DwayneEMTP

That is interesting...and a little scary. It does seem that the website that LS posted does do exactly what they claim to be protecting against...I followed the "pic" and "map" links to a couple of the hotter sounding names and it did in fact take me to google maps and show me just where they lived...seems wierd. If I was a predator I would live on that site... I followed the instructions on my BB and found that the 'geotagging' button was already disabled. But I'll be talking to Babs about hers... Thanks for the post LS, and the link...good info. Dwayne

Hey man, welcome! "Don't haze me bro!" That is friggin' hilarious! Glad to see you here, and glad to see you posting! Medic school can be a challenge. I think it was just around the half way point that I was convinced that I had no friggin' business becoming a paramedic..I was just too dumb...Unfortunately I've proved myself correct since then... :-) I look forward to your thoughts brother. Dwayne

Yeah man, I hear what you're saying. I was trying to make my comments clear so that everyone could see that they were meant to be taken in the original context of the OP. If you tell me that you rolled on a guy spraying blood after his wife slit his throat, ashy, yadda yadda, and yet you got him alive to the trauma center 20 miles away and are proud of your save, I have no issues with that at all. Tell me that he 'coded' enroute and you got the 'save' and he had better have walked out of the hospital or I'm calling bullshit on your story. See? It may seem as though I'm looking for ways to split hairs here, but I'm really not. At least I don't think so. This is EMS, and for most of us that means medicine, and part of that, in my opinion is trying to the best of our ability to be accurate, for the pts sake, for the sake of our professional appearance, as well as for the educational value that comes from having a 'no bullshit' zone. So, though I don't disagree with you in the context that you and the others mention, in the context of a 'code' the context posited by the OP, I still disagree, though am enthusiastic to change my mind given the chance! Dwayne

Was posting the same time as you Mike, so I'll not repeat what I posted to Jim and Herbie above. Actually you did! My first thought was, "I can't believe on top of all of this he's going to make me call him a lying prick in this thread of all threads!!" Heh...Pretty funny Ruffster... Dwayne

In a general sense I see what you're saying Herb,Jim, but in this case the discussion began with,"My last week of work before my TT, I had 2 kids code on me." So I don't really see the ambiguity here brother.. Unless we're going to argue that "code" in the context of EMS is also ambiguous? Dwayne

I very much disagree. In the context presented its in reference to the saving of two pediatric cardiac arrests, a very different context than to say that "I helped save a distressed child." I truly don't enjoy being an ass in this, believe it or not, but I do believe that we have an obligation to teach when we can, even when the teaching may be hard on a good story. The City is first and foremost an educational platform, by it's own definition. These calls don't speak to cardiac arrest, at least not as presented, they speak much more to respiratory induced bradycardia, which is a different animal all together. Combine that with the fact that Mrs. Bull works at a popular tourist attraction above 14,000 ft and the theory gets a bit stronger still. Does that make the care given, and the ultimate outcome less enjoyable? Not for me, no, but for many, yes. I gently challenged the calls not because I dislike Mrs. Bull, in fact she and I have been acquainted for quite a while and visit sometimes. I make the possible corrections (as I of course don't know if I'm correct either) because if we allow respiratory arrest to be described as cardiac arrest its not long before the forums are full of, "I had a call the other day where a woman had, you know, vaginal pain? And while we were taking her to the hospital, I looked down 'there' and it looked like she had vines growing out of the opening part? And, like the ER told me later that she'd put a potato up inside her thing, and it had started growing!!" And these posts will be met with a rousing chorus of, "OMG! I had a call just like that!!" If you stay here long enough you'll see what I mean, I promise. Honesty is sometimes hard on a good story, but hopefully the knowledge gained by picking calls apart becomes more valuable than the dearly held, though most often fictitious, miraculous victory. Thanks for taking the time to post. I look forward to your thoughts. Dwayne

Welcome Jim! Our NY members tend to be a never ending pain in the ass. I'm hoping that you'll try to set a better example! (Good luck with that.... ) Dwayne

Sorry babe, but I don't see the codes or the saves here. It sounds as if both kids improved with CPR and vents which likely makes these a bradycardic/respiratory issue more likely, and not cardiac. I don't mean to be a downer, but want to keep things real and in perspective for those new to the field. Dwayne

