DwayneEMTP

LMFAO... Great advice, but funny as hell too... Dwayne

I'm not sure. Not for any appreciable length of time. Why do you ask?

I'm in Mongolia for another three weeks or so, but doesn't that put me more or less on the same side of the planet as Lybia? Anyway, just so you know. I could probably run for a few weeks after that if the money is right... :-)

I can delete your post, but can't edit it. It's ok, it's obvious what happened. It's a problem the site has been dealing with for a bit... I don't see treatment wise what you might have done differently. And as Doc mentioned, your diver doc seems to be assuming that nitrogen introduced into the body, regardless of the mechanism, is all the same. I would think that a nitrogen injection injury would be completely different than serum/intravascular issues. I can't speak to the hyperbaric treatment, though strangely enough I'm about to trial Dylan with it for his autism. I can't see really where it would help nitrogen wise, but perhaps might in general wound healing, as it seems to in other traumas. It would be interesting to hear the specific treatment justification from the dive doc to see what his reasoning/theoretical reason is/might have been. Thanks for posting. Interesting injury! Dwayne

Krysteen, it's good to have you here! And good on your for having the balls/ovaries to put out your call review. And I've had RSI protocols once, overseas, but never domestically, so nasally intubating came more naturally for me than RSI, as well I noted that you didn't have it there either. And when I did have it, like with the pt below, I'd no experience with it so didn't use it like I maybe should have. The first time I tried to nasally intubate I'd been chomping at the bit to do it. All of the best medics I'd known seemed to do it 3-4 times a day before they'd finished their coffee in the morning, to hear them talk. I friggin' had to check this off of my list! The indications seemed to be there...I was so stoked..but. The reason I asked about resp rate in your post is that I didn't consider it my first time. The patient was only breathing about 6 BPM spontaneously. I was ready man, prepped his upper airway, lubed my tube, placed my BAM whistle, the guy had nares I could have put my leg in, everyone was watching...this scenarui couldn't have been more perfectly staged to exhibit my previously unrecognized heroism! I passed the tube through the nares, got a decent/half assed whistle, pushed in forward...and...yeah, you know...nothing. So I waited, and waited, and finally, after about 3 days, it whistled again! I tried to follow it, but wasn't sure really how to read it, and.....Nothing. I finally pushed it down far enough to bag over it, waited, tried again. After about two or three cycles of this it was obvious that I had totally screwed the pooch when I'd made this decision. I decided to just align things as perfectly as I could and see if the EMS Gods would smile upon me and let me pass it blind. I lined him up dead center, pushed forward gently, felt a tiny bit of resistance, advanced a bit, verified, missed. Did it again and on the second attempt got good lung sounds with good cap waves. What a dipshit. And unfortunatly I'm not much brighter now. But anyway...great scenario. Thanks for participating. I always thing that you know that you've done well when you get most of the strong providers in a thread, and Beiber has knack for doing that. Dwayne Edit. Where are you near the Springs? No worries if you're not comfortable mentioning it, or you can PM if you like. Upon review, did the physician mention why he was opposed to nasally intubating? What did he see as viable options?

And had it been a medic she more than likely could have driven herself home... Just sayin'... Dwayne

You don't mention respiratory rate, but I'm thinking that you'll have to nasally intubate this guy. I understand the issues with the presenting closed head injury, but I don't see any real options here. Plus, you don't really mention anything that would imply basal skull fractures, and lastly, I think that many places now, like not medicating abd pain, are moving away from "No nasal intubation on head trauma." Nose hose it is I'm thinking...or hang out for a few mins and he'll crump and be easier to manage... But in the end...I know this call sucked. There's just no way around that... Dwayne

