DwayneEMTP

Yeah Herbie, it's recited as well as a hard copy. We keep an accordion folder with them behind the seat. Dwayne

At our service we do. We have about a dozen or so written by our medical director that are given to all who refuse if appropriate. Hypoglycemia, syncope, trauma, head injury...I can't remember them all, but I do go through them whenever I write a refusal, which is rare. I think it's a great idea and doesn't really take any extra time. Dwayne

I have a question that has been nagging at me for a few weeks now... 70 y/o male with a history of IDDM. Family calls stating that they talked to 'dad' on the phone 5 hrs past and that he seemed to be listening on the phone, but only made slurring, gurgling sounds in response to questions. After finishing their morning soaps, or whatever, they decided to go and check on him and find him unresponsive. Upon my arrival I find the pt with eyes open/tracking slowly, snoring respirations, unable to speak. Another medic that has run on him regularly and recognizes the dispatched address calls to tell me that she transported him yesterday with a BGL of 480 (per hospital labs) and that he normally becomes hypoglycemic with a BGL below 80. She states that he will refuse transport when normal mentation is restored. BGL now shows 72, all physiological markers make me comfortable that, at least partially, this is a hypoglycemic episode. Family verifies that he will refuse transport if 'woked up.' My decision was to adjust his airway/suction which restored a patent airway, remove to my ambulance and deliver D50, slowly, enroute to the hospital. (Approx 5 min transport.) I chose to remove this pt's ability to refuse, (or did I?) understanding that that would likely have been his decision based on these factors; 1. He had no support system at home. And that of his family was worse than unreliable. 2. He is obviously having life threatening issues in regards to controlling his IDDM. 3. This was his second life threatening crisis in two days, in fact I believe 4-5 in the last 10 days, despite having the County monitoring his "health and welfare." 4. The study I mentioned in another thread has convinced me that perhaps he is not normally mentating, despite appearances, when choosing to refuse. 5) My 'intent' was purely pt advocacy related without elements of 'not running him again today', 'lawsuit avoidance', etc. So my questions... 1) Did I violate this persons 'right to refuse' by withholding necessary interventions until leaving his home? 2) Despite being in the best interest of my pt, was this an unethical/immoral thing to do? And please, while telling me what a terrible medic I am, take a moment to justify your alternate decision(s). Have a great day all. Dwayne

A flight medic friend of mine was showing me a study he'd found concerning this. It was printed out and I can't find it now but will email him and see if I can get it... If memory serves, and it often doesn't as well as I'd like, the study created a very specific protocol to study hypoglycemic refusals. It covered the language used, the amount of time spent on scene to deliver instructions, etc. Basically it made sure that Pt's were alert, had a very thorough explanation of their needs secondary to post d50 delivery and instructions to follow up with their usual physician. They followed up with each pt 24 hrs post contact to attempt to see how well the instructions were followed, and found, (I'm pulling this out of my rear) that something like 80% not only did not remember the instructions, but had no memory of having been attended to by EMS. I was floored! And it has certainly changed the way that I handle refusals concerning hypoglycemic emergencies. If it isn't obvious to me that there is a support system in place to guarantee that the pt will receive the proper care without intervention necessitating their own initiation, I do all in my power to transport. Dwayne

Granted, but have you used your portable xray/cat scan to determine that you have such a fracture? I don't need such things to believe that if I have an obvious femur fracture and a distending belly that the threat of life ending hemorrhage in an entrapped pt may exist, right? For the sake of argument let's say that you can't get an EJ without lateral movement of the head, surely in theory it sounds like it would be a bitch to do. And let's again assume that you will get 10mL/min flow with the I/O or 60mL/min flow with the EJ (not sure if that's realistic or not on the EJ, but it sounds close.) With the above described symptoms, would you still choose to protect a hypothetical risk to life as opposed to attempting to mitigate an evident one? I'm really not arguing for this as I don't know what the most responsible course of action would be. But I do believe that if I had this patient sometime in the next 5 minutes that I would feel the need to manage the fluids first and hope that the EMS Gods would watch out for a spinal fracture. Also, I've only started two EJs (three attempts) and had no need for a C-collar on any of them, but I don't see the major issue surrounding an EJ and C-collar, assuming that the EJ was placed first and secured with the collar in mind. What am I missing? And for the record Kate; I think your thoughts are worth way more than two cents... Dwayne

