DwayneEMTP

It sounds to me as if the OP is trying to paint the picture of a dissecting AAA. And if so, there is little to be gained and much to be lost by palping by an inexperienced, likely heavy handed, new EMTB. It also sounded, (playing devils' advocate) the the OP may be asking why we continue to teach abd palpation to students that, most often, won't have the educational background to do anything educated/intelligent with that information. I can agree to a certain extent on both points actually. Though without giving it some significant thought, which often involves waiting to see what Dust thinks, I can't really argue either way at this point. I do agree that if you're 'yanking the hands' of anyone off of a patient, most especially those of an already insecure, terrified 3rd ride EMTB then you need to take a chill pill. These folks have gotten into the back of the ambulance, again, most often, without the knowledge/education/training necessary to feel confident and productive, which often causes them to do some pretty dorky things. Making them feel even dumber by reacting to those dorky things in a foolish manner simply sets them back, when our job is to attempt to elevate them to a new level while in our care. I look at 3rd riders almost exactly the way I do my patients. They are in a place that they've been convinced by books and teachers that they belong, only to find that nothing actually works the way that they were taught. They are insecure, scared, have no control over the events occurring, and will be gone before they have even a tiny chance to remedy that. Chastising them for unprofessional behaviors that are predictable, in fact unavoidable does no good to anyone. In fact the new EMTB that steps up and gets in my way by being overly aggressive immediately gets kudos in my book. EMS is a contact, not spectator sport. It takes balls to put yourself 'out there' when on early rides, timidity should be discouraged even if initial brazenness is at first unproductive. Why teach it? Because a small percentage of them will stay in the ambulance long enough to learn it's value. Because it's a standard of care regardless of their ability to use that information. Because it forces them to actually put their hands on patients, one of the skills that many have a terribly hard time learning. Because for every DAAA 'near miss' there will be 5000 abds that have exactly nothing wrong with them reinforcing the more important skills stated above. Though you've taken a bit of a beating here, I think this is a great thread! At least it caused someone with my limited brain power to sit and think for a few hours. Thanks for the post brother. Dwayne

Yeah..I hear you. And agree. Censoring here would have been inappropriate, at least to the point of decertifying him, and I guess if I were to play devils' advocate I can even imagine a far out scenario where she's so focused on showing off her new boobs that giving them a grope might allow her to be refocused on her symptoms. How's that for a twist (so to speak)? Groping boobs as patient advocacy? :-) It just makes me want to spit in this dorks eye.... Dwayne

I hear you man. But here's the catch. If you truly want to get your hands dirty, if you really, really want to be a good EMT/Paramedic, then start today. Use spellcheck. Noobs rarely want to hear this, but let me try and make my point this way.... Those that responded, most noted Ventmedic and Dust are terribly competent and experienced. Do you see the difference between their posts and yours? Did you get a feeling for the value of their opinions and advice simply by reading their posts? I'll bet you did. That is what you need people to see of you. Not the 3rd grade posting you've done here. Use punctuation, capitalization, paragraphs, proper spelling. Show those that take the time to respond to you the respect of at least rereading your post before you post it. Intelligent presentation of your ideas counts here. Not always perfect presentation, but something that shows that you can be bothered to spend at least two minutes looking for the information you need. Not to mention that you'll be spending the rest of your career writing untold numbers of reports should you choose this path. So far you've presented as a young, "Show me the guts! Oh, and which way is it to the fire station??" kind of guy. I have a feeling that there is more to you than that...give folks a chance to see it, OK? I'm not sniping, simply trying to give you some information that is often too long coming. Good luck to you. Dwayne

Ditto. Certainly we've all had these kinds of patients? Maybe not, but as I work in Trinidad Co, the sex change capitol of the US, perhaps I just get more than my fair share. And no, though many of them, on both sexes have often looked yummy, there are certain lines one simply shouldn't cross, permission or not. Not assault I'd say, assuming she was able to consent, but the compliance by a medic is certainly evidence of of a level of stupidity that should be censored. Happy new year all! Dwayne