I think it's a slippery slope. It would be good to be able to track errors for the sake of altering education and mitigating future errors of the same flavor, certainly. But EMS, and I guess medicine in general, is not cut and dried. Mistakes are going to be made and it's vital that we are all allowed to learn from them. Should there be severe consequences to admitting those mistakes then the reporting will stop and EMS will plummet even further down the educational/competency ladder than it is now. There is also the cost/benefit to the family members. What did this woman gain by this knowledge, assuming it didn't withhold from her an ability to sue. She is now suffering much more than she was before. She likely has none of the specific educational background and experience necissary to understand the errors made, whether or not they should have been considered acceptable, what the errors mean in the context of her husband surviving. It sounds as if what she heard was, "If these errors hadn't been made he would still be with me now." It's a shame that she was tormented with that when there is every chance that it is untrue. There is just so little that goes on that would benefit the family knowing. When I did my first chest decompression I didn't realize that the needle I was using came in three parts instead of two like the ones that I had practiced with in school. I darted his chest, pulled the top off, didn't hear any air, thought, "Hell, I wonder if that was the wrong choice." and went about my work. I was doing CPR by the time I got to the hospital, noticed that the cath seemed to be leaning, tried to move it so that it wouldn't kink..and pulled the friggin' needle out to the sound of hissing air. I held it up in front of the doc, he knew of course exactly what it meant, and we went back to the arrest. Afterwards I freaked out a little bit when I saw him replace it and have an xray taken, as during CPR we'd started getting blood up the tube. Only then did it occur to me that not having removed it may not have only retarded his resus, but might also have chopped up part of his lung. The doc came to me later and said, "yeah, it wasn't the needle, his lung was cut by a broken rib." Of course by that time I'd already penciled out a new career path outside of EMS. I friggin' hate that story for the part I played. But I think that the doc played the best possible part. Had he found that the needle had been the culprit I believe he would have, and I would have expected him to, reported the incident to my employer and whoever else was appropriate. I ended up admitting it in a call review and got myself jammed up anyway with a letter in my file, but, you know... :-) The point I'm trying to make in this novella, is that though there was an error it didn't ultimately effect the patient outcome (We got pulses back, few him out, but he dies soon after). I learned my lesson forever, as does anyone that I'm put in the dubious position of helping to educated, so the system is better, and there is no real benefit to the widow in knowing each detail of the attempts to save her husband, either positive or negative unless knowing will give he a right to compensation. So, I guess what I'm saying is, 'sweeping under the rug' and the attempt to hide from liability as the article seems to imply = Bad. Withholding information that is likely part of the learning and practice of emergency medicine when no real malfeasance is in play = realistic and productive, though not sure if it's good. Dwayne

Heh...my last gig was on a Dutch drilling vessel, the Maersk Developer. Part of my job was to enter the comings and goings of personnel into a maritime program in Dutch....Good God!!! Aside from your horrid taxes, and you're not understanding that there is never, ever a reason to put 6 vowels in a row in any given word, I could find nothing not to love about the people, or the company. Very kind, people before pennies (my saying, as well as my impression, which could of course be wrong, having only been with them three months.), hard workers. I felt welcome from the moment I stepped on board and I was sad to leave. But deep down, I'm American through and through. I'd get claustrophobic in a country that you can ride a bicycle across... But I'm grateful for the offer brother. And it holds here as well should you decide to come this way... Dwayne

I hate your system WM...It's stupid, and can't possibly work... (Do you hire American Immigrants??) Dwayne

Really? This whole mess is because of Jesus and his ilk... God destroyed whole civilizations in a fit or rage, and ultimately the entire world right? I would think that these situations are walking down the exact path lay by religion... Dwayne

Yeah, what RM said. The good news? Should nurses ever decide to invade prehospital EMS, the educational standars will increase, the money will increase, and more than likely professional standards will uniformly raise as well. The bad news? There won't be any medics involved....Oh wait...Maybe that's also the good news? (Can anyone tell that I've just had my latest run in with one of my 'remote medic professional' bretheren? Fuckhead. Him, "We remote medics have to stick together! This is bullshit!" Me, "You are complaining about getting jammed up for turning an early stage tonsilitis into an emergency medivac by treating it soley with Tylenol for 5 days..."We" belongs nowhere in your statement man." It seems like, if I am to honor, "do no harm" that choking some people to death should be mandatory to safeguard future patients from them. At the very least it should fit under triage somehow...Just sayin'...) I don't see it happening, but if it should perhaps the nursing unions have the clout and money to fight the fire unions...but again, as RM said...why would they want to? Dwayne

