DwayneEMTP

Up to this point you'd about given me a stroke.... Whew! Dwayne

Your attitude is wrong to begin with Brother. If you got a 94% in your class using spelling, grammar and punctuation like you use here then your class sucked. They set you up for failure not just on the test but certainly in the field. You think it's bullshit that they expect you to be able to read and understand 8th grade level questions? It's not. There are far to many wankers in this business already and from everything that you've posted it seems clear that you are happy to be yet another one instead of trying to raise your game. The NR tests for the minimum standard to enter EMS, a standard that most consider well below acceptable. Yet you want to try and find tricks to make it easier still. If you can't pass the NR, and you're failing every section other than operations, then you are not ready for EMS and don't belong in an ambulance, or in this case, I'm guessing that you're real goal is a firetruck as Operations seems to be the only thing that you're interested in. You need to step back from this for a few minutes man and stop wishing that the test was easier and instead wish that you were better. It is truly a childishly simple test. You need to sack up, take a long look, and see if you really want to be a professional EMT or if you just want to be another hosemonkey with a patch. Get committed, decide to be a real professional EMT, and I promise you that in the future you will laugh, and be disgusted, at how simple this test really is. Dwayne

Holy shit Chris, how cool was that?? I almost didn't watch it as I'd assumed that it was something you found online but figured that if you posted it that it was most likely worth watching...and it was. And, for the record, I heat my fluids to precisely lukewarm and shake the hell out of them before delivery....It keeps the math easy as lukewarm is exactly the same temp in either F or C. Thanks for taking the time to explain that!! Dwayne

Man, I don't know about a top ten, but I'll try... My new favorite is Person of Interest, http://www.cbs.com/shows/person_of_interest 2, Idol, 3, So You Think You Can Dance 4, NCIS (Not the idiotic L.A. one, but the one with actual actors on it.) 5, I'd rather slit my own throat then watch anything that begins with CSI... 6, The Voice 7, The Amazing Race 8, Parenthood..in my opinion possibly one of the best shows ever put on television. 9, Late night with Craig Ferguson. I have a major weak spot for anyone that becomes an American, and only an American, when they didn't have to to work. His book's title, 'American by choice' says it all. 10, Terra Nova, my newest guilty pleasure. Don't ask when or where any of them are on..Babs records them all when I'm gone and then we watch them in the evenings, so I have no idea. Dwayne

That depends on your priorities. You've got a critical patient in the back, that I've now abandoned if you send me out to triage the car accident, right? You go out and make sure that the ambulance is still in drivable condition, if everyone is claiming to be ok you put them in the front, if they'll go, or if more than one, one in the front and the other in the capt's chair, and go on your way. That seems to me to be the patient focused decision. In this scenario at the last service that I worked at I could expect, at night, about 10-15 mins before the next ALS ambulance will arrive. Fire would already be there, but I'm trying to work this out as a lone ambulance, worst case scenario. If you have fire assistance then you have the basic check the rig, do a quick triage, and then let fire take over until you get back. The most good for the most number...and then you get fired and sued...but, you know... :-) Dwayne

Edit: Was creating my post in between chasing my boy around the house with his toy helicopter, so redundancies are accidental due to others posting at the same time. I can't say for sure, but sand packs pretty well under a surface like his back, so my guess would be that though the surfboard would have been really good thinking, it would have made little difference. Yeah, slow by today's standards, but I'm not sure when that was shot. First, epic fail of an Asian student going to Australia to learn English. Must have been, like, an indentured servant exchange program or something or surely he would have chosen a country where they talk normally. Second, though my guess would be that they don't run a lot of arrests, their calm, professional manner would trump many of the codes that I've seen paramedics run. Kudos to them. Edit: Also, they were constantly thinking and communicating. I noticed that at one point the guy on airway went to check for a carotid pulse and palp'd both sides of the neck at the same time. He was in that position for a moment only before I could see the, "Oh shit, that's not right" movements and one hand was removed. It's so nice to see people doing the right things instead of trying to do things that will look to the crowd like the right things. Also, there was no unnecessary talk. Everyone was listening, spoke when they felt that they had something to say and then shut up again. Cool, calm, professional, each person doing their job without trying to stand out as a hero for the cameras...Awesome. Dwayne