These were my thoughts almost exactly, though expressed more eloquently than I would have been able. [devil's advocate] If they had no gear because they were not on duty then their value there was limited to those things listed above. Though they had little to offer, and would possibly have exposed themselves to liability, I'm willing to bet that another, different story would have hit the media had they tried. Medics prove impotent in the face of emergency! (notice it says medics and not firefighters, as we all know the media is incapable of seeing Fire as anything but superhuman.) Witness, "The woman was dying! All they did was put a jacket under her head and call 911! I thought they were 911! She couldn't breath and they just stood there asking questions! It was ridiculous!" [/devil's advocate] It sounds as if they may have acted like assholes, though this situation, if they were off duty and without equipment, was a likely lose/lose. It will be interesting to see how it all fleshes out. Dwayne

http://www.screenjunkies.com/tvnews/jack-bauer-has-few-questions-santa-claus

I've only taken pics on scene, not counting Afg, a couple of times. Both were because I believed I had a significant MOI yet the pt presented clinically sound. I need the pic to convince the ER not to blow them off and send them home too soon. As I was seen taking them, I also asked one of the nurses to witness me deleting them off of my phone, just in case some other asshole posted something that might later be credited to me. We are expected to clear via NEXIS here. I can't really imagine a reason to post such a picture to tell the truth. Are you such a loser that you need to try and prove to others that you've actually seen a dead body? It that truly the defining moment of your life? What is the point to posting such things? As said before by my betters, legal or not, it's unkind, unprofessional, and possibly career ending...just say no to ridiculous tokens of false grandiosity. Dwayne

Or, if this seems to be an issue for you, simply snap a rubber band over each foot to differentiate.. I think I read that in a mystery novel... Dwayne

The blade passing the teeth is considered an attempt here...no peeking. I tend to think that this is a good rule. I think it causes you to use more intelligent, non invasive anatomical indicators to help guide your intubation decisions as opposed to a quick, "Oh, I see the cords! Let's do this guy!' Plus, it's my guess that most 'quick looks' might as well have been attempts when all is said an done as they end up not being quite as quick as they should have been. Not dissin' your service or your advice brother, just offering a possibly different perspective. Dwayne

We're required to have one per quarter in the OR under the tutelage of Nurse Anesthetist regardless of our intubations in the field. I thought this was dorky at first, but then I discovered that I learned something from them each time I went in. They are also big fans of EMS so are truly focused on helping us be better providers. We're lucky to have this opportunity. I've got six oral tubes and one one nasal tube, not counting the OR. Ten/one if OR is counted. Orals 100%, nasal 50%. This is over 6 months, so not quite two per month. I truly have no idea what the minimum standard should be. I've never really found intubation to be a terribly difficult skill if you're prepared before beginning and use a gentle touch. I'll have to leave the answer to that question to my betters. No idea what the national average might be. Dwayne

Yeah man, we get that, but did you get that the discussion surrounds the order in which these things should be done? Also, most people learned to regurgitate that sequence of events their first week of medic school. Why do these things? Why in that order? Should they be done differently? Can you actually answer/justify your answer to the question from the original post? And why can't you believe that we're having this discussion? Obviously it's gone on for pages, so there must be something to say, right? Also, if you really want to impress then provide the science that shows Nitro and Morphine are beneficial to your pt. Dwayne Edited for clarification of a phrase. No contextual changes.