I loved this story. Everything about it, and you're right, that some calls get to you. And then you're even more right. We all have things to learn from these shared experiences. Good work brother. I like this a lot, for many reasons. First, he is a child now, right? Like a child he's in a situation where he has no logical tools at his disposal. We know this, right, because he's chosen illogical tools instead? So relating to him on that level, within reason of course, makes sense to me. Also, it helps remove the 'fault' from your treatment. Did he really try and kill himself, or was he pretending to get attention? Is he habitual and just arriving at the logical conclusion of his previous habitual behavior? Is this the 15th time he's pulled this crap? It doesn't matter to our care, does it? Obviously he's broken in some way, and dealing with broken people, either physically, or emotionally is what we do, right? Awesome attitude for a provider man, I'm really proud of you. One thing I've found that seems to help here, to help some look at getting help differently, is to say something to the effect of, "I know that you think that getting help means going to someone that will help you to pretend to be better. That you'll feel the same pain, but they'll teach you to put a better face on it. But that's not true. I've been where you are (And I have, and in those moments it's near impossible to believe in the possibility of 'better', much less good) and its not about pretend. If you seek the help, and commit yourself to it, one day before long you will walk out of this this dark tunnel into the sunshine and it will be good, not pretend good, but really good. You will be happy to be alive. And you know what? If you have anyone in this world that you love, or have anyone that loves you, you have no right to choose not to get healthy, because they need you just as much as you need them." I don't know why either. But I'm glad he did. Because next time I end up in an emotional shit storm that I can't seem to find my way out of, I hope you'll come and take care of me. Heh, check your grammar. I think you mean 'lose' it. Unless you were so upset of course that you went back to the station and pooped your pants. But hey, no one's judging... :-) Made perfect sense to me. And you've not posted anything so far that I can think of that wasted my time. Thanks for sharing man. This story exemplifies the best of EMS, so it doesn't surprise me that it came from you. I have had a few calls similar to that, and will post later if I can sneak away... Merry Christmas all! (And don't tell me it's too early ! I wait all year to say that!) Dwayne Edited for grammar. One of the things I hate about criticizing people's grammar is that I then have to spend about 3 hrs rereading MY post to try and ensure I didn't make any bonehead errors. :-) For the record, Ugly's presentation is alway really good in my opinion, I just thought it was hilarious to talk about him pooping his pants.

+1 from me for making the effort! Dwayne

Zippy, I've never had any issues with pt slipping around on a quartered blanket. A properly restrained pt shouldn't have much room to slip around, and if the situation occurs to cause them to slip I can't see where the blanket would cause them to slip more than they would when wearing clothes, a gown or being sweaty and naked. The main benefit, other than feeling like a better person for making them more comfortable, is that it eliminates most of the voluntary movement in the majority of pts. They don't fight so hard if they aren't so uncomfortable. And more comfortable means better history, more compliance to interventions, more cooperation. At least that's been my experience. Without a direct order from a physician, or some other unforseen, unavoidable complication, I will never again choose to board a pt without the blanket. Dwayne

LBB seems to be in the same category as resps during CPR. Lots of evidence that we're hurting people with them, but very little to show that we're helping anyone with it. In this scenario I would likely follow Dr.s orders unless there was an obvious reason to question them. And then I would quarter a blanket before putting them on it. Lots of variables that haven't been discussed, but in this scenario, either for the transfer or at their home, from a science based medicine point of view, spinal precautions would be 'cover your ass' only with no provable benefit to the pt and some possible detriment. Dwayne

See, I don't get this. You claim that we take an oath to do no harm, yet why have you placed the IV in the persons arm? Is it somehow to their benefit that you've done so? Are you being this persons advocate by doing so? This is a good example I think. If its proved to be unethical for him to end a life at a pts request, is it also then immoral, and if its unethical, but not immoral, should he feel obligated to stand on his morals and damn his ethics? That I can truly see as a personal decision. Are you then saying that an EMTs role in capital punishment is so morally certain that the ethics should be ignored? On what grounds do you find the moral weight you seem to give to capital punishment? Where is it's over riding moral goodness? Prison is about punishment, not rehabilitation, you shouldn't confuse the two. I don't think that I've made the argument that there aren't some evil sons of bitches on death row, but even if I had I don't really see where that changes that the argument of morals and ethics when EMS is involved in their execution. Is that also your feeling about the AMA then? I don't understand this at all. Please don't translate "I don't understand" to "It's so stupid I just don't get it" as that is not my feeling at all. I have respect for your opinions, and even agree with some of them, but I'm truly lost here and would be grateful if you could get into more depth so I can more easily explain why you're wrong.. :-) At this point in our captial punishment history I would in fact refuse to participate in a capital sentencing. Not because of religious faith, but based on my moral certainty that possibly killing innocent people on purpose or accident is an evil fucking thing to do, regardless of the precautions taken. Thanks for your thoughts all... Dwayne

