DwayneEMTP

And hell, I don't fit either category. I've not been a medic long, and have never been in the military. But I have been on the planet a few days longer than some. For me this isn't specifically a medical question, it's a general question of "what do you need to do to feel valuable?" For me, I need to do what I feel is right, regardless of the applicable rules. Unfortunately it seems this attitude keeps getting confused with "Do whatever I want and damn the rules." Not the same, to me at least. Rules are a valuable resource, as are protocols and SOPs. But they are not foolproof. I feel that, as a medic, I'm tasked with preserving life and mediating suffering to the very best of my tiny ability. To decide that I will choose not to do so, despite having the tools necessary, because someone forgot to write a rule that applies perfectly to my current situation means that I fail in my moral and ethical responsibilities. I've often done that on accident and on purpose in the past, but make every effort at this time in my life not to do so again when I can help it. I once pounded on some gang bangers with a baseball bat that were attacking a young kid. Some were minors I'm sure, the 'rules' say I shouldn't have done so, as none of them produced a weapon (I think that’s what it says), the rules say (I think) I shouldn't hit kids with baseball bats, The rules say I should have stayed away from them as I have a family to support, the rules say (I think) that I'm opening myself up to a lawsuit. But see, I'm not smart enough to figure all of that out in a moment. If someone had told me I would have to deal with that situation tomorrow, I would have looked into it, but, in the moment, I chose to act, as opposed to not act, and do what I felt was right, because that’s what I can live with at the end of the day. Do I think the person that makes different choices is less of a person than I am? Of course not. Sit a while with ak. He can talk medicine, politics, download porn, run an arrest, all at the same time and still have brain cells left over. I'm not like that. I have to hold my breath when treating a pt, because if I shift the mental resources to breathe I'm likely to lose focus and fall out of the ambulance. If life has brought you to a place where your cert is more important than those things we've discussed here, ok. If you're smarter than I am and can figure out all of the political/legal ramifications of each action you take before taking them? Ok again. I can't. Not because I'm better, but because I'm different. And my differences have brought me and my family a lot of pain at times, and may bring us more in the future. I don’t believe I have the answer, I simply have my answer, which of course is subject to change given different circumstances and new information. Dwayne

No man, I don't think it's a cop out. I think it’s one of the few no bullshit answers in this thread. This scenario, though incredibly unlikely of course, for some reason seesaws my brain back and forth. It seems there is an obvious "right" answer, to save the baby by whatever means available, and another obviously ‘right’ answer, don’t risk your livelihood when it’s not your emergency, but for some reason it just doesn't sit right still...know what I mean? I've made the decision for myself, (though I've been around a few days longer than you, so have no issues that you haven't done so yet), but can't find a solid argument to make for what's right for others to do in this situation. Maybe it’s like quantum mechanics, there truly are several absolutely correct, though opposing answers to the same question. Thanks for your response. Dwayne

Let's try again. Your previous statements and those that follow contradict what is in bold above. That was what I was commenting on. An opinion. Reread it and I think you'll find your tantrum is unwarranted. As we all are. I'm not suggesting "you" do anything. It's obvious you don't have the education to make any of those type decisions. I was simply giving my opinion, about my decisions, based on my experience. You extrapolated it to yourself and then decided to cry about it....That's not on me brother. Did you actually take that away from my post? Ridiculous. I'm unwilling to explain my comment at the 3rd grade level simply because you decided to post in a fit wihout making at least a minimum effort to think first. If your logic and intelligence are to be judged by your statements here and your inability to follow this simple conversation I wouldn't allow you to run a BVM, of course the idea of you doing a cric is ridiculous. Again, reread my post. Perhaps more slowly this time. At no point did I suggest that you should do anything. I gave my opinion of me. If that's got you feeling like a pussy, not my fault brother. My way is not everyone's way. Since being in Afghanistan I've made three decisions that I felt were necessary, but had a significant risk of getting me sent home. Each time I got my ass chewed by management, but was reassured by the doctors that I had performed competent, necessary interventions. That's MY way, I can't figure out why you keep insisting that it has anything to do with YOU? Outstanding...you actually used 3 sentences to say absolutely nothing. So you've decided that if you ever live in a perfect world that you'll know exactly what to do when you don't have any idea what to do? Silly. No, but hopefully you're the only one that keeps blaming certifications for personal decisions. Your hand aren't really "tied' man, you've just chosen not to act under a certain set of circumstances. Good for you. Good luck brother.... Dwayne

