DwayneEMTP

Hmmmm....what do the studies show concerning infant mortality with mothers that have died of MI I wonder? I don't know what the incidence rate is secondary to asa for the above issues, but I've not seen that pregnancy is an absolute contraindication for asa...I'll have to look it up though. We have many meds with precautions regarding pregnancy. Does the incidence of fetal morbidity truly outweigh the advantages of asa when applied to acute MI? Any of our smart people know the current thinking? Dwayne

Rid, I'm certainly not arguing with you, but would like to run my logic by you for your thoughts. I understand that we need to manage preload/afterload, as Starling's law is much more important now than it is normally. But if the LAD is blocked, and if there is significant right sided involvement we know it must be blocked pretty high, wouldn't the heart benefit from the arterial dilation that "might" (I have no idea if this is logical or not) at least move the block lower in the artery so as to effect smaller protions of the myocardium? Just thinking out loud... Also, on the EJ. The medic I ride with put an EJ in a gunshot victim that was bleeding badly from the right bicept. Fire had attempted 4-5 IVs in one arm, we were attempting to get one in the leg...all of them blew out almost immediately! 8-9 attempts, all unsuccessful. (In the trauma bay they also made, I think, 6-7 attempts before getting a 20g started. I never heard the theories on what was going on with this guy's vascular system.) So the AMR medic got an EJ. After, I asked him about getting an EJ on a patient that was awake as the protocols say this "shouldn't" be done. He told me, "He needed an IV, not an excuse. You DO NOT want to go to our medical director and explain to him that you couldn't practice medicine because "the protocols said so", not if you want to continue to practice under his license." I love this system... My opologies for the distraction in the thread, but I've found that many people have many different ideas on this, so perhaps it isn't a terrible sin... Dwayne

Yeah, with a 45 minute transport it's hard to imagine not getting a line of this guy. Every indicator says Inferior/right sided MI. Borderline BP, a little brady, pale, sweaty, nausea, vomiting. The medic should have been thinking Inferior/right sided MI before the monitor was ever placed. This patient needs treatment. For the treatment he needs a line. EJ if nothing else. Push the fluids to build the pressure you need to medicate is what I'm thinking. We need to dilate the coronary arteries, this is most likely going to be accomplished with nitrates. Push the fluids until you get your pressure, deliver the nitro, and monitor your pressure. It seems to me, and I could be wrong, that the "Tons of fluid and no nitrates/vasodilators" rule for inferiorwall MI with right sided involvement is great in a perfect world, or for a snappy anti-intuitive response to someone new to cardiology, but I can't really make the physiology line up in my head as a hard and fast rule. In the real world this guy needs coronary perfusion. We can fudge the pressure with saline, but there's not really any pretending the hearts being perfused if it's not...right? If time is muscle, something needs to be done to feed the pump long before the 45 minute drive to the hospital is complete... Once again I probably should have researched this instead of pulling it out of my rear, and made some attempt to appear as at least slightly less dorkish...Yeah, well. That's never been my strong suit. Dwayne

With complete respect to both of the above posters.... One of the issues found with CISD is that it often seems to convince people that they should be much more damaged than they are. People believe it and thus become more damaged. If Neesie is an adult, as I'm guessing she is as she works in EMS, then I believe we either completely waste our breath, or worse, do her a complete disservice by attempting to convice her that "No normal person would come away from this undamaged." I for one am going to take her at her word. I've often been upset and unable to sleep, money, relationship, a certain autism diagnosis. But this didn't mean I needed to come to completely distrust my own coping mechanism! It simply meant that my little pea brain needed a little time to assimilate this new, disturbing information before putting it away in it's own little pigeon hole where it now resides comfortably. It sounds to me like she came here hoping to hash through this a bit, like many of us would like to... Let's not attempt (I have faith she's stronger than to allow that anyway) to convince her that she doesn't know her own mind. Having people with more experience, that you respect, tell you that you are broken, you just aren't smart/insightful enough to recognize it can make a relatively uncomplicated situation complicated very quickly. Dwayne