So then, when you have to pull the switch on one of those beautiful red headed children of yours, you will consider that an acceptable loss? Evidently $50,000 buys more than it used to.... It's easy I think to consider being part of capital punishment when you consider that the mistakes that have been made involve other peoples children only. But more more difficult when you consider that there is every chance that the mistake might involve one of your own... I am suprised by the overriding thought here of, "Fuck ethics. They were convicted and I'm more than happy to be part of the team that kills them." Had I asked, "Do you think that it's ok to do a 12 lead on a woman with gnarly great boobs just to you can get a peek and play with them a bit?" The entire board would have erupted in, "That's bullshit! That's unethical, immoral, unprofessional behavior!" But when I ask, "Are you willing to assist in the killing of someone despite the fact that you've joined a proffesion that has sworn to be a pt advocate above all else?" the majorit have said, "Well, sure. The shithead had it coming!" So suddently ethics is out the window then? When a behavior makes you feel good and strong and macho, like assisting in an execution, then ethics are bullshit, but when they make you feel all warm and fuzzy, such as in being offended by sexually perverted behavior they have a strong social value? Who's going to be the first to step up and explain what appears to be a hypocritical, or simply shallow and ignorant thinking? Dwayne I would argue that the majority would not consider state sactioned killing as murder. If you defend yourself, have you then committed murder? You have not, based on the accepted definition of the word. Murder definition: Intentional homicide (the taking of another person’s life), without legal justification or provocation. http://www.duhaime.org/LegalDictionary/M/Murder.aspx I posited the question with morality and ethics, two terms unfortunately often considered synonymous by many. I'm proud of you crotchity! Because if there was ever an issue that illuminates state sanctioned racism, this would be it. And I agree with you that we can't really have the moral and ethical debate without considering the religious implications, though I hadn't thought of that at first as Annie was kind enough to point out. Humans are complex creatures, rarely making any decision based on one set of criteria and in our country, as in most, religion is rarely separate from those decisions. Dwayne I disagree on both. The fact that we have not been able to find a correct answer regarding morals certainly doesn't mean that it doesn't exist. I believe that it does, and do not disallow it based simply on the fact that I've not been intelligent enough to find it so far. I believe that you misspoke when you said that we can argue ethics all day. Is assisted suicide unethical at this point in time? It certainly is, as the AMA and many legal bodies say so. And that is the ethical standard. Is it immoral? I don't believe so as long as it's very, very, closely controlled. I could be wrong, but that appears to be an oxymoron to me. You aren't responsible for the execution, but the execution will not occur without you there, so if you are there then the execution must be in at least part, upon your shoulders, right? (I'm guessing it goes without saying, but I will say it anyway just so I feel better that, "Well, if I'm not there, somebody else will be!" is not a logical argument, not one in keeping with the spirit of the intended debate in this thread.) Continuing tangent.. (My thanks to Lone Star for his comment on this being out of place and trying to keep the thread valid and on track, but it's just too juicy to pass up.) Close? Really? Do you have children? Grand children? Neices or nephews? Would you consider their innocent deaths acceptable losses for the continuation of a practice that is many times more expensive than a term of life in prison, and creates irrevocatble consequences? Really? You and a couple of other seem to feel that as we now have DNA testing and TV show like investigative techniques (that, by the way are not employed on all classes of society) that the chance of error in false convictions is zero. A quick Google search will show you the error of this thinking. The problem is that, though capital punishment has been scientifically proved to have no value as a deterent if just feels so fucking good, so God damned just that folks love it and are willing to look past their intellect and jump on board for strictly emotional reasons. And they don't have to pay for the mistakes made. The mistakes are kept quiet, rarely if ever in the news, so those wanting to participate get to feel heroic without ever being responsible for their decisions...that is where it sticks in my craw. Anyway, good discussion I think! Fun anyway... :-) Dwayne

Man...you just had to rub it in....