As a student you belong in this conversation as much, or even more so, arguably, than anyone else. Good on you for having the balls to jump in. A couple of questions Mr. student man... :-) Mobey mentioned that his rationale for intubation was patient exhaustion. And I completely agree with that now, after his explanation, so assisted ventilations at a minimum would seem manatory, right? I also thought that bagging was a viable option, and bagging in a neb treatment even more so. But lets assume the transport time is 5 minutes. Do still feel the same? How about 30 minutes? 60 minutes? Does your feeling on maintaing this patients ventilation status change in each scenario? What might the issues be should you choose to bag in each instance instead of intubate? I haven't noticed you posting for a bit...good to see you here! A friendly note to you, and others...simply for the ease of reading, paragraphs help. I sometimes, and I know others do as well, simply pass up posts that are in a giant block. Though sometimes you end up breaking parahraphs in illogical places, reading in pieces is much easier online. Dwayne Edited to correct spelling errors only.

Now you're just teasing.... Hey, at the EMS thing going on in Texas, is there a website for that? Are they going to be doing any recert stuff there or is it just a place for EMS to congregate and get shitfaced? I mean, I'm good either way, but I do want to recert in a few unrequired things just on GPs. Dwayne

I like that you thought to mention that. Many of us, me included, get used to spewing the mantra of 'It's not your emergency', and I think that's important to help people learn to relax...but that should always be paired with, "But it IS an emergency to them, don't forget that." Pretty cool... Dwayne

My original ride time was a horror and nearly caused me to quit EMS all together. I honest to God used to get sick to my stomach starting on Wed when I had clinicals to start on Friday. After that I rode in the Springs (CO) where they had a mentoring program. Preceptors were educated in the role and paid for the time they spent preceptoring. Those rides, my next 4 144hr chunks, were each spent with a different preceptor team and did what they were supposed to, shaping the rest of my opinions on medicine, the morals and ethics of EMS, and the spirit of paramedic medicine as a whole. Great topic, as I think that preceptoring is the Achilles heal of EMS. Many times services are providing the preceptorship as a 'favor' so the schools are afraid to rock the boat and chance losing them. Students become victims to limp dick ambulance teams that finally have some power to man handle those that are defenseless. On my first rotation my preceptor would stand over me while I was trying to start an IV yelling, "You can't start an IV? Jesus Fucking Christ! C'mon! You wanna be a medic?? You'll never even make a decent basic!" Crazy that I had put up with that, but my family had sacrificed terribly over the last three years and I couldn't imagine going home to tell Babs that I had quit. I also had no idea that I had options other than being kicked out of the program because, 'I couldn't hang.' I've done very little preceptoring, but when people came to learn, I loved it, when they came to log time so that they could get their fire certs, I hated it. I was seldom given the task as, though I know this may come as a shock, I was considered too abrasive. I don't think the committed students ever felt that way..we had a great time. But those that I could find no way to motivate, well, they often got tired of being given a shitty task every time they tried to lay down in the back of the ambulance. I've heard of few that do it well. Hell, at the last company I worked with you didn't need any type of preceptorship to be a remote medic. You went to a ridiculously simple class, the majority of which was spent explaining how macho you were for wanting to go offshore, and then away you go. No clinical time necessary, no significant EMS time necessary, no remote time at all....Craziness.. That's why when you see me gush over someone like Eric, maybe you can udnerstand. To run into another medic that truly gets what being remote means, takes it to heart, and works every day to be good at it...well, I'd rather spend my day looking for hens teeth than trying to find another... Dwayne I will take that a step further to say that, with few exceptions, it's only the mistakes that really matter. You may learn 50 things from a mistake, but how much do you learn from a success? That one line of thinking works. The real learning begins when things don't go according to plan..anyone can run the calls where things go right the first time... :-) Dwayne

Damn it! You had me at dinosaur and then lost me at Texan... Never ending pain in our collective asses, those Texans are... Welcome man. It's truly good to have you. I look forward to your thoughts.. Dwayne