I can tell you for a fact that the hospitals in Colorado Springs and Pueblo will all activate on my word alone, despite a negative 12 lead. Though my protocols demand a 'clean' 12 lead if possible before activation. But, should I activate based on s/s alone, which I've done once, there had friggin' well better be justification when I hit the doors. So, not sure where you've worked Crotchity, but here 12 leads combined with a medics impression and assessment carry some weight. Dwayne

It's been my experience that a pt in any significant pain will rarely speak in full sentences or show no sign of change in respiration so I'm assuming this isn't a a high level of pain. In this pt I'm likely going to get a set of vitals, skins, clear definition and location of the pain a 12 lead and then apply O2. I can't think of a single time that an ER doc was disappointed that I came to him/her with a baseline set of vitals. It's our job, as I understand it, to attempt to build a differential, apply interventions per our discoveries and then track the success or failure of those interventions. I've seen a couple of patients now, and it's been incredibly rare that I've come across one that would have benefited from me applying interventions without first having some idea what was wrong. What physiologic changes occurred when I applied the O2? Was the pt tachycardic? Was he freaking out because of occasional PVCs? Anxiety attack? What effect did the O2 have on those conditions? If they partially/fully resolved I will go in one direction, if they didn't I'll go in another. Only a thorough assessment will tell. The logic path I'm going to follow will depend on the initial presentation/assessment of my patient and the changes that occur secondary to my interventions. Oxygen is a drug, right? What other drugs do you use without being able to track their positive or negative effects? I do find it kind of funny that some speak with scorn of those that would choose to assess and THEN treat as oppopsed to doing it the other way around. Of course this is all with the understanding that my partner will get me rock solid vitals while I apply my 12 lead and fire is standing by chomping at the bit with their NRB already running at 15Lpm...probably the entire process will take around 90 secs to 2 mins. I have very little faith in 12leads but they can be useful and the hospitals love them. I'm not so much withholding the O's on this guy for that so much as getting the 12lead at the same time as my assessment, doing two things at once. Either way, the O's aren't going on until I've got a halfway decent baseline and at least a vague idea of what's going on, if possible. Dwayne

P3, though I hate stories that have been reported in the popular media to be reported as fact, you've also failed to give us the benefit of your source(s) of information. Where did you get your own 'unbiased' information? Not sniping, just asking you to be fair when calling others 'slow.' Dwayne

That is funny as hell right there.... Dwayne

Medic X to Base. Go medic x. This is Dwayne riding 3100 enroute to you with a 40ish year old female secondary to violent sexual assault 3 hours past. Pt was found with altered mentation laying on her kitchen floor amongst a significant amount of what appears to be her own blood. Pt earlier told mother that attackers tried to make her drink bleach and pt has strong smell of bleach in hair/clothing though airway appears patent at this time. Pt has several stab wounds to both feet that appear to penetrate all the way through as well as two wounds to her abd, one at umbilicus center, the other approx 3" above, pt has significant amount of clotted and unclotted blood at vaginal area. Abd appears to be distended, mother states abd is not only larger than normal but larger than it was approx one half hour past. Pt is tachy at 136, pulse somewhat thready, resps 32. IV access x 1 established with another working now. I'm going to be traveling non emergent secondary to traffic concerns but should be coming through your doors in about 5 minutes. Any questions? Base: No questions, see you when you get here. Upon arrival they were "shocked" to see me come through the door with a bloody, altered pt with two bags of fluid hanging. I was chastized by the charge nurse because I should have "Told them the pt was critical when I gave my radio report!!" After listening to the recording the doc later 'splained the value of listening to reports instead of just waiting until it's time to acknowleding that they are finished. In hindsight I guess I should have actually used the word 'critical' in my report. Not sure if this helps or not Doc, but actually listening to reports is one place I see a weakness in the system. Dwayne (Three hour delay secondary to mom and daughter being addicts and mom was hoping she'd 'get better' so that the police wouldn't need to be notified.)