(I was so excited to jump on "equipment has to be approved by a medical director." as most of us own our own stethoscopes, but of course you had to go an screw that up by quantifying it. Thanks for hosing my chance at a cheap superiority thrill! I'd think you'd be more considerate during the Christmas season.) And I'm curious, what equipmant is one going to be willing to buy to improve level of care? I'll bet you dollars to donughts that we're talking about a pulse ox in this situation, and though I'd love to say, "What the hell does a medic need with a pulse ox in 99% of situations!?" I've become aware that even if you're capable of doing your job without it, that during transfer of care there are many that will feel that you haven't, if you haven't used it. I love my patients, but I'm not buying a monitor to improve their care, not am I going to trust a $30 SPO2 to back up my diagnosis. So I too am curious of what we're talking about here...But alas, as often happens, we may never know. Dwayne

So it's ok then for me to march my Jews into the gas chamber as long as the guard before me did the same? Awesome question, and I have no friggin' idea. Here is where we begin to disagree. If we are to accept the definitions of morals as: mo·ral·i·ty (m -r l -t , mô-). n. pl. mo·ral·i·ties. 1. The quality of being in accord with standards of right or good conduct. ... www.thefreedictionary.com/morality then we can agree to here still, as it is possible for me to believe that it is morally acceptable to kill in the name of justice where another may not. But, if we are to accept the definition of ethics as: 1. ( used with a singular or plural verb ) a system of moralprinciples: the ethics of a culture. 2. the rules of conduct recognized in respect to a particularclass of human actions or a particular group, culture, etc.:medical ethics; Christian ethics. http://dictionary.re...m/browse/ethics Doesn't it then remove the decision from the grasp of the individual and place it in the hands of the body responsible for the development of the ethical guidlines of the group, in this case prehospital care providers? Particularly following joint statements such as this...(Plested at the time of this speech was President of the AMA. I believe this to be relatively current but couldn't find a date on the page or document excerpts.) http://www.deathpena...o.org/node/1775 In his statement for the AMA, Plested noted: The American Medical Association is troubled by continuous refusal of many state courts and legislatures to acknowledge the ethical obligations of physicians, which strictly prohibit physician involvement in a legally authorized execution. The AMA's policy is clear and unambiguous — requiring physicians to participate in executions violates their oath to protect lives and erodes public confidence in the medical profession. But is that the public perception? And if there is a paramedic 'soul' so to speak, is it bruised by such behavior? I'm not morally opposed. I would, in the most beastly manner and with joy in my heart beat to death an intruder or one responsible for damage to my family. And that is not exagerating for effect. But as long as facts such as this, Post-mortem DNA tests have shown that some people were innocent of the crimes for which they were executed. Since 1973, 90 people waiting with death sentences have been fortunate enough to have lawyers and reporters intervene to demonstrate their innocence. (http://historymatters.gmu.edu/d/5420) exist, then I will be opposed to the death penalty. For the record, I'm making my argument based on what appears to be morally and ethically sound grounds as it applies to my sensibilities. As with abortion I'm in no way confident that what may prove to be right for me must also then be right for all. I'll never be part of aborting a child, but I can't pretend that I, in my uterusless state, are qualified to decide for everyone. I'm excited to hear the thoughts of all... Dwayne

I though you were so full of crap here. That perhaps you saw someone playing with one of those nasal intubation scopes, but lo' and behold, Google turns up pages of them.. $2 stethoscopes. Amazing. On the flip side though is the issue of people deconing their equipment, including their 'ears' which I have to admit, though I likely do it more than many, I don't in fact do it after each patient when I get busy. No excuse for that and now that I've admitted it to the world will try and make sure that I never have to do so again... Yeah, you beat my brains out with your figurative mental walker daily. I'm better for it and say thank you... Dwayne