Actually, you are certainly well informed. Yet, in every forum I've been exposed to it emphasized life over limb. Something about a well splinted corpse, or the such. Roj. Nor would I hope you'd protect a hypothetical spinal injury in the face of a realistic hemodynamic emergency. In fact...if I remember right, a large part of my thinking on this was taught to me by some big hairy friggin' dude in Afg...his name escapes me... Heh...Ok, so you might have a point, as it is getting difficult to find a decent argument here... Story of my life...but I'll take my chances. Thanks for your response ol' man... Dwayne

My response would depend largely on where he was found. I had this call and had to argue with my partner and the police defending my decision against transporting, as the pt was found in her living room. If I found this pt under the interstate, I would attempt to transport for his and others' safety. In their house, where do I find the right to force transport? Dwayne

I find the decisions curious here, to tell the truth, unless we're assuming multiple I/O starts. We've got a distending belly with obvious femur fracture which implies to me possible massive internal blood loss, yet each has chosen to start a single I/O so as not to be left having to manage the EJ. But what about flow rates? I've only started two I/Os, and my delivery rate sucked. Both had B/P cuffs applied and inflated to 220mmHg, the second had, after 40cc Lido, 3 NS flushed 'slammed' into them to attempt to create a 'cavity', as I've been told that may have effected my flow rate, yet both still sucked. I've talked to many others that have started many, and they claim that they have never achieved any kind of aggressive fluid delivery rates with them. Perhaps your experiences have been different? I believe I would utilize an EJ here despite the obvious inconveinciences based simply on the necessary flow rate needed to mitigate these injuries until extrication could possibly make other alternatives more available. I'm not realy sure of the relevence of this statement given the scenario. Certainly no disrespect intended to the opinions of my betters, but given the scenario, I believe that I would take the EJ route. Immobilization will have to wait until I've stabilized circulation. (All of this of course assumes that physiological markers verify the above expected internal blood loss.) Just a thought.... Dwayne

I've always thought of that term in the inverse.. An MI presentation is still a possible MI despite the monitor telling you that all is well. Unfortunately as long as we still have chuckleheads that believe that their pulse Ox can give you life/treatment altering information despite pt presentation then we'll continue to need such reminders. Thanks for sharing all. Dwayne Edited for typos only.

Does you class not have a required pharmacology text? That would make it much easier as you're certainly right, finding the information you need can be tiring and frustrating. Keep in mind though that that frustration can also pay high dividends by forcing you to think through your meds as opposed to simply memorizing them. But Mobey gave you the secret. I now carry one of the pocket sized nursing drug guides. I like it a lot, but as with any single source, I've sometimes found it to contain errors. Good luck. Dwayne

