DwayneEMTP

LOL..I see you now! Holy shit! How cool to have you here man...Have you posted in a while? Guys, this is Eric. We met during my time on the oil spill. And though I worked with probably 100 different medics down there, he's one of maybe a half dozen that I came to respect as a truly comitted remote medic and understood what that meant. (Not including myself in that list as most were much stronger providers than me.) Man Eric, it's good to have you here. I hope that you'll participate, we could use another opinion from a good provider here. And if you can sort them out from the bullshit that sometimes buries any forum, we've got some truly smart, intelligent, kind, committed folks here. Admin is a rock star when it comes to letting us go our own way until it becomes obvious that it's not working. It's a fun and easy way to stay current. Are you home, or out on the rig? Dwayne

Yeah, that's why I mentioned that I was going to relay it in gross terms only. I was assuming some type of cerebral damage in both. I wasn't sure, but that was my working assumption. The girl from blunt trauma. Her unfocused crying and what appeared to me to be a retarded response to my touching her eyelid led me to worry about that. (again, speaking in gross terms) The boy, with the injuries described, should have been much more animated in my opinion. I actually wondered if being squeegeed between the bike and the frame of the trailer could have cause a temporary, severe cerebral hypertension doing some type of damage. And his baseline resp rate was retarded..that result had to be produced somewhere. But if we remove the possibility of cerebral trauma, the MOA combined with the noted injuries cause me significant concern that though I had no immediate, objective, indication, that the index of suspicion was very high for an acute abd. Plus, an add'l two hours min from definitive care secondary to nothing more than the injuries to his hands and knees seemed irresponsible. But I am curious...given only the information provided here, given the best case scenario to be extrapolated from the s/s presented, you would have waited on scene for over an hour for a second unit? A question, not a challenge. Dwayne

Man...see, this is what I love about you guys. While you state that many have no concept of ever needing to transport two patients in one ambulance, I truly had no idea that there were places where that wasn't a common reality...having never worked big cities...Pretty cool... Welsh and Bushy, what about two patients, one cot? (No, that's not a gross out video.) And, of course, I did take them both. But I did choose to take them both on one cot only because I really had no idea what was truly going on with either so was afraid to let either one be out of my view for long. So I put the boy, who was strapped to the L/B on the cot, the sister who was secured in a KED with their legs next to each other, strapped the hell out of them and away we went. As it turned out we got a hole in the weather, Flight for life notified us that they believed that they could get much closer if we wanted them to. I really wanted them to. They landed about 15 minutes away, took the kids in my original configuration and away they went. Of course, different decisions may have been made had my crystal ball been functioning properly, but I doubt it. But I'll never forget FFL choosing to stay on top of the call and notify me when they felt that they could punch through a hole in the weather instead of just sitting at the warm hospital drinking coffee. It would have all paid the same for them... I love remote medicine for the challenges of being 'stuck' with really sick and/or injured people, but long transport multisystem/head injury trauma can kind of freak me out. Not literally, but enough that it takes the fun out of it. There is just so much going on, much of it you have to be theoretically aware of all the time if you're going to catch the physiological markers quickly...I'm not so good at that often. In this case, I just wanted smarter people to take these kids off of my hands... But one thing was for sure, neither of them was staying home, and neither of them was going to sit still waiting for add'l help... Thanks all. Dwayne

Hey GM, I get the distinct feeling that I know you off of the City? If so, send me your name in PM, would you? Or here if you're comfortable.... Welcome back! And yeah, this is being typed from Mongolia, so y'all don't get off the hook so easy. Good to have you back man.. Dwayne