http://www.naemt.org..._positions.aspx "Participation in capital punishment is inconsistent with the ethical precepts and goals of the EMS profession." What do you think? Should EMS personnel be allowed to make their own moral/ethical decisions concerning being involved in the taking of a life when the unique situation of capital punishment is involved? If an EMT can be prevented from participating in a legally sanctioned killing while off duty, as in a state sanctioned execution, should they then also be disallowed from using lethal force to defend themselves and/or others based on the same 'do no harm' ethos? If a physician, who is held to the same or perhaps higher standard of morals and ethics, is allowed to participate, then doesn't it become a no brainer that inclusion of EMS personnel is a given? I'm hoping that we can get into the spirit of exploring the morals and ethics of EMS and go beyond "I would never do that as I'm tasked with preserving life and not taking it!" as I'm also a human being and have a family to support. So perhaps my stance changes if I get $10,000/execution? $50,000? I look forward to your thoughts! Dwayne Edited to repair formating, no contextual changes made.

Good advice from all, with the exception, and I apologize that I'm going to bag on you a bitAmb21, of pumping the cuff up to 200 before beginning to listen.Try it, it hurts! Then imagine the frail muscles and tendons of the children or older folks that you will often be running on. That's the easy way, but it's also the lazy way. As is watching the needle jump. Every fiber of my body says that there should be a dependable relationship between the jumping of the needle and the auscultated sounds, and though I continue to try and give some validity to my intuition, I remain unable to do so. Also, if you're using the stethoscope provided by your company I want you to stop what you're doing, take that $12 dual lumen piece of shit that seems to be in every ambulance and run in a smack your supervisor across the head with it. (Though in the short term this may not seem like sound advice, I think that you will find that EMS runs on stories, and the value of this story will pay WAY higher dividends over your career that the value of keeping this particular job. Trust me on this.) In my sometimes no so humble opinion dual lumen 'ears' have almost no place in an ambulance. I've used some that were really good, but when you're moving they just give way too much random noise for you to learn with. You need to back things up now, make them easier, and then you can throw foolish obstacles into your path. Now is not the time for a dual lumen stethoscope. And as Herbie mentioned, regardless of your scope, make sure you know how to use it. Also, palping the artery is great advice. When he started they didn't have stethoscopes, they just had to put their ear at the crook of the elbow, so knowing the exact location of the artery was vital. Soon though, thank goodness, one of his partners saw an old movie (not so old then of course, but I've only see them on reruns) where someone spied on the people in the next hotel room by putting a glass against the wall and listening through it, and his practice was changed forever! (Don't tell anyone, but I'm convinced it's the reason for freakish 'roundness' of his ears to this day.) And lastly. This is not a skill that you should be learning in the back of an ambulance. You do not, not, not, not, practice new, sensitive skills under pressure if you can help it. You should be practicing this at home. Unless you are a complete asshole, of which I've seen no signs so far, you should have ample family and friends that will help. Quiet room, no tv, no radio, not during one of your Friday night parties, it should be very quiiiiiiiiiet. Palp the pulse as Herbie instructed, put your stethoscope on that spot and begin to inflate your cuff. As the cuff begins to put pressure on the artery it will get a little bit noisier for a few seconds before it gets quiet due to be occluded. Once it gets silent increase the pressure a few mmHg and then begin to release the pressure. Very Slowly at first! Ok..now this is the good part...As you slowly release the pressure you will begin to hear the heartbeat in your ears, right? Awesome! Now you've found a spot to auscultate...as you continue to release the pressure I want you to move your stethoscope around, in small movement, to use it like you might use a metal detector, seeing where the sounds get stronger, or weaker. Once you've found the loudest spot you've gone from A spot to THE spot. Even if you started out on THE spot, I still want you to move it around so you can see what it sounds like in different places, different distances from THE spot. What this should do is give you a feel for the underlying vascular anatomy, see? If you're like me when I was new I'd be trying to get a BP thinking "Oh God, please, please, please let me hear it!!" Hoping that the EMS Gods would send me the sounds I needed to do my job. Fuck that, I'm not asking, I'm going to take the information I need! It's been my experience that any time I truly needed the EMS Gods to send me the information that I needed to keep from looking like a complete shithead in front of a gazillion people (with seemingly nothing better to do than stare at me) that they simply laughed while making fart sounds with their hands in their arm pits. So I don't really trust them so much any more. Anyway. Babs is shopping, Dylan and I are done raking leaves and I had way too much time to write a bunch of crap that probably could have been said in three sentences, but reading it is the price you pay for asking questions on a forum with no real standards for who can reply. :-) Going to forgo the lung sounds for now as I have used up all of my spare time rambling, but others will give good advice I know, and if not then I'll throw in my two cents when I can. Good questions. Very brave to ask them here man...I have a lot of respect for that. Dwayne