You know LS, every time I think that perhaps you're starting to move in a direction where you'll post logically, to show some type of decent objectivity you end up pulling me up short with this kind of nonsense. I keep coming back at you hoping that you'll want to 'play smart' yet you seem to believe that if you can just add enough !!! to your posts that we'll suddenly begin to believe that they make sense. Not happening man. It was her job to keep her personal dog safe? Do you truly believe that you will find that stated somewhere in her employment contract? Me either. Her dog is her property. Maybe you don't like it, but there it is. And Cos has, over and over, attempted to show you that the law does, when it works correctly, revolve around intent. Show me, (tongue in cheek as I know you will simply ignore this sentence) where the story shows that she had any idea that the dog was even in her car. Where does it say that? My neighbor killed (with my help) my dog with the uncaged gopher poison he put in his garden. (this was a rural area that allowed his garden to be directly opposite my home. The lack of fencing was common and accepted in this environment.) Believing that he'd done it purposely I went over to punch him in the head. (Yeah, I know...But I'm older now) When I saw the shock on his face, as it had simply never occurred to him that a dog would eat something intended for a gopher, upon learning that he'd killed my dog I instantly lost my animosity (pun intended) toward him. Why? Because his remorse suddenly breathed life back into my pet causing him to dig his way out of his grave and came home? No, not really. Because it was obvious that 1) he was already punished more than sufficiently, 2) there is not a single thing to be gained by punishing someone for something that they didn't INTEND to do. Simple as that. Something that I truly, in the spirit of friendship, hope for you...Your posting history shows a very clear trend of you making an indignant post full of capitalized words and exclamation points, continuing to reply to each intelligent response with the same illogical argument that you used from the start, and then simply quitting when people won't agree that someone should be beaten or killed for the grave sin of doing something that offended you. You need to learn to say, "Oh hell, I didn't think of it like that.", "Hmmm...I guess you're right." or some such thing. And you need to stop hanging around with people that allow you to succeed with elevated emotion connected to no serious logic tree. It's making you weak, and I hope better than that for you. Being proved wrong is a gift LS. But being intelligent enough to recognize when someone has bettered your argument is sometimes difficult and takes practice, though it's well worth the effort. It's unfortunate Cos that we agree on this one... Thanks to all for your responses. Dwayne

A finding of homicide certainly doesn't also mean a finding of murder. The two are related, but not synonymous. Dwayne

I've not heard of it being a wide spread problem 'at work' in the professional services here. Certainly you can find plenty of stories if you like, but I don't believe it to be a common work issue. At my service we have a 0 level of alcohol and 0 detectable metabolites for illegal substances. And they mean it. Dwayne

No, I don't hate basics in any way. Some of them get on my nerves, but being a basic is simply a co morbidity to being an ass to begin with.. :-) Yeah...I hear you. A word of advice for the future. Its imperative that you compliment for no reason, forgive the unforgivable, and talk a lot about how lovey lovey things are in chat...until you can man up and produce, no high fives for you man... See! That's a perfect example! If you were to talk like a normal person I might think you were saying that sometimes I mean to push, run right past aggressive and end up acting like an asshole. Now if that is what you are/were saying, then I'd have to stop and say, "Hmmm...He seems to have a point. If my posts continue to kill threads because they scare people off perhaps it's time to drop the self righteous bullshit down a notch or two?" Yeah, I get that. And can learn from that. And hopefully post more productively because you took the time to respond. Thanks man. And if so, then isn't the first, most productive thing that they can learn is that EMS requires intestinal fortitude? I mean, C'mon, if you can't be brave here, how will you ever pretend to defend your patients against all comers? Yeah, I get that. You lose me here brother. When you, Matty and I spent a few days kicking each other in the teeth, how long would that have lasted, or how convoluted would it have become had I not simply said, "Cos, I think you're and idiot and should be killed." and you, "Well, Imeth not so terribly...eth thrilled with your most seriously unattractive countenance either!" (or something like that) Paraphrasing of course... :-) I think the best thing to come of that was a lesson in arguing and/or debate. That was as aggressive as I've been here in a long time yet you never blinked, as well, you never got so bent out of shape that when it was time to let it go that you had trouble with that...We need to be specific. In one post I addressed Firefly, Kiwi, and Fiz. How long would it have taken for me to make those same juvenile points anonymously? Plus, people need to be held responsible for supporting their ideas and positions. No one benefits from coddling those that will suffer from being coddled. Right? That made my day... You're a peach. (And I don't really think you should be killed) Dwayne