Yeah, I think you're missing the point then. If it was a procedure that any run of the mill medic would be expected to perform as a normal standard of care it wouldn't be much of a scenariou, right? That's the point though, almost non of the above average medics here would do so, so does that mean that you won't either, simply because they won't? Is that you're standard of care, then, do do what others believe is right? From your posting history, you don't strike me as a follower. What is your personal standard? Not busting your balls brother, just playing devil's advocate. Dwayne

You're talking out your ass here Mobey. Obviously you're scared to lose your certs despite the only logical outcome to this well defined scenario being death. You've drawn a line in the sand, ok. I don't agree with it, though I don’t completely disagree either, but it's your comfort zone man. I simply think that there is little time to think about politics when hinky situations arise, at least I'm not smart enough to do so. I think that too many of your patients are getting poor care if you have to do the cost/benefit of your certs vs treatment each time you come to a situation you're not sure of. Perhaps you don't have those situations, but I'm practically a factory for them. For me, I had to decide early on that I will perform what I logically and intellectually believe to be the best interventions, making every attempt to stay within protocol and SOP if possible of course, and should I lose my cert for providing proper (Defined as: proven in hindsight to have been of obvious benefit to my viable patients) care then I don't want to play anymore anyway. Have a good day all… Dwayne

Oh man...I thought that was funny as hell.... Dwayne

Sorry Lady, this sounded like a mess from the word go... I'm guessing this ladies’ SPO2 was in the toilet, and I know it was used as the hosemonkeys do love their machines, so any idea why Solu-Medrol was Fire's second line drug for pulmonary edema, assuming that is what was pushed? Also, I hear you about letting the 'experience' run the call, but this is what I've found for me; that each time I have allowed myself to lean on someone else's experience over my own logic and education, it has been a mistake. I can't think of a single time that I thought, "Man, I think A is right, but I'm not sure. Mr. 20yrs thinks B is right, and he's probably seen this 100 times before, so we'll do B." Every time I wish I had done my own medicine instead of hoping that someone else was smarter than I was. Also, are you sure that you had control once you entered the ambulance? In the Springs Fire can choose to retain control all the way to the hospital if they want. They were pretty stand up guys/gals, so the only time I witnessed them doing so is when they had students on board that they wanted to give experience to…but just wondering. Hopefully in the future you will take that control if it’s available to you… And I agree with others who say it’s time to move if you can. I know why you’ve told us that you stay there, but you’re too smart to believe that you can change this place and remake it into something completely different, which is what it needs. And you’re plenty smart enough to know that no matter how smart you are, that the choke hold they have on medicine there is damaging you as a medic. Right now you are leaving drag marks from your fingernails trying to hold on to the education you’ve earned at a very dear cost when you should be piling on new information from strong medics, from strong medical control doctors in a progressive system. I know you want to stay, but I’m not sure you can be the medic you want to be there. I don’t believe you can be constantly around bad/lazy medicine without it polluting your skills and knowledge. You simply can’t live with pigs without getting shitty…just sayin’… Me, and my two puny little brain cells think it’s time to reevaluate your motivations for staying. Keep your chin up Babe… Dwayne

Rich and black. Rich gives you options to buy change for yourself and others if you choose to. Black, in America at least, gives me an automatic pulpet to preach from, preassembled with the requirement that the rest of the country listen. Would you rather weigh 800# with the worlds best care, or be famous and beautiful like, (Choose your current favorite sex symbol) yet be unable to have sex?