First, and these are genuine questions, not attempts at insults: Are you typing, or using a voice recognistion program? Is English your primary language? If the answers are typing/yes then you will have a very difficult time getting anyone here to take your seriously while presenting yourself so poorly. As stated in the site rules, spelling, grammar, punctuation matter. You should think of your questions, type them out, reread them, read them yet again, and then post. Just trying to be helpful. If your answers are VR and/or NO then stick with it and we'll work it out. Tons of people here are more than happy to help those that need addl' support. Either way, there are thousands of people here that are intimately familiar with EMS and EMS education, but you're going to have to be more specific. Good luck to you... Dwayne

Hey all, I thought this video was pretty amazing. There's a part where a marine kneels down to shake a little girl's hand and she hugs him instead...Made me cry like a baby.... Hope you like it. Dwayne http://media.causes.com/576542?p_id=10418028

Yeah man, stupid initial response. He has a point, but it certainly wasn't helpful. I don't know about that school, so I can't help there. But it's unlikely that it will make a huge difference when trying to get hired. Whoever is hiring will have their own testing, hopefully, and that will be given much more weight, along with your perceived competence, than where you went to school. Try not to make any more significant decisions regarding EMS until you are through, or near through your Basic. While doing that you will make a lot of contacts, meet a lot of medical people and end up with a lot more accurate, significant information. Good luck man.. Dwayne

Ooops...ended up with the wrong quote in my post. But you all will get the point I'm sure. Those are hilarious squint! I've seen them before, but always find a few of them to laugh out loud to...grin. Thanks brother. Dwayne

Hey all, I think I did a poor job of representing our QA/QI process, or it is simply different than what others are used to. No one was on my case. Where I work this is not a punitive process. We submit our reports and they are reviewed before being permanently stored and uploaded to our medical director and are encouraged to argue our points of view in order to improve future accuracy. I actually enjoy this process. I believe that intelligent documentation is a very real part of my personal mental call review as well as an awesome benchmark for my professional attitude. Poor spelling, grammar, sentence structure? I would not consider it a favor if those that know and care about me would be comfortable watching me slip day by day further from my goals. I don't believe I'm better than the medics I have no respect for. Those that have met me will tell you that I'm not packing many more brain cells than are necessary to keep me breathing. I will slip, and my intellectual/professional quality will fail, the same as theirs did. Knowing this, I have chosen to do what I can to surround myself with smart, strong people that also find joy in the process of making me stronger and smarter as well. That is why I hold so many at the City dear, and get a little cranky when others imply that this is simply a place "to hang out and chat." I abhor the thought of being one of 'those' medics, the ones that do many parts of their jobs simply to get by. I hope to one day consider dust, ak, chbare, Vent, and many others of course, my peers, yet am very confident that I will be unable to do so without the kind, yet completely honest criticism from those that surround me. Please don't misunderstand. I'm grateful to all of you that came down on my side, ready to go to the mat to defend me. But in this instance I'm fortunate to work at a service that believes that details are important, education and criticism are important, but that anger, fear and punishment are not the most efficient tools to delivering those qualities to their employees. I find great joy in times such as a few weeks ago, when my boss came into the crew area and said, "Can someone please tell me, with a chest pain patient, what is our first pharm intervention!?!" All said, "That would be O2/ASA boss!" He said, "Mr. Womack, would care to share your treatment of your "chest pain" patient yesterday??" See, I had a lady that had obvious muscle pain secondary to using her new walker. History of developing pain was clear, Bilat chest, arm pain, tender to palp, complete resolution of pain with rest and shallow respiration, perfect lungs/12 lead, no cardiac history, etc, etc. I said, "Ok, Yeah, I didn't give aspirin, that was kind of a bonehead stunt...I get it!" And it was, and I did. I was so secure in my diagnosis that I failed to do the one simple, cheap, relatively safe thing that is proved to create a more positive outcome in AMI, just in case I was wrong. (No, he wasn't implying that I should have employed my cardiac interventions despite my assesment findings, only that, in this case, I could have taken steps to mitigate the patho issues should there have been an MI hiding underneath. see? I didn't do bad, my diagnosis was spot on as verified by the hospital, but I could have done better. And better, I tend to believe is where we'll someday find outstanding.) Everyone laughed and gave me hell, but only because we all understood that the reason to celebrate this misstep was because we all learned from it, as well as it wouldn't be so funny if I didn't show pretty good judgment most times. Anyway, I didn't mean to write a book, and I know that this environment isn't for everyone, but I wanted to explain this a bit as our service's attitude on performance as well as productive criticism and education is one of the things I'm most proud of when I mentally compare 'us' to 'them.' Have a great day all, and thanks for your feedback! Dwayne Edited to repair a few typos. No significant context changes.