Heh heh...you said....well, just sayin'... Dwayne

Firefly, Thanks for your response. I I certainly hear you when you say that you're tired of people bailing instead of digging in to fix problems. But surly you see that that is going to be a decades long solution. At least. Wendy is terribly over educated for the certification she carries, she simply digs EMS. Unfortunately her first foray into working the streets landed her in a backwards redneck service that still allows medics to get their rocks off by proving their superiority over basics. Idiotic. And yeah, when I see a post like Kiwi's I begin to wonder why I keep bothering with this shit too. He's a somewhat respected member here despite the fact that he spews that crap. We have 'respected' members here that preach higher education but are not able to do so in proper sentences. Sometimes it seems that the lazy and ignorant have used hugs and high five's to take over, and at times it's simply heartbreaking. You belonged on this board a few years ago when Dust and ak ruled the day and stupidity never went unchallenged. It's a different world now. I posted a month or two ago asking people to please explain their post edits. It was deleted. I can't imagine editing a post without explaining what I changed, even to mention that it was for spelling only, to be fair to those that may have come after me. I can't remember the last time that professional courtesy was offered here. Am I starting to sound like Wendy? Grin..yeah, I know, but I keep coming back too. Why? Because if no one speaks up, nothing changes. Not so long ago my response to Kiwi, you and Fiz would have started a 10 page debate..but now it's a thread killer. No one has the balls to debate and take a chance on being wrong or getting their feelings hurt, at least very few are willing to do so. I find it ironic that the biggest balls left on here come from our female posters...perhaps we need to change the saying to, "Yeah, they just don't have the boobs to run with this crowd." :-) I'm with you on change. I fight for it every day at my service, and it's one of the most progressive, well paying services in CO. Our medical director rides with us regularly, operating as our "basic" third rider, every single PCR is reviewed and commented on, we have a wide scope of practice, yet still we have the 'good ol' boys' and some firemen that think this is a game, or a hobby. Keep at it lady. Things do change. Probably not in my career, or perhaps yours, but at least being a pain in the ass gives us something to do during our down time... :-) Thanks again for your response. Dwayne

This is the most idiotic, self serving, backwards bullshit I've seen on here in quite a while. And there's been a bunch on here to compare against of late. If you're uneducated, ignorant, or simply lazy, then yeah, a broken arm is a broken arm. Though you have no idea what the "best" way to splint the arm is without some knowledge of anatomy and physiology. "Reduce it and get pain meds on board"...Holy shit.... Is pain control the only reason to administer pain medication? I hope you're answer is no. If Paramedic Jim Jim wants to spend his life working at a basic level, then yeah, this should be his plan. What type of fracture does it appear to be? Can I do more than simply verify pulses and splint? Of course I can. And Jim Jim can kiss my ass while he focuses on splinting the arm as he forgets to check for the possible pathologies that may have caused the fall, the co morbidities related to such a fall, etc. You espouse the ignorant cowboy medicine of days gone by, while parroting the idea of better education. It's transparent to anyone reading the post quoted above. Purposeful ignorance should no longer go unchallenged in EMS, or on a board that claims to be a source of education. Digging yourself into a hole with tunnel vision is another symptom