Dylan Womack, 2050, wherever he happens to be. You suddenly have the amazing power to either cure all disease, or all violence, which do you choose?

I'd say "Terri, so help me God, if you don't put that back!!" :wink: But given the most likely scenario, probably nothing. You discover that the 18y/o neighborhood kid is having sex with your 16y/o daughter. Do you call the police? (Man, I think we need a thread simply to discuss some of these answers....)

Ahh...see, you should have tried explaining it before you got her all liquored up and naked. Just sayin'.... Sorry brother, my perspective is queer'd. I think we belong here, and I don't believe EMS as we know it is suffering terribly in my absence. And yeah, we do in fact do some good here, you much more so than most of us. As for the general consensus on this, most everyone I know has had to listen to my diatribe on the subject, so I'm with you, I'd be curious to know what the uninitiated think. Be safe man, we miss you here. Dwayne

I think you simply need to be a realist. I really, really want to be a Paragod. I want to know every answer right away, never be nervous, never out of my element. And some times I get this ---> <--- Close! And then... This morning. 57 year old male, dropped 140# barbel while bench pressing, fell right on top of his zyphoid process extending bilat of course. When we arrive he's laughing with his buddies, getting hell, simply called to be "checked out so I could have some peace of mind." Think a near 60 y/o Rocky Balboa...the guys a rock. BP 128/86, P 64/full/reg, R 12 clear all fields, able to take full, deep breaths without significant pain, no respiratory distress. No sign of trauma at site of bar contact, no pain/crepitus/deformation with even aggressive palp at any point on the thorax/ribs/spine, xyphoid process feels intact and in it's proper location. Decide to take him to the "Primary Care", sort of like the ‘out patient clinic’ at Kandahar. Lay him down on the cot to get a good abd palp and reassess the contact site, get a new set of vitals, but now he's kind of getting pissed because he wants me to quit "dicking around." I have my driver start driving, about a 5-7 min, very bumpy transport. About 30 seconds into transport he says, "I can't get my breath very good." No SPO2 at this time, because any idiot can see there is nothing terribly wrong respiratory wise. Reassess lung sounds while lying down and think that perhaps he's getting slightly diminished on the right, but if so it’s so slight it’s hard to tell, I'll watch it closely. Now he starts to panic and wants to sit up. I help him sit, (Think MASH cots, not American gurneys) and he's in obvious distress. I grab his pulse, he's up about 20 points to 86ish, but it feels weird, I can't really explain it, sort of a wave instead of a pulse maybe, it just feels like nothing I've felt before, but not as tachy as I'd expect for the level of distress he seems to be showing. Pt is becoming pale and diaphoretic, obvious respiratory distress, so I tell my driver, "Go ahead and light it up Mikey, let's go to the ER instead." As it happens, Mikey is a new driver who has never worked EMS, and he and I have only run a few non emergent calls together. So he takes off, L/S and just beats the shit out of us. I try hollering over the radio to slow it down, but between the sirens and the sound of what I'm sure are large chunks of the ambulance falling off, he can't hear me. So, now I'm thinking pneumo, I have no idea what's the hell is going on with his pulse, the patient is screaming in pain with his tiny little gasping breaths, begging me to stop the ambulance, Mikey has decided to make sure every chick on base sees that he is going somewhere very important and he doesn't care if he has nothing but lights and sirens left in his possession when he gets there, and I've removed any opportunity for further assessment, and any possibility of treatment, by allowing all of this to happen. We transfer care, Mikey glowing from his exciting few minutes of stardom, and me with my "he was fine and then a bunch of weird shit started to happen” idiotic report to half of the hospital staff that mobilized when they heard our sirens, and it becomes clear that my Paragod patch may be perpetually lost in the mail. Turns out he had two broken ribs, that never did become painful upon palp, a newly developing baby pneumo, and cardiac tampanade (Per the GORGOUS English lady doctor that got to witness me in all of my wonderfulness). I'm assuming that the tamonade caused the "weird pulse" and the pneumo and tamponade may have caused to air hunger, but I'm still not clear why he never became more tachy? As I'm leaving, feeling like a complete asshole for obvious reasons, the same GORGOUS Dr. says, "Good job with him." I looked at her for a few seconds, and then we both started to howl with laughter as she's trying to squeak out, "What is a weird pulse exactly??" There may be a gazillion reasons that I shouldn't have done a better job, but reality forces me to accept the fact that I just plain screwed up, a bunch of times, on this single call. If you stay real brother, EMS will keep you humble. Dwayne

