Ann Emerg Med. 2010 Jun;55(6):527-537.e6. Epub 2010 Apr 14. Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071147/?tool=pubmed [2] Warner KJ, Carlbom D, Cooke CR, Bulger EM, Copass MK, Sharar SR.Paramedic training for proficient prehospital endotracheal intubation.Prehosp Emerg Care. 2010 Jan-Mar;14(1):103-8. [3]Garza AG, Gratton MC, Coontz D, Noble E, Ma OJ. Effects of paramedic experience on orotracheal intubation success rates JEM (2003) 25(3):251-256 [4] Burton JH, Baumann MR, Maoz T, Bradshaw JR, Lebrun JE. Endotracheal intubation in a rural EMS state: procedure utilization and impact of skills maintenance guidelines.Prehosp Emerg Care. 2003 Jul-Sep;7(3):352-6. [5] Wang HE, Abo BN, Lave JR, Yealy DM.How would minimum experience standards affect the distribution of out-of-hospital endotracheal intubations? Ann Emerg Med. 2007 Sep;50(3):246-52. Epub 2007 Jun 27. [6] Zautcke JL, Lee RW, Ethington NA. Paramedic skill decay. J Emerg Med. 1987 Nov-Dec;5(6):505-12. [7] Youngquist ST, Henderson DP, Gausche-Hill M, Goodrich SM, Poore PD, Lewis RJ. Paramedic self-efficacy and skill retention in pediatric airway management. Acad Emerg Med. 2008 Dec;15(12):1295-303. Epub 2008 Oct 25.

Quick points: * I won't fault you for pulling the tube in case #2. If you have any concern that it's not tracheal, you should remove it. [Aside: capnography could have been helpful here, as could doing another direct laryngoscopy to check whether the tube has migrated, and checking insertion depth / pilot balloon inflation. But if you're still in doubt, far better that it comes out.] * Personal opinion: in most situations missing an intubation is not critical, providing you can manage the patient with basic maneuvers. You are going to put tubes in the esophagus from time to time. As long as you recognise this promptly, and remove the tube before any harm occurs, this is minor. But letting a misplaced tube sit in the esophagus out of a refusal to accept that you may have missed is unacceptable. * When you're not paralysing, you often have to deal with some muscle tone in the jaw. I think when you have a weak gag, a little lidospray, or a small amount of sedation can be helpful. Sometimes you can finesse the tube in. If the patient is actively biting down, and fighting the intubation, it's time to back out, give some pharmacology and approach again, hopefully with improved intubating conditions. * You mention this may have been a primary respiratory arrest. If you're dealing with a lot of compliance issues, having to use high pressures, and having issues with oxygenation and ventilation in the post-resuscitation period, then obviously an ETT is going to be of benefit. But realise that doing an RSI is very committing. Paralysis may further compromise ventilation, and the patient will desaturate very rapidly if you're not able to adequately preoxygenate. * If your major concern right now is airway protection, and if BVM ventilation is giving you reasonable oxygenation / ventilation, the patient's mentation is improving, and there's some spontaneous respiratory drive, it might be worth deferring the intubation. If the patient continues to improve the hospital may be able to do some magic with BiPAP. * A lot of these patients are cardiac arrests, right? Remember that good CPR and correction of the underlying cause are the focus here.

I'm not sure if this is directed at me, but just for the record, I'm not attacking you personally. I'm just disagreeing with your opinions / position. There's a very real distinction between these two things that a lot of people seem to miss, especially when discussing situations on the internet. Do you? I mean, I have no education in management, and no experience as a manager. So I'm pretty much completely unqualified to have an opinion here. That being said though, it seems hard to think that any set of policies & procedures can adequately predict or attempt to address every particular situation we deal with in the field. I can think of numerous instances from my time in EMS when managers chose to ignore or outright violate various policies in specific situations. Often this was justified as being done, "because it was the right thing to do", or it was seen as being "in the spirit of the rules". These people managed to do this in the confines of a collective bargaining agreement, dealing with a fairly aggressive union. If there's a conflict between a written policy, and the best judgement of the supervisor, or the employee, shouldn't one of the first questions we ask be "is this policy pertinent to the situation at hand?", or "in light of these events, should this policy be changed?". This may be a silly question, but aren't the policies and procedures of a given organisation a dynamic entity subject to change over time as new situations are encountered or best practice changes? I don't understand what you're trying to say here? Of course I can disagree with the company's policy. I'm also able to disagree with statement's like "the sky is purple" (take that, Jimi Hendrix), or "1+1=2". I don't expect my disagreement with a company's policy is going to magically change the fact that they have a policy I disagree with. I mean, it would be nice. But it doesn't seem likely to happen. I don't understand the logic here. Surely safety (which is essentially risk), is a continuum? We can agree that me placing a portable radio on top of the dashboard while driving an ambulance is a "safety concern". Me sitting on the hood while my partner drives 120 km/ h is also a "safety concern". Just because both of these actions are unsafe, doesn't mean that they're equally unsafe. I think this is another false equivalency. You raise a very good point that the patient compartment of an ambulance is not a good place to be in a collision. I just can't agree that the risk of injury in a collision is the same whether the patient is restrained in a harness on a cot, compared to lying on the ground. If this is the case, then why use the restraint system on the cot at all? Would you have an issue with a crew that routinely transports patient's without seatbelts? Or a crew that refuses to use a child safety seat or restraint system (e.g. a Pediamate) because "the patient compartment is fundamentally unsafe... so why bother trying to provide an incremental increase in safety?". [Edited for "there" verus "they're"]