Herbie, though I like many, many of your posts, I going to ask that you step back for a few days and assume that you're just not getting VentMedic. Of course, hopefully it goes without saying that perhaps you understand her perfectly and I'm the one that's confused, I'm just asking that you look at her posts through new eyes and see if maybe you've gone off in the ditch. One of the greatest gifts to me as a provider is to get to have conversations with 'realists', something that is too often a rarity in EMS. Vent, Dust, ak, Eydawn (though she's still just a kitten)..hell, a bunch of others, fit this profile for me. Many of my most closely held attitudes and opinions began with their council until I had the experience to verify their 'rightness' on my own. If you think Vent's opinions are harsh and aggressive, you would have really hated the 'old' Dustdevil. He's in a different place in his life now, but a few years back his opinions made vent's seem like a she's 'kind of on the fence..' As to the original topic, I think that perhaps (I haven't tracked it) half of my Medic Alert calls are accidents, maybe 25% "I just needed help with (my oxygen, getting back into bed, finding my medicines) and the last 25% people that are seriously acute and in trouble. I truly love to run calls. I don't care if the call is an emergency or not, I friggin hate sitting around quarters listening to the TV spew idiotic crap into my already questionable brain and take any excuse to get outside. One thing I've found inspiring is that one of the lady medics I respect a lot where I work started documenting the "I need help" Medic alert calls and dispersing that info to the other crews. I've started to follow suit. One that I got from her the other day went something like, "Martha, 86 y/o female on home O2 is having trouble changing her tanks or identifying when they are low or empty. Her health is beginning to fail so I believe that we'll see her much more often in the coming months. She lives at "xxxx", the best entry point is, "zzzz" her O2 is in the hall closet and her spare tanks are in the garage. Her normal delivery rate is X via NC secondary to COPD. No other significant pathologies. She's nearly deaf in her right ear and it takes her a while to get to the door. Mention her couch cover (a present from her grandson in Iraq) for cookies and stories!" I love the way she turned a common complaint into something healthy. We all look much more forward to running this call now, which we do once every week or two, as these details have made her 'real' to us, not simply another mistakenly pushed button. We're a low volume, rural service, (2-6 calls/day with a high percentage of significant acuity) so I'm not pretending that this would be so easy in many of your systems, but just suggesting that as this worked to brighten our days, there are likely ways to do so at your services as well. Anyway, just some thoughts after a pretty long week... Have a great day all... Dwayne

Unless you attributed the 'tired feeling' to a neurological deficit, which it certainly sounds that you didn't, I wouldn't have immobilized this pt. I just had a like conversation with my medical director after clearing several pts via NEXIS and then having the ER freak out and immobilize based simply on, in my opinion, "key words." As you mention, bicycle/auto, auto/telephone pole, ped/auto, etc. In EMS you certainly can't judge a book by it's cover. I asked my Medical director, "Does there come a point where getting along with our rural hospital is better for my pt than attempting to do more progressive medicine?" His reply was, "No, there doesn't. You explain your reasons for your choices, if they don't understand then educate them, if they still have issues they can complain to me. You, in no case, choose regressive medicine to make someone, anyone else happy." I wanted to kiss him on the mouth. Assuming this pt had no drugs/alcohol on board, was mentating properly, then I don't see any indication for immobilization. The words bike/automobile in the same sentence do not trump intelligent assessment. Not ever. Awesome question, and responses. Dwayne

I have no idea what you're talking about.... Just sayin'... Dwayne Thanks Doc, I'll check it out... Dwayne