Yikes, sounds like a tough call... You do understand that circumstances killed her long before you intervened right? I have heard that working kids near the age of your own children can be very difficult, as it makes it near impossible to disassociate yourself from the situation. It sounds to me like you know what you need, and the best way to cope. You don't list your age in your profile. Depending on how much life you've seen you might make different decision on how best to care for yourself. For example, I'm 44 and have traveled most of life's roads face down...in the ditch. I'm confident I've got the tools to deal with such a situation. For example, on Friday I teched 6 patients and three of them died. Dispatch called my medics cell and asked if we'd like to be routed directly to the morgue for the rest of the day. :wink: People kept asking me, (not my medic thank goodness) if I was ok, did I need anything, to talk to someone...It felt surreal. Two arrests, one end stage lung CA that died as soon as we moved her from the bed. I didn't kill them. I couldn't have saved them. They didn't really touch me. Moved on, had fun with people giving me hell, and went back to work. 25 years ago I don't believe I would have reacted the same way...25 years ago I also wouldn’t have accepted help even if I felt I needed it. Today I would in a heartbeat! If you’re ok, that’s ok. Don’t allow people to convince you to be more damaged than necessary. And if you’re not ok, that’s ok…get the help you need. CISD has been completely, thoroughly and scientifically debunked. As many here have said before me...if you need help, find a professional. CISD doesn't work for most, and seems to damage many. Good luck. I know you'll do well...just be sure not to confuse doing well with doing it alone. For some that's best, for many it's not...pick the best route for you and your family. Dwayne

Proof positive that their nets have HUGE holes in them...Just sayin'... :wink: Dwayne

I’ve found that repetitive questioning is common with trauma, and head injuries specifically. I know that doesn’t come as a surprise to anyone, but I seem to have noticed that the more “damaged” a person is, the shorter the questioning ‘loop’, as well as the time between it being repeated. Know what I mean? For example, patient A hit her head on the floor after fainting. Approx. every five minutes or so a “loop” seems to reoccur. “What happened? Am I OK?, Who is watching after my kids?”, etc.. Until she seems content with the answers. Assessment continues until the ‘loop’ begins again. Patient B, severe physical assault involving head and other areas. Blood/fluid in ears/nose/mouth/severe mandibular swelling. His ‘loop’ starts “Who in the hell called you a**holes!!!”, “Am I going to live?”, and repeats approx every 1- 1 1/2 minutes or so. The more severe cranial trauma (Based on MOI, external exam and LOC) seemed to have the shorter loop, repeated more frequently. These are just “seems to be” observations of course, as I’ve only dealt with 15-20 traumas involving this phenomenon, so I’m not pretending that I’ve discovered something factual, only something of interest. So my question is; is there a cause/effect relationship, when present, between the length of time between the ‘loops’ and/or the duration of the ‘loop’ itself, as it relates to the severity of trauma? Thanks for your time… Dwayne

Hey Jump! Welcome to the City. Interesting topic, as I've never heard of if. At first blush Freak's explanation makes sense...I'll have to look into it as well. I look forward to the discussion! Dwayne

Assuming that there was a suicide attempt, and that she truly made an honest effort to take her life with her children present... That would be your advice? :shock: Yikes LS, are you still taking those drugs from surgury? I think it's time to dial em back a few notches... Dwayne

LS, for myself, I'm going to have a hard time expecting someone that has made the completely irrational decision to commit suicide (Irrational for most at least) to be responsible for monitoring their own med compliance. It seems to me if you go down this road that the fault lies more with her med provider than her. I'm not saying her employer is responsible for her care, that she should be held blameless, or anything else not specifically stated in my posts...Only that the above argument doesn't seem logical to me if looked at from a mental health point of view. As well, I'm treating this story as an abstract exercise, as there is no answer to it without a much more indepth examination of the circumstances surrounding this than is, or probably could be, related here. This is a life. My comments would never be so flippant and/or certain if they actually carried any weight... :wink: Dwayne

Yeah, regardless of this single behavioral incident, this woman has a history. How long that history is, and the type of baseline behavior it shows should absolutely play into what happens here. A single incident does not a life make. And the fact that she chose to hurt herself instead of others does not, in my mind, make her a danger to her patients. Of course it doesn't preclude it, but her life's path shouldn't be automatically, radically changed on the knee jerk reaction of "if she'll hurt herself, she'll hurt anyone!" There have been times in my life where I hit a crisis point for which I had no tools to cope. I've done things I'm not terribly proud of in those times, but if we're willing, and the appropriate help is available, then we grow past them, develop the tools, and move forward. Becksdad is a basic that posts here on occasion. He has told this story here elsewhere, so I'm comfortable repeating it. He was prescribed a medication, for what I can't remember, that had a very low incidence of causing seizures. He took it in the hospital, where it was prescribed, and had a seizure while delivering his next patient to the hospital! In Florida, as elsewhere perhaps, if you have a seizure you are banned from EMS patient care or ambulance operations for a minimum of 5 years. He had no previous history of seizures, (and he's late 50's I think), the prescribing Doc went to bat for him, but still, no more EMS. He didn't take any more of the med, and hence, no more seizures. (The hospital where he often delivered patients snarfed him up within a couple of days and he's now very happy working there.) He and I have become very close friends over the years (We met after having a knock down drag out argument at the City) so I know for a fact that he is VERY smart, compassionate, and committed to making sure he was a sterling example of EMS and patient care. But EMS only saw the seizure. People make mistakes. At times Karma thinks it’s funny to bury it’s boot in your ass. People get sideways and sometimes need help finding the road again. At the very least we owe anyone the chance to stand on their past behavior and performance before deciding to separate them from their hard earned career. Dwayne