How do you think this would promote a "safety culture" in the work environment? Do you feel that firing someone for exercising judgment and having a genuine concern about the safety of the patient will promote safety in the future? Or do you think that it's more likely that providers will be reluctant to identify concerns to management and will engage in more risky and potentially dangerous behaviour? Furthermore, if OP is otherwise a model employee is this really sufficient cause to terminate? Isn't best management practice in this situation to attempt to coach and counsell OP so that they become a more productive employee and adhere more closely to SOPs? Wouldn't it be a waste of OP's (presumed) valuable experience, and the cost involved in hiring and training him/her? Obviously this situation is a judgement call. I've been fortunate enough to work in a service where a bariatric truck is part of the fleet. In the setting of a scheduled stable patient transfer, I would wait until this unit was available. Granted, that doesn't appear to be an option here -- but I can't fault the OP for having a safety concern, and I think I would have done the same thing. As you say in one of your many posts, we all have the right to the opinion. But that also means having your opinion challenged. What I don't understand is the logic and reasoning you're using in your thought processes. I don't understand why you've felt it necessary to attack usalsfyre, especially when you suggest that because he would refuse to transport a scheduled stable patient due to an identified safety concern that he's somehow bigoted, racist or hates drunks? Not only does such an ad hominem attack have no place in a mutually respectful professional discussion, it also does nothing to strengthen you argument and is logically incongruent. Not to mention rude. It's clear that transporting this patient is very different from working a pediatric cardiac arrest, yet you've chosen to draw an equivalency between the two. As several (many?) poster's have identified, there's a whole different risk / benefit at play here. It seems that most people who've responded here would be quite willing to transport this patient in a less than ideal manner if there was an acute life-threat. It also makes little difference as to whether other procedures, such as IV dopamine in a CHF / sepsis patient, are dangerous but accepted. This doesn't make this situation any safer. Not one person here has said anything negative about the obese. In this particular instance being discussed, it's already been suggested that there's another medical reason for the patient's weight -- although I don't think that really matters. Is it not possible to have this discussion without it turning into an argument and a series of personal attacks?

Congratulations!

I'm used to 2.5mg or 5mg in 2.5 ml. I've never seen the need to dilute it. Are there times when I should be?

I think there's a tendency as you get older to look at the current generation of students and highlight their flaws, while forgetting what you were like when you were a student yourself. I haven't done a lot of teaching in EMS in a few years, although I've done some teaching in other settings. I do think that the educational requirements we set in EMS are way too low. I believe that we've reached a point where if we want to develop into a profession, we need to increase the training time. This isn't going to be easy, and is going to require a coordinated effort.

If I thought the pepper spray has exacerbated the COPD -- which seems entirely plausible, probably and reasonable in this situation, then I'd absolutely give some ventolin. OC spray could definitely cause airway reactivity. I would make an effort to attempt to distinguish an anxiety response from dyspnea as a result of bronchospasm, but if in doubt, I'd err towards treatment.

I think it would technically be IM

Right back at you! [Wait a minute; -- is this how the internet is supposed to work?]

I think I owe you an apology. Sorry. I don't think I really understood the spirit of the post, as much as I just saw a couple of lines, and felt, " Wow, this is kinda of a broad categorical statement about a large number of people". I felt like I had to challenge it, because it could give people the impression that EMS is a place where homosexuals are unwelcome. Now I understand a little more about where you coming from, I feel a little stupid. For the record, I wasn't trying to imply anything about your personal experiences. I was just trying to challenge the statement, if that makes sense. Sorry if it seemed personal.