Even the term 'load and go' can be an issue when considering whether or not too much time was spent on scene. When I was new at another service we were dispatched to motorcycle v guard rail, reportedly at high speed. Arrived on scene to find a 50ish y/o male packaged with spider straps, fully clothed, leathers and all, to a long board by fire. multiple breaks to arms and legs, about half of his face left of the pavement, unresponsive. They'll yelling "Go! Go! Go!" but as they lift the board I can see blood running off of it at a pretty good rate. I asked, "Where is all of that blood coming from??" Fire chief says, "Just fucking drive God damn it!" Classic load and go, right? I grab a radial pulse and get nothing. Carotid is thready and very rapid. We set the board on the cot and I start ripping off spider straps, my partner pulls out his shears and starts taking off clothes. Fire had done a good job of putting all of his parts back into anatomical alignment before strapping him down, but they didn't asses anything. He has a compound fracture (or whatever it's called now when fractured bones protrude through the skin) of his L tib/fib as well as his L femur, which is just pouring blood. I'm guessing that the femoral artery is involved based on the flow rate of the blood. He had many other injuries, but these were the most critical. We get him naked on the side of the road in about 30F weather, (heater is blasing lava temp air in the box) I put on a tourniquet above the femur fracture, get him untangled from his clothes, re strap him and load him up and do the rest of treatment enroute. Get bilat IV with blood tubing hanging, try and pack the femur lac so that I can release the tourniquet but there's no chance that I can pack it well enough in the time that I had to make much of a difference and still do the other things I need to do. We hand off to the ER, fire is majorly pissed off and complains to anyone that will listen, including my boss, my medical director, the ER doc, and the family of the man being treated, (You would have been very proud of them Flaming!) that if this guy dies it will be because of my paragod attitude. Anyway, it turns into a major clusterfuck for providing what appears to me to be a logical course of treatment. But my medical director saves me in the end. Now, there are likely some here that have more experience than I do, that will say, as fire did, that they can cut clothes off of a trauma around the spider straps, and in the ambulance, just as fast as without them, and on the side of the road. I won't call bullshit on that, but will say that I can't...it just takes to friggin' long with the straps on and in the ambulance on a critical patient and I believe that it may have killed this guy if I'd tried to do it. As well in that confined space with the straps on there is just so much more pt manipulation necessary, in my opinion. Anyway, this is a great conversation. I've never really tried to define load and go in my own mind before as I just don't tend to think that way. It's an interesting exercise trying to do so now... Dwayne

Ignorance only. I wasn't making the case not to do it, but explaining how shocked I was that a few degrees can make such a big difference in pt care, even a ped. I will certainly consider these issues differently in the future. Dwayne

I've never hesitated to strip a trauma patient in the cold and snow if I thought that I needed to do so immediately, but have also always covered them with a blanket after. In Colorado I got a bunch of shit because I'd warm my fluid in the pts microwave before transport if I thought that they needed the help. (Did you know that 'everyone' knows that saline when nuked in a soft bag causes toxins to leach out of the bag and makes the fluid toxic too? I didn't, and continue not to know this, but am constantly informed by medics that it's 'obvious' and 'everyone' knows it. Just sayin'...) Though I've not always taken relative hypothermia as seriously as I should have. For instance at the CAP lab Wendy and I were in the same sim baby scenario that was run by another medic. It was a blue baby found drowned. She had much to add, but one thing she wouldn't give up on is trying to cover the baby with a friggin' blanket! I love Wendy, but I was gonna choke her to death with that God damned blanket...though it was clear from the monitor that the baby's tempt was, not sure, around 95-96F, it just wasn't a priority for me. Anyway, she finally fought her way through all of the macho medics and got the baby covered, it's temp came up on the monitor, and another sim life was saved. When the ER doc/instructor for the medical school came back into the room, they watch everything on remote cams, he said that it wasn't a bad resusc attempt but that we should have covered the baby much sooner as the patients body temperature will always play some part, and often will be THE difference between success and failure of attempted interventions. Friggin' women...think they know everything...and it turns out, sometimes they do. But you could have knocked me over with a feather. I would have bet much that the few degrees of core temp would have made little if any difference at all. I mean, C'mon! Surely I lose more than that when I go swimming in cold water! I was truly shocked... I refuse to ever use a backboard, except on really hinky patients where it will end up sliding around and being a hindrence, without a quartered blanket on it. I just see no sense in it. No sense in the board for sure, but not to put a blanket on it makes no sense to me at all. Great question Rom, as always. Thanks man. Dwayne