of ignorance, not an over abundance of education. I get so sick of hearing the 'old time' medics talk about the "college educated medics that run around on scene like idiots...they just ain't got no common sense!" I didn't run around anywhere like an idiot during an emergency when I was lacking a college education, and at no point was I required to turn in my balls and/or common sense during or after. Overheard a coworker talking about her fire medic brother on my last shift. She relates the story about his run on a severe ped asthma attack. She said, "He had Albuterol on board, they were just a couple of minutes from the hospital and he'd just asked the kid, ' are you feeling better?' to which he replied, 'yes' and then he just coded! Nothing he could do....they lost him." I wanted to give her a swift kick in the throat. I asked, "what about Epi or Mag Sulfate?" She said, "There just wasn't time after he got worse. He was getting better and then just died!" I'm guessing you've seen ped asthma? Do you believe he 'got better' just before he died? Do you suppose her brother was blinded by his education? That he got tunnel vision from too much knowledge? He was either an idiot, that didn't see the physiological signs that told him his pt was incorrect in his self evaluation of his condition, or a coward that didn't want to push drugs. How would being less educated have with helped that? Right, it wouldn't. Just sayin'.... Firefly, I'm surprised by your evaluation of Wendy's posting history. It it seems you've been here long enough to know that a few grumpy posts don't define a person's posting history, right? She is easily in the same category with ak, Dustdevil, Fiznat and many others where A&P is concerned, and the vast majority of what's important is A&P right? I'm surprised to hear you devalue her opinion because she hasn't worked on a truck for very long. That's a weak argument and I've come to expect more from you. Experience has it's place, but very little of what I do every day involves experience. It involves confidence, organization, delegation, investigation, and a solid application of physiology/pathophysiology. Was my 30th breathing difficulty less stressful than my first? Sure. Did I examine it very much differently, or reuse the same decisions from my previous cases on this one? Not really...new person, possibly about to get run over by a different zebra..it all starts anew. I can't figure out why, exactly, that you were offended by her post and then spent paragraphs reexplaining all of the things she had already stated in a few sentences? Review her older posts and I think you're going to feel a little silly about asking her what she's doing here. Fiznat, you're my hero, but I very much disagree with your feeling that you have to do things the way others do them, or simply do what you're told until you've reached a point where you've earned the right to practice in a way that you feel is morally and ethically sound. (If I understand your post). I entered medic school with very definite opinions of right and wrong. I was gifted with many new opinions of pt care and advocacy while there. I refuse, and yes my life is sometimes made more difficult because of it, to work at a level below my moral/ethical/intellectual ability simply because I've chosen to enter a field where sub standard practice is often accepted as the norm. In no way am I a superior medic, but hopefully some here can attest to the fact that I've become a decent medic, and perhaps one day will be good, but I can not justify in myself, or suggest to others, that they degrade themselves and the field by feining 'less competence' simply to fit in. We make changes in the industry by elevating ourselves, and hopefully in the process giving others a helping hand to become better, not lowering ourselves to get by. My two cents... Have a great day all. Dwayne