Yeah, I see your point, and that of the Doc as well...I'm a convert. But I certainly would have screwed the pooch on this call had I run it prior to this discussion. Thanks to all, for your thoughts. Dwayne

No Doc, I think you were clear. I simply marched my assumptions out assuming that if 4 mins release from womb was optimum, (equating that with ROSC in an adult, see?) I'm guessing that that is referring to a live infant without deficits at release of medical care, that the effects of down time would be near the same for the baby as an adult. Adult with ROSC at 4-5 mins I believe equals favorable prognosis for release from care without deficits. If that is assumed to be true, then at the 30 min point the viability of delivering a child without catastrophic deficits (as with a non hypothermic adult) would almost non existent. So, as it seems that medicine has begun to take the steps of not attempting resuscitation when viability for minimal quality of life becomes near zero, I simply drew the same line in the sand for the infant. Save the baby to live as a brain dead lump, no objectively verifiable quality of life, attempt to save it by saving the mother, or lose both, perhaps to the betterment of the child. See what I mean? Of course that’s more assumptions than even my big ass can cover, but there you have the sum total regurgitation of rubbing both my brain cells together. I'm not sure how to express it as clearly as I'd like. I had really only intended to clarify that your information was clear, and gratefully accepted, though I perhaps drew a ton of illogical conclusions from it. Dwayne

I was making my arguments based on the stats the Doc supplied, and some reasonable assumptions I drew from them. If we increase the viability window to 30-40 minutes, or longer, then certainly those arguments are no longer valid. How many ‘non archaic’ systems have emergency c-section in their protocols? I’ve heard the urban legends of the procedure being performed in the field, but this is the first I’ve heard of them being within any street medics SOP. Dwayne

Actually, I'm impressed that they are making a decision here rather than simply saying "The neck was involved, so put on a collar." Lots of 'ifs' as to whether it is needed, but very little question that you're going to have a shitload of people crawling up your back on site and at the hospital if you don't. Moot to me though, as if he's going with me he's getting a tube, to which I'll put on a collar anyway. Ditto on the research. Dwayne

Man, as much as I loath disagreeing with the Doc, I have to go with Kat on this one. If 5-10 mins post arrest is your most viable time to remove the baby (I'm assuming Doc that as we have that little bit of data, that it is hospital based, with O2, airway management, and good CPR which were unlikely to be used initially with this woman I'm thinking.), and without data to show how quickly viability degrades after that, it seems the only realistic option for saving the baby is to attempt to save the mother. 2-3 mins post arrest before 911 is notified, another few minutes (In many places) while they dispatch Fire, and then the ambulance, 5 mins response (right around the corner), 5 mins for gear into house, monitor placement, IV, rhythm analysis, 2-3 mins to package and move to unit, 10 minute transport, 2-3 mins to transfer to ER. And this is if all goes pretty peachy. I don't see her on your bed Doc in less than 30 mins with the likelihood of the first 5-10 being bystander CPR only. I have to say work her and curse the EMS Gods that this situation sucked. On the flip side, perhaps this boils down to simple, standard triage. I can't work an ACLS code properly alone in the back of the truck, which sacrafices the mother if we move. But I can intubate and do good CPR which may keep the child viable while possibly, almost certainly sacrificing the mother, so do I choose to triage and sacrifice the mother with the child being by far the most viable patient? I don't know. Having come upon this situation, I would have worked the code if I had limited resources. And likely, in my ignorance would have worked the code if I had resources running out my rear. But now I'm not sure I know the right answer. Dwayne EDIT: None at all, but what good have we done if those are not in fact the issues? And regardless of what the issue might be, not only can we not beat the clock on this one, but by the time we can see the finish line with a telescope fate will have been on the other side for 15-30 (best/worst) minutes sipping brandy and signing autographs, right? Don't we take out 2% shot over our 1% shot?