I agree that in this patient that it almost certainly did no harm... But If I was BEorP what I would be reading here is, "It's close enough to zero difference, and this situation almost never happens, so what difference does it make?" As I know you all, I know that that isn't what you're saying, but that's how it could be read I think. While the point I get from him is, "Leave for the hospital if you can, as the 3-5 minutes 'might' make a difference, and sometimes catching all of the 'mights' can add up to a significant difference." And man, I get this completely. I once stayed on scene with a medical patient trying to get his sats up above 50%, convinced that if I could just get some friggin' air into him I could make him stronger before moving him...I won't go into detail but I had terrible compliance to bagging so made multiple nasal intubation attempts, chest decompression, etc, on scene. He went into cardiac arrest enroute. The problem arose when I looked at my timeline while at the hospital. When I considered my scene time it turned out that he would have been at the hospital, though not really much of a hospital, 5-10 minutes before he arrested had I just bagged, scooped and ran. I told the doc, "You know what doc, I totally fucked this one up. I would have been here 10 mins ago if I'd just scooped and run. I don't know what that means for him, or for me, but I'm not going to cry over whatever beating that I've got coming." He said, "It meant nothing to him, but yeah, you fucked this one up. Next time make better decisions." I said, "What would the better decision have been here?" He said, "Obviously to bag and run, right? Look at your timeline. But I probably would have decompressed and tried to intubate before leaving." and then walked away. I remember standing there thinking, "So what does that mean!! What should I do next time??" With my timeline as a guide I wish I would have just run to the hospital. Without hindsight I know I would have always hated the fact that I transported him for 15-20 minutes with his sats in the 50's. I was confident that if I didn't get some O's into him before moving that I would be running an arrest in the back on my own, so didn't think of doing these things on the way. I think the doc was telling me, "Sometimes medicine sucks. Get used to it yet still make better decisions on very call." Which I try and do, with varying success. Turned out that he had a big spontaneous pneumo, so the decompression was appropriate, a significant P/E, was end stage lung cancer...etc, etc... If I could have gotten him ventilating/oxygenating again I believed he would have been hugely improved before we moved him. Unfortunately even if all of my brilliant interventions would have been successful the P/E means that I still wouldn't have achieved my goal. Goddamnit! I guess my point is that there is always a balance between making our patients strong enough to be moved, and to travel if we can without denying them access to the really smart people as soon as possible. I really, really wish I had a machine for that decision. It's a balance that I'm not anywhere near 99% on, even with all of our fancy gadgets.... Dwayne

Excellent scenario...I'm screwed no matter what. If your local protocols say that you stay and she deteriorates, the parents are going to sue. If they don't and you leave, CK's scenario is likely to occur and they will sue. But either way, I have no idea what my protocols would say addressing such an incident. What is the staffing of the truck? M/B? M/M? Though it sounds bad, we're really talking little more than a fender bender here. If the situation is M/B then there's not much of a call. I've got an intubated patient that has/is deteriorating at a rate that I believe dictated intubating...I'm going to the hospital. Depending on the number of people in the car I'll likely call dispatch, tell them I'm in a cluster fuck, load the vehicle occupants in the truck with me, if they'll come, and continue to the hospital. I really love this scenario, as it's a true moral/ethical/legal dilemma in the U.S. Take the patients and everyone is safe but the vehicle is left unattended and the drivers '$20,000 diamond necklace' disappears (from her 1974 rusted out El Dorado), leave them and there's no mysterious necklace but a complaint of "I told them my back was killing me and they just drove away!", or wait and the pts family, justifiably in my opinion, claims 'We called for help but instead of helping they sat on the side of the road until my baby nearly died!" So my answer, of course based on actual patient presentation, is that I take all and go to the hospital. If I can't easily convince them to come with me then I leave them for PD, transfer my patient and then go back if the backup ambulance hasn't arrived yet... Dwayne