Great points all Spork, though I don't completely agree. As was stated by another, the patients that I've seen most often with life threatening hemorrhagic shock have not been to the extremities, though the extremities have sometimes been involved. I think the reason that it's common to use tourniquets in the OR and not so much in the streets is that it's uncommon to see OR docs and nurses running around freaked out making them less likely to crank a limb off with it, or forget to take it off later. Now, I know that WE are all perfectly calm on scene and have been from day one, but I've heard rumors that some can get a bit wound up on nasty traumas, particularly when newly released. Once again I'm going to open myself up to a beating and admit to breaking a cardinal rule. When I needed to break it, as before that, I had no idea why it was an unbreakable rule, so couldn't in good conscience follow it when it seemed counter productive. And, to tell the truth, I still have not a single clue as to why it's a rule. I once, here we go....put on a tourniquet and then removed it before getting my patient to the doctor. I know...I'm a bad person...but here's the reason. In Afg we had a construction worker working on the second story of some containers, so say, approx 20ft up. He fell off of the side and on the way down caught his arm on a piece of scrap metal that had been sitting on one of the scaffolds. The exposed metal was terribly sharp and caught him just under the armpit, missing his Brachial artery by, I'm guessing, smidges, caught under the skin and pulled through much of his bicep, exposed nearly the entire elbow joint, followed down the the outside of his arm exposing muscles, bones and tendons and the incision stopped at his wrist. We were maybe two miles from the Role3 and back in the middle of construction, he was running around like a madman throwing blood everywhere, it was a pretty good mess. One of the few times when I really wish he would have hit his head too...at least he would have been quiet and still. Long story short, I got him on the ground, I was with another medic but he was kind of freaked out and no help, and after a quick glance put a tourniquet on it. That stopped the blood flow while I did a quick physical exam, and my partner was wrapping the arm. I'd helped him pull the wound margins together, as the wound sort of a spiral around the arm, the margins were relatively clean and complete. We aligned the margins, wrapped them tight-ish in the hope that they would stay at least partially approximated, and loaded him in the "ambulance" for transport. (Parentheses will make sense to most that have been there.) Enroute I began to worry about feeding the wound margins as I wanted to try and leave the best chance for repair. I released the tourniquet slowly so as not to hurt him to bad but also to see if there was a chance that the dressings would hold.There was some bleeding, so I added another, tighter wrap, and other than some very slow seepage it seemed to hold for the 20 minute or so winding drive to the Role3. I don't really remember what happened after we dropped him. I gave my report to the trauma team, non batted an eye at my story, and I went about my business. I can see your point that had there been undiscovered injuries that the time it took to wrap it, or the blood that I spent testing my dressings could have retarded his condition. I get that...I really do. But I also can't get onboard with the flip side of, "He's already kind of fucked. So I need to do everything in my power to keep him from getting more fucked. And should my good intentions cause him even more damage than necessary....well, that's just a bad turn of luck." The above is not meant to be disrespectful, but a bit of a paraphrase of the "don't risk feeding the margins" part of your post. (My words of course, not yours. Judging from your post I'm willing to bet you have a much smarter way of describing these topics.) I stayed away from this thread when I saw it continue to grow in the belief that nothing good could come of this topic if it was being discussed so much...boy did I screw the pooch on that. Great conversation I think...thanks to all for participating. Dwayne

Right near the quarters I responded from, if they can get in there...about an hour, probably an hour and a half now, with patients on board due to the bumpy road and weather conditions... And Bushy, thanks for participating in the spirit intended. Many of these calls look cut and dried until you see them through the eyes of others. Dwayne

So, I was surprised by the bariatric patient thread when there were several, (if memory serves), that said that they have never, nor would ever transport a patient on the bench seat. I've done this a gazillion times (Not sure exactly how many a gazillion is, but it sounds like a lot). At my last service, my partner and I were the only ALS unit at night in a rural county, also the 3rd largest county in the U.S. We had a 2 minute chute time (From dispatch to running lights and sirens.) If we knew we were going out of the City then we notified the backup unit and they had 15 minutes to cover our position from the time of dispatch. The outside edges of our response zone were approx. 30 miles to the north and south, and if we went east and west were almost immediately into the mountain country where a response could be an hour or more. Fire and law enforcement are under strict orders to not operate ambulances and others responding are nearly completely untrained first responders that have a near perfect record of freaking out and being a danger to themselves and others on most calls. So there's the setting, as I expect that it exists in many, many rural places around the country. Ok, so here is an actual call.... Called for four wheeler accident with a child involved. That is all the information we are able to get before arrival on scene. I'm going to give the scenario in gross terms as that hopefully will be all that's necessary to allow you to make your transport decisions. Upon arrival we find two children in the back of a p/u truck. a 5 year old boy and a 4 year old girl. Looking at the scene I see a big hole in the apron running around the bottom of a jacked up mobile home. And, I swear to God, about 20 first responders running frantically around, many of them crying. While getting a history I find that the boy was puttering around and the little girl tried to climb up behind him. While doing so she grabbed his throttle arm causing him to rocket off, dumping her and running over her head/neck with the rear tire. He continued on hitting the home at a near perfect angle to mash the handle bars down and smash him between the bike and the bottom of the trailer. He was stuck there with the edge of the trailer settled on his chest with some witnesses claiming that he was unable to breath until they pulled him out. Witness one through 4 claim that took about 10 seconds. Witnesses 5-8 claim about 7 minutes, witnesses 9-12 claim that this accident happened last week some time. The girl is screaming her brains out, blood is coming from her nose, left eye, left ear, the one that was mashed to the ground. Her tears are running down both sides of her face so it's hard to tell if the blood is diluted due to tears or CSF. She is breathing about 30/min between screams, though she stares straight ahead up (immobilized per first responders) and when I touch her eyelid one blinks about half way with the other not appearing to move at all. PERRL, all other vitals within acceptable limits for this situation when all things are considering. But of course it's one set of values only. The boy is laying quietly, both knees are abraded and swollen ,I assume from hitting the bottom of the trailer, Both hands are a mess, his fingers mangled, he has deep scrapes running from his pubis, across his chest, and it appears that his chin may have stopped his forward progress as it's split wide, to the bone, and bleeding freely. His eyes are open and he is breathing upon first view on his own approx. 6-8/min with depth somewhere near normal. I can't activate flight to scene due to weather, though I do start them to the closes hospital available to them. I can activate the unit at quarters and send them my way, but they will have a minimum of an hour response. Again, for all of course, but for those of you that claim that you have never, and would never transport a patient on the bench seat, how would you handle this call? Though it may appear to be a trap, it's truly not. I'm fully aware that there are many, in fact most, here more intelligence and deeper in experience than myself. I only saw one realistic way to deal with this issue...I'm curious of the thoughts of others... Thanks all... Dwayne

Heh...you know I wanna! Pretty sweet gig and schedule here brother. I miss working with you though, so don't let me drop off of the radar... Dwayne

Man...I really, really want to take Ketamine for a test drive. I've never used it.. Dwayne

I wanna get sick in your neighborhood! I'm old, and homely, so you even get bonus Karma points for taking care of me in your off hours... Lucky girl...