Yeah man, you're right about this...I screwed the pooch. I'd made my response before I knew the working diagnosis, (left my post open while I'd done other things) but even then I was tunnel visioned on, "She seemed to be improving pretty quick." and "Fighting the tube." or something along those lines. I absolutely agree that she would/might have improved, but would almost certainly not been maintainable without significant, read 'no effort on her part', ventilation support. And that almost certainly required a tube, though of course other factors would play into this decisions. How much did she improve, what kind of compliance were they getting to the bag, how far were they from a hospital appropriate for this patient? Now, though I rarely base treatment plans on proximity to the hospital, I just really hate intubating the very elderly unless absolutely necessary. If her physiological markers were improving and had become acceptable for the situation with a BVM and O2, in this case I may have tried to maintain her in that manner until one of the smarter folks in RT could have assessed her and made the truly life altering/ending respiratory decisions that are likely in this gals future. Thanks for the heads up Brother...This is a really good thread! Dwayne

LOL...Eric. It's good to hear. You still have that really good job? Hell, another 21/7 you should be able to retire and just let that pretty girl support you.... Speaking of Patron'....Maybe we should work on a visit one of these days. I'm 28/28 now, and may be screwed up through the holiday season as they've all been promised to my b/b, which I would have offered anyway. But lets try and put something together? Hey, I'm going to try and make it to the EMS convention in Texas in Nov..any chance you could make it there?

In my opinion, both patients were emergent, and both would likely have suffered detriment if treatment at a trauma facility was delayed longer than absolutely necessary. Had it been two adults I would have put one on the cot, and one on the bench and transported in that manner as the risk/benefit would have, in my opinion, tilted the scales in the direction of my taking calculated risks to save lives. Unfortunately girl your argument will remain as impotent in this thread as it was in the other..perhaps be even more so. Dwayne Edit. I'm not arguing with your belief that ambulances are flimsy pieces of shit, though the two ambulance crashes that I've run on, both roll overs, the box was in pretty decent shape and the cot was still in place. In one, the basic that had been sleeping on it when the crash occurred was strapped in and hanging upside down uninjured. You keep throwing out these numbers/measurements, claiming, "every ambulance in the country is made exactly like this", and though you keep screaming for research you've not offered anything but a video to back your claims. Just sayin'.... Edit 2. Who ever said that my situation was different from an Emergency bariatric call. Every person that I can think of in that thread claimed that they would do whatever they had to do in an emergency. You're the one that claimed that fat people don't have emergencies but only call the ambulance out of embarrassment. I've been trying to stay onboard with you off and on, but you're making it near impossible. Stick with a story girl, and ONE scenario, unless you lay the groundwork for another.

Agreed with some of those above. The list above, though ideal in a world so perfect that we'll never see it, is years of study that just isn't going to happen. And with Race and Gulf. If you're taking a good, college level course that demands anatomy and physiology as prerequs, (If they don't then you should find one that does), then you need to take some time to relax and explore leisurely. You will truly be giving up nearly all of your life if you plan to do well in a good program. I completed my 2.5 years with a 3.78 average, not the highest in the class, and it was truly one of the most stressful times in my life. I wouldn't trade the opportunities that it's given me for anything, but I wouldn't do it again on a bet. On the other hand, if you're going through a quicky program, you'll need much of what's been mentioned, as well, many doors will be closed to you unless you're wanting to become a fireman. The best resource you will find prior to either program? Truly, EMTCity...if you can wade through the occasional bullshit, it's golden. Dwayne

Heh...speaking only of your balls to the wall, perfectly honest or nothing approach to the way you used to present call reviews. Man...my behavior here is so much more honest and brave based on your example. The intelligence and kindess of your posts never changes...But I do miss your call reviews. Dwayne