So are you suggesting then that fighting with and sitting on this combative patient until the ambulance was rolling, instead of sedating, (Theoretical case of course, and assuming worst case, no IN drugs.) is a more realistic approach? As she soon died from her injuries I have a hard time believing that this could be considered 'doing no harm', right? Actually I think we need to define 'delaying transport' as I don't believe that transport would be delayed if it was not realistic to actually get the patient into the ambulance. An extremely combative trauma patient is not so different from one that's entrapped as I doubt that you will do much less damage by continuing fight with them then you would by simply ripping many traumas out of their entrapments. It's not your general argument that I have an issue with but the absolute statement. I've heard of that study, but haven't read it on my own, which I would need to do as most every study of it's type that I have ever been exposed to has been heavily flawed. But even so I'm willing to bet, and you can help me out as it seems that you have read it, that their conclusion wasn't 'There is never a need to begin an IV prior to transport as no trauma patient has ever been helped via that intervention." We need to put the 'never start an IV before rolling' with the Golden Hour and the Platinum 10 as absolutes that have no real place in intelligent patient care. In my opinion of course. Dwayne

Yeah, again, not talking about snapping photos while a patient is circling the drain. The vast, vast majority of the patients that I've treated would not have been harmed if I took 15 seconds to take a pic...Though of course the vast majority would have realized any benefit from the doc seeing a picture of the nursing home or the little dent in the bumper either. And for those that would be, a picture really isn't necessary. They're fucked up, it will be obvious upon arrival from all of the IVs, broken bones and bloody bandages. In this case a picture of the ruined car isn't going to provide any add'l useful information... But, when I've got a patient with a tiny lac on their head that self extricated from a destroyed car, looking doe eyed and just a little too happy, saying, "Whew...that was close! I can't believe I didn't get hurt!" it might give the doc some idea of the transfers of energy to rule out predictable, late show, injuries, right? Or am I the only one that's had those calls? Dwayne

Yep...been addressed....

The above statements can not go together in any type of system that actually runs calls. If you truly had experience you would understand the fallacy of believing the both of the latter statements. The only medics that I've known to believe such bullshit are a few old burnouts and the whacker, wannabes. Your theory makes sense to those with no concept of vascular compensation, but to the rest? Yeah....not so much. And if you have a zero failure rate on diagnosing MIs then you're just not running any MIs, it's as simple as that. Dwayne

From another thread...http://www.niagarafallsreview.ca/ArticleDisplay.aspx?e=3408114

What's a MegaMover? And does it transform into a car or something when there are no patients on it?

Ahhh, gotcha. But no matter how this worked out it would not have been your fault if he went home and blew his head off unless you're going to be responsible for this guy for the rest of his life. You had an obligation to transport him, an obligation to treat him appropriately, and an obligation to make sure that the ER knew that he had, in your presence, made threats to his own life, and an obligation to make sure that you were heard. That is the end of your role. I believe that you went off into the ditch when you played the role asked of you by the LEOs. How would you feel about your decision if you'd discovered that he was arrested, jailed, and forced to register as a sex offender because of that decision? There is not a single thing about your post that leaves a bad taste in my mouth. I think you did the best that you knew how to do, and in hindsight have decided that maybe you should have done differently. That, right there, is an epic win. Good on you girl. A million times after a call I've thought, "God damn it! What the hell was I thinking when I did that?" Questioning yourself is good, being willing to change your mind based on new info is exceptional. Don't you spend on friggin' second looking at your shoes on this because you wish you would have made a different decision. But we do have to stay in our lane on some things. When you stepped out of yours you set in motion some processes that would have your name on them but that you would have no control over. A position that you really, really don't want to be in especially after the cops and the hospital proved that they were unwilling to do their jobs. Can't you hear the cops and the hospital when this dude files his law suit.."We didn't want to keep him, but the medic insisted on pressing charges so we couldn't let him go!" Defib. I truly get your arguments about letting him go in the police car, but it only holds true if we assume that this guy is truly, and only drunk, and then not so drunk as to have no chance of a need of medical care during the transport. We don't get to choose our patients, even when their assholes. Dwayne