Well Mike, based soley on your word I just ordered two full set of the Smart Wool stuff. Holy Crap! I could just about have hired a full time person to ride around in my jump suit to keep me warm! (Stop in now, all of you!) But I have faith in you brother...I look forward to giving them a go...but for $100 a set or so, if I continue to freeze my chee chees off I'll be sending you evil thoughts..... Dwayne

Actually, on the face of it, I have no problem with removing a large scope of practice from all and then allowing those competent to do so to return to their previous status, with those that aren't finally being relegated to the lower standards that they seem to find acceptable. Here in Afghanistan, even more so in the States, I get very tired of standing next to the scared, ignorant, puffed up with importance poser that gets to share my title, thus convincing most that we are equals and peers. Will such a plan be a pain in my ass? Sure, but I have no fear of proving that I'm able to perform at the level my patch claims I'm capable of. To those that are worried, I say, thank God you'll finally have to put up or shut up. You've gotten to ride the "competent professional" gravy train for generations now, I'll sing the praises the day you're finally forced to step up or get out. Of course my comments are geared towards a system that will logically and thoroughly be applied across the board, county to county, state to state, nation wide, without wavers for Fire so they can avoid their terrible 'staffing' issues. Dwayne

Of course we investigate. But there is a reason that murder has no such statute. Not only is it more horrendous than many others, in my opinion, but the evidence often survives. I think very nicely. I’m guessing that the investigation started on the child’s word alone, at least it’s difficult for me to imagine another way for it to have begun. As you say, molesters, rapists, serial offenders are not one victim victimizers. And you don’t victimize children without being around children, so finding other possible victims should not be terribly difficult once a molester is identified without running ads in newspapers and with television news organizations. I’m not at all suggesting that he’s not investigated pending the validation of this child’s story, though I’m finding it near impossible to believe that such validation is possible after years of counselor pollution of her memories. These stories make good news and tend to get DAs reelected. What I am suggesting is that it’s near impossible to prove that he’s guilty at this point, unless he happens to have a happy face tattoo’d on his penis that the child happens to remember. But much more important to me is that he’s almost completely unable to defend himself against such charges nine years later. So yeah, given the option of letting a sex offender walk or putting an innocent man in prison for a long time as well as branding him as a sexual predator for life, we MUST choose to protect the innocent man. And I swear to God I’m going to come out guns blazing on the first person that seriously uses the “have to break a few eggs to make an omlet” idiocy as an intelligent argument. I could also make the argument, though would have to think about it further to do so with conviction, that from this point forward they should expend all of the state’s resources to prove him innocent. He has been destroyed. They claimed he damaged a life, now they’ve destroyed one in return. If the punishment must fit the crime, then he’s been punished. They perhaps should feel obligated, in the name of justice, to restore his good name if he’s been falsely accused, don’t you think? Dwayne

Even given my possibly flawed reason for their existance? How long do you think? I'm 45. Should I know be able to convict my grandfather, who bathed me as a child, of molestation as, now that I think of it he really seemed to wash me for longer than seemed necessary? And how does he defend himself agains such a charge? And what evidence have you used to decide that he does in fact have a "sorry ass?" Your responses of late belong more in the "how we confuse our feelings with knowledge" thread than in a logical debate. I'm calling to you here buddy...Time to suck it up, step away from the foo foo feel good threads and get back on your analytical horse. I know you can, I've seen you do it often... Dwayne

Well then, list me amongst the whiners. First of all, we have no idea if this man is a criminal, and at this point, barring an act of God, we never will. He's being accused of a crime that he has no possible way to defend himself against honestly, by people that have nothing to lose and everything to gain by seeing him found guilty, whether he is or not. My initial questions still stand should you choose to answer them. Dwayne

Kind of a Don answer Ruff, as of course this is everyone's feeling. But the whole point of the thread is, how do you decide guilt or innocence at this stage? And also, shouldn't the Statute of Limitations have run out long ago even if he is guilty? There is a reason we have such statutes, the main being, in my limited understanding, that evidence degrades, both mental and physical. Though a child can make up unlimited accusations with the help of adults at this point, there is no way that I can see for him to defend himself. Dwayne.