From a learning perspective, what an excellent post. I love how it walked through the 'What if, but if that changes, what then, but what if I do this instead?" of EMS. Second unit if it left from quarters is probably an hour twenty out as the weather is making the roads muddier now. But it can't really leave from there or it leaves the town uncovered so there would need to be the back up, back up ambulance called out. So likely an hour 30 or hour 45 for the second ambulance to arrive, and hour 20-30 for it to return to the local hospital, 20-30 mins for transfer on to the FFL helicopter if it goes per usual, and 45 mins to a trauma center. So, waiting, lets say, 4hrs to difinitive care. If I take them and run, (Though it worked out differently) say, 2hrs 15-30 mins or so. Unless I run past the hospital/helicopter and take them on my own, though the time would probably be about the same. And both kids fit on a normal LBB without significant issue. The problem was that I didn't trust anyone else to drive for us on the muddy mountain roads, so was forced (in my opinion) to have my partner drive and provide care for both patients on my own. Not sure about the boy, though I think that he was in ICU for a while at a childrens hospital, but I believe that the girl died. Though again, both were hearsay. Thanks. And I seem to have been noticing a different tone to your posts lately. Good to have you here man...thanks for playing. Dwayne Always some bullshit words of wisdom as opposed to any type of thought out response... C'mon man. Sack up and put yourself out there a little bit. You might find that you actually have something to contribute. Dwayne

(Edit- Redundancy due to posting at the same time as the others.) What was your working diagnosis on this patient? Why were you called? When you say that she was coming around quickly, coming around from what? It sounds to me that this patient was intubated for the sake of someone wanting to get a field tube. I don't really see the indication for intubation here, though of course it's just a sketch of the call review so perhaps the indications were there. It also sounds like we have so many cooks in this kitchen that we ended up making a Kemche diet Latte abortion burger instead of a souffle. I've intubated struggling patients before, but nasally, not orally. Some with sedation, and some without, but all were resp issues near exhaustion. Why wasn't a nasal intubation done instead? I'm guessing that the answer is that most folks are scared of them. And it does sound as though once intubation was considered that patient care went out of the window. And I'm sorry Brother, but I have to include you in this as well though I know your passion for the subject, as the argument should have been strongly, even forcefully made to withold the proceedure when it was apparent that it might not be necessary any longer and in fact, from the outside looking in, wasn't necessary to begin with. What are you feelings on intubation of geriatrics in general? Do you see a difference between putting a geriatric in a position to be intubated and placed on a resperator as opposed, say, a 20 year old? You're thinking on this subject seems spot on to me. Why wasn't your logic followed on this call? And to worry about retarding the resp drive on an intubated patient is pretty ridiculous unless you believe that you will be extubating this patient before hand off at the hospital...and I don't really see that happening. I notice that you say that you didn't snow her with meds...depending on your working diagnosis, and what you used for sedation, snowing her was likely the kindest thing that you could have done. Being intubated sucks physiologically speaking, knowing that you're intubated sucks much, much worse. This was a lightly medicated trauma, right? Treat it as the trauma that it certainly is unless contraindications exsist to disallow it. Great, brave post. In fact follows in the footsteps of the Fiz of days gone by.. I have a lot of respect for the fact that you posted this in the spirit of allowing others to learn from it despite the near certainty that it was going to get your ass kicked. That's in the best spirit of EMS in my opinion. Dwayne

Yeah, your point is spot on regarding Afg. If you wanted to look like a complete asshole over there just bring a damaged patient into the Role3 and explain that you didn't provide what you felt would have been a benificial intervention because 'my protocols don't allow it.' Working there ruined me forever I think. After that it's very hard to say, "I know you'd feel better if I give you another Litre of fluid during our 2 hr transport to the hospital, but my protocols only allow for a 500cc max." Very difficult to follow up on these types of patients there as they either get stabilized and sent out of country to Dubai, or stabilized and loaded on an ambulance to an Afg hospital..neither conducive to follow ups.. This is an excellent example I think of, "Of course I did the right thing. I lost only a little bit of blood, and feeding the wound margins is obviously a benificial intervention with very little risk involved!" But then of course I have to hold my argument up against the one used to support MAST...which of course bitch slaps me right back to the real world. Maybe one of the Drs can comment, as my treatment plan made sense to me, but it's possible that the wound margins will be fine if left with no treatement for days, in which case I'm just an idiot dicking around when I should in fact have been taking another set of vitals or something... I have no data support either argument really, but I feel like a rock star medic when I follow mine..and at the end of the day that really is the most important thing I think... :-) And for the record, why should a tournequet not be removed except by a doctor once it's been placed? I've assumed in the past that it is so the Dr can see where it was placed and assess any vascular damage that may have been caused by extended use or over tightening, but I really have no idea... Dwayne