Shoot Scar, I looked at that post and thought,"That's just like him!" Well balanced, a little over the top, colorful, sort of irritating, but ultimately valid. :wink: Dwayne

Man, great question. Once again I got to learn something I had no idea I wanted to know, because I had no idea I didn't know it...Know what I mean? Pretty cool... Dwayne

I think you'll find that many here feel that BLS doesn't belong on an emergency ambulance... From your post I can tell that you are intelligent, and being so I'm willing to be that you'll agree that we need to address the "rule" and not the "exception", right? You sound passionate about what you do, and some do continue their educations. Hell, Eydawn is twice as smart as I'm ever likely to be, and she's a basic. But she is not the rule in my experience. Last night on the way home from the Springs (CO) I could see smoke in the distance...made me think of a small brush fire perhaps. Just by accident, out of the corner of my rearview, I noticed a small rusted out brown car, doing probably in excess of 100mph begin to lose control as he passed from the fast lane into the slow lane to get around a slower (65mph) moving truck. I was forced to drive off onto the grassy shoulder at 60mph or so to avoid being hit, as I certainly would have, had I not seen him. He regained control, and as he passed me I could see the fire fighter license plate as well as the star of life stickers (many) in his back window. Yeah...a wanker volunteer basic (I'm guessing volunteer of course because all of the paid fire I'm familiar with drive the huge, shiny, penis extending trucks/jeeps) chose to risk taking my wife's husband and my son's father as well as their only means of financial support off of the planet so that he could be the first hero at an event that really needed an old man with a garden hose. I could almost hear him thinking as he went by, "See! If they'd let me have lights and a siren I wouldn't have almost killed myself!!!" Unfortunately that is what many professionals think of when they think of basics. Perhaps not to that extreme, and I have known many that didn't fit the bill. But being pissed that it's unfair is not going to change it. Basics seem to feel that medics are immune. But I'd be willing to bet that if many spent time on a trauma nurse site, we'd find that the nurses spend very little time on conversations involving "why we should all thank God for brilliant medics." I believe there are many basics that are very intelligent, continue their educations, and are very competent. The last basic I rode with (Not current) had 7 years on the street, college Anatomy/physiology/cellular biology that she'd taken on her own time, not to fulfill a requirement of any kind. I didn't meet/see a single medic that didn't show her complete respect, often asking her opinion. But again, she's an exception. She's also now chosen to go to medic school. As long as every yahoo from a podunk volly fire service gets state plates and a "I'm a Life Saver!" basic cert, yet continues to remain ignorant, act childish, pseudo hero-ish, and just plain idiotic, screaming for respect is just going to make you tired. (Yeah, OK Rid...I'm starting to get it) Dwayne

-5 for violating Wendy's Law. You don't like this thinking, so your best idea is to litter the thread with your idiotic insult? You've been a member what...two weeks and have decided that you know the City needs and what it doesn’t? Give me a break. He showed you the respect of taking the time to carefully prepare his post and make it easy to read, you should have done the same. Like a grownup. When I opened this post the first thing I noticed what that it was actually more than two sentences long and in paragraphs! As I read, I found it pretty well written and that it very clearly described an opinion that many basics share, complete with outstanding descriptions of their frustrations and good list of what I believe to be their misunderstandings and misconceptions, from a poster with very few posts. I would like to think we've talked this subject to death, but it keeps rising, so obviously it needs to be talked about some more. I for one choose to talk about it with someone that is able to spell, and express their arguments clearly. Statements like the one you made above may make you giggle and feel clever, but they make you look ignorant and childish. You couldn't even be bothered to present an opinion with it...? Good OP on a much discussed, abused and overworked topic. On another note...OP, a search would have led you to many relevant conversations that relate to your original post. Dwayne Note: Must have been posting the same time as you Dust...No intention of being redundant, but am not going to delete it after taking half an hour to type it... :wink:

Lord, you about gave me a heart attack. Actually, though I did think it was kind of funny, I posted it curious to see who would pitch a fit :wink: It would have broken my heart if you had been offended! You're too strong for that, plus have been around plenty long to know better than to take many of the things I say so seriously... It's kind of a running joke between my wife and I. She gives me hell and I say, "Man, we were nice enough to give you the vote, and you repay our generosity by being a pain in the ass?!" (We both know of course that no one 'gave' women anything, the decided they wanted it, had a right to it, and took it.) To which she replies, "Yep, I think I'll be president next...." I'm glad it gave you a chuckle, and I'm proud of our ladies that no one felt the need to defend against something so silly... Dwayne (And for the record, I look forward to the day that I can say, "Good God! We let you be president, and this is how you show your gratitude!?" I'm not excited about the current woman becoming president, but I'm on board with the right woman.)