First, how does this belong in this thread? Second, if you're not military you won't be doing much of anything for the Army. Third, you need to keep checking contracts while you're over there, that's not a lot of money for that length of time. Fourth, if that's what you've been told about how the overseas taxes work, you've been misled. So far is sounds like you've been speaking to the glory hounds about overseas contract work and they're giving you bad info...get the straight skinny from ak or chbare. And lastly...It is an amazing experience, worth doing for free so the money isn't a big deal, but it is really important, 'specially if you have a family, that you start getting some accurate information. Good luck brother.. Dwayne

I have no idea what this means, but "surgeon point" sounds interesting. Explain? Dwayne

I tried my coworker's for a day and man, it seemed awesome! It's the first time I've ever heard heart tones clearly, you can explore the lungs to the point where I almost felt like I was looking at a picture of what was going on. You can get unwanted sounds, (bowel/cot) but if so, you simply push the little volume button until you get the range of sound you want and it works like any other steth, in my opinion. One day was enough time to find a bunch of positives, but I'm not sure it's enough to really ferret out the negatives, just sayin'... But anyway, there you have it in a nutshell. Dwayne

Happy birthday girl... In a strange twists...YOU are a gift to US! I hope you have a happy day...(think curled toes) Dwayne

I think many, perhaps all, misunderstood my point, or at least my intended point. Or perhaps it was just ignored. Ask anyone that knows me personally or has worked with me and, hopefully, they will disabuse you of the idea that I'm satisfied as a 'taxi driver.' Do I believe that intubations are critical on a small percentage of my patients? Yes. But I also believe that Bicarb should decrease mortality in my arrest patients, yet the science screams 'bullshit.' I had only one real point, and that was simply, "If the science, solid science, should show that correctly placed and managed tubes are not decreasing morbidity/mortality (And I have no idea what the studies say about that) then why does EMS begin to use illogical terms when describing it like 'right', 'privilege', etc.? IF the science is showing that it doesn't help then I have no desire to continue to do it. I know the aspiration arguments, and share them. But I have not tracked my tube/non tube outcomes. For me, tubes are akin to Bicarb. It certainly should make a difference. It seems obvious that it will make a difference, but it's all moot if the science is showing that nationally PH-EMS (prehospital EMS) is doing more harm than good with them, right? It makes no difference if I have saved 5 patients this year because I'm a wizard at intubations (which, of course I'm not), if my peers have killed 500 nation wide then the fix is in, so to speak. Call me lazy, or ignorant for not screaming for a fix instead of, in this case only, simply accepting reality, but who here is willing to stand up and say that EMS is so good at coming together, so good at uniting to increase standards, that attempting to fix this issue nation wide while continuing to allow a bunch of idiotic wannabees to continue to drop tubes in the stomach is a really good idea?? We have people on this site that parrot the cry for increased education yet do so with so many typos that thier thoughts are difficult to understand. We have 3 month medic schools. Right? Isn't our main moral and ethical obligation to patient care? Are we caring for our patients when we allow a bunch of half trained knuckledraggers to continue to kill their patients with intubations so that we can continue to try and save ours with it, if we know that we truly aren't saving as many as we thought? Wouldn't it be the 'ambulance drivers' that continue to cry for a skill that science (for the sake of argument) is saying does no good for the most part and does harm for the rest? Again, why does EMS use the words, "Right"(as in I Have a right), "priveledge", when discussing this issue? It's not my right or priveledge to intubate. It's another tool I use to hopefully deliver pts in the best possible condition I'm capable of. If I'm simply bullshitting myself that I'm actually using that tool, to do that thing, then I want to know so I can do better tomorrow than I did today. Just sayin'... Dwayne

You know, this is where I get confused.... "If numbers don't improve then you're going to lose your right to intubate!" "If you don't prove that you can do it effectively then they are going to take it away from you!" "The science says that it makes no difference even if you're competent so you're going to lose it if you're not careful!" I think I'm genetically damaged as a medic in that intubation doesn't make my nipples hard like it's supposed to. If it became a basic skill tomorrow my basic could do every one if s/he wanted..I've just never found it to be that sexy of a skill. It took me less than an hour to understand the mechanics, practiced a few hours after that (a gazillion maniquins and 16 live as a student), I've successfully intubated a few dozen times since learning without a failure, there's nothing terribly challenging as to deciding medical need (with the exception of nasal intubations, for me at least). It took me longer to become proficient at starting IVs than it did to successfully intubate, and I certainly do more good with those. Why is it that we daily preach 'Science Based Medicine' yet when it comes to ETT we suddenly begin to use words like "Have the right", "Going to take it away", "May lose the priveledge."? If the science shows that our properly placed, maintained, and managed tube is not improving patient outcomes then we should all say good riddence, shouldn't we? Spend that time doing something more productive? I don't mourn MAST pants, I don't wish I could still do the Heimlich on drowning patients, I have no desire to return to uncontrolled fluid delivery on trauma patients, I don't yearn to hyperventilate head wounds, and if the SOLID science says I'm wasting my time....I'll never give intubations another thought. Why does EMS seem to have such a hardon for intubations? Dwayne

When he said that some have had a 'special' opportunity to meet her...yep, he meant me!! Ok, others too, but they're not important... No worries Dar! I've waited for you!! Tell me you've finally dumped ol' what's his name and are headed this way as we speak!! :-) Dwayne (Welcome girl..we can always use another member who's smart AND beautiful. And no Matty, I don't mean you.)

I'm curious firefly, If your source is so well respected, why have you been so careful not to name him? A "well respected source" for intelligent debate is cheap and lazy. Name him, let us look at what he has to offer for ourselves. Kind of like the "A source close to the celebrity!" bullshit in the paper. This is a learning forum. What I'd like you to learn today is that it's proper, intelligent and logical to name those that 'you' consider well respected and leaders in their fields. Right? Dwayne