I have a feeling this is one of these things that's going to generate a million "That's been talked about for generations, it's bullshit." type responses, but it's the first time I'm seeing it, so I'll throw it out there and see what happens. Increased training requirements coming for EMS providers By BUTCH HEMAN Staff Writer Carroll County's approximately 100 professional and volunteer Emergency Medical Services providers face additional training time for new national standards and certification levels that will take effect in 2010. The National Highway Traffic Safety Administration, which sets national standards for EMS care, in 2000 identified a singular scope of practice as a goal toward having a quality and consistent national emergency medical system. The first draft of a national model was released in 2004 and the final version was approved last year and has been passed by every state. "There always have been national standards," said Bill Fish, director of the Carroll County Ambulance Service. "But every state has been allowed to pick and choose what part of the standards they want to develop. Now they're trying to get every state on board with one set of standards." Under current standards, there are 11 levels of first responders, emergency medical technicians and paramedics. The new standards will narrow the certification levels to just four: emergency medical responder, emergency medical technician, advanced emergency medical responder and paramedic. - Community first responders will be required to take a few hours of continuing education to become emergency medical responders. - An EMT at basic level can take continuing education to become certified as an EMT under the new system. - An EMT at intermediate level can automatically become an EMT or take continuing education to become an advanced emergency medical responder. - An EMT at paramedic level can automatically become an advanced emergency medical responder or take continuing education to become a paramedic. - A paramedic specialist can take continuing education to become certified as a paramedic under the new system. The Iowa Department of Public Health Bureau of EMS, which regulates EMS agencies and certifies the over 12,000 EMS providers in the state, adopted the new national scope of practice model in July. Fish, who serves on the Iowa EMS Association Board of Directors and is a former longtime member of the Iowa Bureau of EMS Advisory Council, said having one set of national training and certifica-tion standards makes sense. "Consider if you were driving from here to Colorado," he said. "If you'd have to call 911 for a car crash, you'd expect a certain level of EMS care, just like if you were robbed you'd expect a certain level of law enforcement no matter where you were. We're just trying to create a standard where it's quality care across the board and there aren't places that fall through the cracks." Implementation of the new standards and certification levels is being held up. "No one has given final approval to bridge the training," he said. "The standards for training to get from where an EMS provider is certified now to where they want to be certified under the new system have yet to be set." Current training requirements range from 50 classroom hours for a first responder to 660 hours for a paramedic specialist. EMS providers are also required to take 12 to 60 hours of continuing education every two years to become recertified. Fish said the IDPH will probably set the state's EMS education requirements through administrative rules in 2009. The new training standards and certification levels will be implemented in 2010. "I think everyone in Carroll County EMS is very receptive to the change," said Fish. "Our system has the training in place to bridge that gap without real concern. We have the instructors and equipment." The Ambulance Service will provide training for all EMS members to meet the new guidelines. "If you move laterally, you're not going to need a whole lot more, but if you want to move up, there's going to be quite a bit of training," said Fish. "Yes, the volunteers are asked to do more and more, but as a consumer you expect to dial 911 and get a certain level of care. The volunteers have to understand they have to meet a certain level for being a provider." Tests for becoming certified under the new guidelines will be administered online. Certification will still be done by the IDPH Bureau of EMS. "The public in Carroll County won't notice a change. It'll be seamless here," Fish said. "If you call 911, you're going to see your local responders, and they're still going to be trained at the highest level possible." Thoughts? Opinions? Debate? Dwayne