Great question. I'm not busting your chops here, but what do you mean by vocal sounds? If it was the sounds of the patient’s lungs, surely the medic could hear something? Or do you mean he was making purposeful sounds secondary to his distress or the like that perhaps masked his lung sounds preventing decent auscultation? And is there any chance that you can be more specific about the patient's general appearance? Skin color, accessory muscle use, general physical condition? Where there any meds/med history available? Home O2 use? All of the above would be important, but I would work hard for the lung sounds. CHF would not be an absolute contraindication for albuterol. Treatment is going to be based on your differential diagnosis, which will be based on the physiology involved, which will be strongly suggested by your signs/symptoms...is he choking (FBAO/Bronchiole constriction), or drowning (Pulmonary edema/MI/CHF), or being smothered (COPD/Pneumo)? See what I mean? These aren't the only options, but the ones that you're most likely familiar with as a basic. And on this patient? Get your IV access. No matter what, find it. It should have been a priority based on his condition. Should have had it before administering nitro if at all possible (especially if you’re going to administer it with Viagra… :wink: ). Almost regardless of which ailment he’s suffering from, there is the possibility of creating a significantly more positive outcome for this man, but that ability is severely limited without IV access. Also, there are times when you have to make the best of some bad choices. In this patient, you need to get him to breath, right? It’s possible that assaulting his heart becomes a necessary evil temporarily to make that happen. I'm certainly not saying that's the case here, only that we don't always have the "single system involvement" answer that we'd like. I like the way you’re thinking! Dwayne

The one that's guaranteed to make me vomit? "You ppl ar meen! I just camed her to hang oute not B jusgeded for the way I speels stuf and stuf lik that!" Oh wait...that's with a wh...Sorry. :wink: Dwayne

Does this condition effect both, or just one or the other...? Dwayne

I guess it was brain fade. I could remember clear as a crystal that the skill sheets mentioned checking distal PMS, and checking for DCAP-BTLS during trauma...But just went and checked, and you're right. Nada. My apologies for the poor advice. Wait! You don't suppose this means I wasn't actually a famous gigolo do you? :shock: Dwayne

See, it starts out simple enough, then the next thing you know they want to vote...and life gets complicated... Before long they'll be thinking they should be president! :shock: Dwayne

Yeah, but don't abandon DCAP-BTLS just yet! In every scenario from basic to medic I think I was asked what I was looking for, and they seemed to expect DCAP-BTLS, which often followed, "And what does that stand for?" I certainly agree, Dust, with your assessment of mnemonics. But the NR is just as in love with them as many of the schools are...So I think it pays to know them until that is in the past. Dwayne

Are some of us not getting that we're not talking about laughing at suicides here, but at people that simply use the word "suicide" for attention? (Not you FD, following your post was coincidence) One medic I precepted with once said, when pulling up to a drunk/psych(?) woman that weighed at least 400lbs, "God, If I'm ever reincarnated please don't send me back as her ankles!" Then proceeded to get out and treat her like a perfect lady. I thought it was funny as hell. I can empathize with the emotional pain of being so heavy, and perhaps the pain that I believe is necessary to cause someone to become so heavy, but it was still funny. It seems to me that if you believe that laughing at a kid that claims to have put a gun in his mouth, pulled the trigger, and missed(!) is the same as laughing at someone with a serious self inflicted gunshot wound, or perhaps one that has recently ingested a glass of Drain-o, then political correctness has truly come to rule the world. Terminally unhappy people, to me, are not at all funny. People that do idiotic things in an idiotic way to attempt to wallow in the compassion we have for those truly in anguish deserve to, at the very least, be laughed at behind their backs. And if you believe that I would not have treated the “almost” gunshot kid with respect, kindness and my complete attention, then I’ve still not made my point very well. As far as treating him like I would treat my family member? I’m not sure how my medical director or the state board of EMS would react if I snatched him up by his hair and made him apologize to everyone on scene before dragging him kicking and screaming to meet his new counselor. Dwayne