Though I know not a direct answer to your question, perhaps it will give you a bit of information explaining the 'why' of the answers you've already been given. Also, though it's relatively easy to find research showing that PPV during CPR causes issues, I was unable to find any studies that show it to be a benefit in that instance. (Though was terribly committed to the task.) Has anyone heard of recent studies that show a benefit of PPV in an arrest? Edit: I would think that PPV during compressions would increase the likelihood of Abd distention, but that's intuitive only. Though I have run across information that says that it takes very little pressure, surprisingly little, during PPV to cause distention. http://www.dshs.stat...entilatory2.pdf (Words in Italics indicate paragraph breaks created by me for ease of reading.) "Purpose of review In recent years, it has become increasingly apparent that resuscitative ventilatory procedures, classically thought to be life saving, may have profound detrimental effects. Recent findings Most assisted breathing techniques during resuscitation involve the provision of intermittent positive pressure ventilation to inflate lung zones for erythrocyte oxygenation and clearance of carbon dioxide. A growing number of studies involving low-flow states, however, have demonstrated that provision of overzealous (or even 'normal') ventilatory rates with intermittent positive pressure ventilation can significantly diminish both systemic and coronary circulation, most likely through inhibition of venous return. Recent laboratory studies of hemorrhage have shown not only a direct detrimental impact of each positive pressure ventilation breath on coronary perfusion, but also how dramatic improvements in blood flow can be achieved, without loss of oxygenation, by delivering breaths infrequently during such low-flow states. Likewise, in cardiac arrest models, studies have shown that interrupting chest compressions, even to provide breaths, can be extremely deleterious by abruptly (and continually) lowering the aortic pressure head to the coronary arteries, thus impairing restoration of spontaneous circulation. Even with endotracheal intubation and uninterrupted chest compressions, frequent positive pressure ventilation still inhibits circulation during cardiopulmonary resuscitation. Despite directed training, paramedics (and other rescuers) have been shown to still excessively ventilate during cardiac arrest resuscitations. (Bold added by me) Summary Ventilation can have profound detrimental hemodynamic effects in low-flow states, exacerbating the circulatory compromise. This underappreciated confounding variable may be one of the reasons many clinical trials of resuscitative interventions have failed despite dramatic successes in the laboratory." Hope this helps man...great question.. Dwayne

First, though I adore her desire to attempt to arouse her husband while driving I'm not sure that it's the safest practice. I always make sure that I'm driving when that happens...because I'm responsible...Just sayin... Were you able to feel any pulses? Carotid, what did it feel like? Temperature? Posturing? On first blush I would be looking for a dysrhythmia and/or CVA, his meds sort of fit, but you'll have to try and track that down through pulse quality without a 12 lead. Second thought would be towards a vasculopathy, or as always, a combination of all... Dwayne

Yeah, other than the dispatched time and the address I completely disregard the type of incident given. Now, having said that, part of my clinicals in medic school was to spend 24 hours at two different dispatch centers and I was shocked that they hate the stuff they have to dispatch nearly as much as everyone else. At least at the centers that I sat at they were required to dispatch the call as it was received, no matter what information they are later able to obtain, unless it was going to upgrade the severity of the call. But anyway, it's always felt to me that preparing for the dispatched call was sort of like letting PD or a citizen give me my initial impresssion. Weird I know, but there you have it. Get the address, crank up the tunes (within reason of course) and chill until you're actually able to see what's going on with your own eyes... Good post Herbie, good to see you back. I hope that you're healthy in mind and spirit. Dwayne

Do you do a lot of emergent hospital transfers? I gave the + to the original post as I think the logic is sound with the exception of the police escorts. Rarely are lights and sirens needed. Perhaps we could use them only when they actually were, and if they were gone, or severely limited we could get every yahoo in the friggin' country to stop trying to do our jobs for free... Thanks for sharing your thoughts... Dwayne