Pretty interesting... This thread is the first that I've heard that the CBT offered any insight into your score whether passing or failing. I thought that it was straight pass/fail regardless. Dwayne

Richard, no offense intended Brother, I truly didn't know that. I was under the impression that all of NYC EMS was cross trained and worked both duties. Though, of course, knowing that you're EMS specific explains the quality of your posts... :-) Dwayne

At the point that I am put in physical danger, something which I didn't see any indication of in the OP. Yeah, that's never a likely outcome. You're posts are always well considered in both thought and spirit. What rule or law was broken? I can come up to you at any time and ask you to have sex or inquire as to whether or not someone has tried to do so in the past and not be arrested for it, right? I'm not aware of any crime that has been committed here. You have the right to walk away. This patient didn't ask to be transported, per the OP. He was offered the choice of ways to be removed from his home against his will and took the lesser of two evils. At that point, if you believe that he should be transported, you are in fact obligated to put up with his shit if you are unable to find a way to mitigate it, regardless of your sex. Of course it does, in many, if not most cases. Altered is altered whether one chose to bring it on themselves or not. We can pretend that a self initiated altered mentation should be treated differently than say, an altered diabetic, or as mentioned earlier a postictal patient, but that's just simply not the case. What is your obligation to this patient then, as his patient advocate? If you've decided that he has a medical need to be transported, as I believe that a (possibly) drunk suicidal patient does, then what are your options? Are you going to forgo your moral and ethical obligations as a medical provider because you've been offended? Will you then put your medical patient into the back of the police car instead because the police ARE obligated to put up with people talking dirty to them when our delicate sensibilities are offended? But it IS EMS. We deal very often with altered people. That is a huge part of the job. I certainly wasn't implying that she has no right to pursue legal consequences if she feels that they are warranted, I just have no idea what they would be in this case. And if an apparently drunken patient asking her to have sex with him, or inquiring as to whether or not another medic has done so before is what sends her over the edge, then I would be uncomfortable with her as my partner. That is simply, like it or not, a situation that is predictable, and expected from many altered people, and should in fact be accepted as part of the job. I once had a postictal patient struggling and fighting yelling at me, "Let me go your motherfucker! Let me go or I'm going to kill you and everyone you know!!" Should I then have filed charges against him despite his being meek as a kitten once he was fully restored to normal? I'm even more surprised by what appears to be your feeling that a woman is less emotionally able to put up with this kind of verbal nonsense from a patient than a man would be. The opposite has been my experience. I did notice that MG mentioned several times that the LEOs didn't intervene, as if there was an expectation that they should have. But they shouldn't have, in my opinion. This is now my medical patient. In my experience officers attempting to help only makes it difficult for me to work whatever mojo I may have to be able to calm the situation down. It's my patient, and all that comes with it is now my responsibility. I don't expect, nor need anyone to help me deal with this verbally offensive patient...mainly because I'm not going to be offended by an altered patient to begin with. (With rare exceptions) A healthy person would not rather be with me in my ambulance, drunk and escorted by police, than in their own home watching TV. Offensive as we may find it, the intoxication is another symptom, and that makes it my responsibility. What other choice is there? Dwayne

Hypovolemic shock http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001220/ Well worth the read for most providers.. Dwayne

You are first and foremost a patient advocate, right? Let the cops make their own cases. I think that the LEOs have one of the hardest jobs on the planet...but that doesn't trump your job... He was inappropriate verbally...well, that's EMS. In no way does the LEO need you to press sexual charges so as to keep this guy from killing himself. The threat is enough. Do what you think is best for the patient. That is your moral and ethical obligation. Period. Dwayne

A career EMTB and hosemonkey yet still some of the best posts on the City....I hate that you blow every theory of EMS that I have out of the water... But I choose to consider you an anomaly, so it still works out.... Dwayne

Aussie, as someone who knows your boss well, trust me on this... Keep a supply of med rare steaks wrapped in old issues of Penthouse in the fridge, nuke and throw a package through his door every few hours and you may not have to hear from him for days.... We don't call him Yeti for nothing. You're welcome... :-) Dwayne