There Are No Better Options when a patient won't fit out of the door! And no, we've all heard the rumors and urban legends about patients growing into their couches and needing to be extricated with it, but I'm willing to bet that not a single person has seen it....Another question mark here in my opinion... I give up girl. Truly, if you can't see the difference between acceptable risk when there are limited or no options when compared to those times when there are, then I just have to bail on this conversation. This is 6th grade EMTB stuff...I'm confident that you could get it if you wanted. And whether or not your user name was meant to state your dick preference, again, I'm confident that you knew exactly how it would be perceived when you chose it. Thanks for the conversation. And I mean that sincerely. You remain unchanged, as do I....I'll catch you on the next debate. Dwayne

I wonder if there is the equivalent in Canada? Don't you need electricity to have an autoclave? Maybe Canada doesn't need inspectors... Just sayin'... Dwayne

Yeah, but 10 years is an awful big oops. Do doctors offices and such not have regular monitoring like, say, restaurants?

Hlpps, I'm sorry if your son was offended, but this is intended to be a professional adult forum. I'm confident that you have been aware of the tone that these conversations take for a long time now. What did he think when he read that mom hates little peepees and gets bitchy 'when she's on the rag?" It's unfortunate that you failed to protect him from an environment that you felt is mentally/emotionally damaging for him. I've left my computer open to porn in the past and had Dylan discover it...though it truly never occured to me to blame the website for the 'splainin' I had to do. And I'm thinking that by playing the paragod card that you've now identified yourself as the manager of a volly paid per call organization/or a small transfer service. Why don't you just openly state your position? You've known the context of my argument from my professional description from the start. When people keep guessing at yours, why not just state it. So, from your argument, I gather that you don't require your medics to properly restrain patients during transport? After all, there is no proof that it keeps them safe, right? Do you carry spinal boards? C-Collars? Epi, Lidocain? Yeah, I know you do, and I know your crews use them all the time, assuming that you actually have ALS crews...though I'm beginning to have serous doubts as to your honesty in these matters. Do me this favor, as you claim that must ALWAYS follow company protocol. Post here your companies protocols for properly restraining patients during transport. And now here, post the protocol that claims that you may disregard the above protocol when it's inconvenient during a non emergent situation. And no, I don't have to post mine, first of all because I have a bag full of cool shit that I don't have oversight for, thus no protocols other than acceptable practice, and secondly it's morally and ethically my responsibility to break the rules, in the safest manner that I can conceive of, to get my patient to definitive care. Now, don't wuss out on this. These are your arguments. That you MUST follow protocols, that your company is so progressive that it doesn't follow archaic seat belt nonsense, so this should be simple for you. I'm looking for the protocol provided by your company that supercededs the one requiring you to properly restrain your patients. I have expressed my respect for your cast iron ovaries in this argument, and meant it. But now every post seems to smack of you understanding that you're wrong, but hoping that if you keep piling bullshit on top of bullshit that at least someone will drown under it...You know better than that...most of us can swim in bullshit for days without breaking a sweat...We've been doing EMS for a while. Dwayne

I haven't, but I like your style. Dwayne

Hey...welcome back, whoever you may be... I'm guessing that there is a reason that you're back under a different name? If so, screw it....start off fresh and let's get this party started! Dwayne

I'm about 40 miles south of http://en.wikipedia.org/wiki/Oyu_Tolgoi_mine But you might want to think this one through a bit before making the leap... :- ) Dwayne

Then why would you choose not to use one? Why would you, as you stated, fire an employee for choosing to utilize a more appropriate form of transport? You're making quite a leap when you change the scenario to state, "Most 911 calls aren't truly emergent, so why are they different from a non emergent transport?" That was not the scenario state, nor the one that I believe that most of us have been arguing. As well, if you don't know the differences in the legal issues involved in most locals between the duty to act in an emergency when compared to a non emergency then I have to question the honesty of your stated experience. Had I been called emergent to transport a bariatric patient that I believe purposely called for reasons non emergent I would get my supervisor involved and explain the situation and almost certainly this person would be speaking with the police about mis use of 911 while they waited for the bariatric ambulance. Just sayin. Being fat doesn't mean that you also get to be stupid and irresponsible. Unlikely. I've been here a few days, so yeah, I'm confident that I know who is reading and pay attention to the responses I get to my way of making my point. Which, for the record, as can be attested to by many here that know me personally, is the same way I make them in person. Nor do ladies in my experience publicly claim to hate small dicks, profess their love for hard bodied cops, nor publicly use being 'on the rag' in defense of rude and/or obnoxious behavior or comments. Not completely true I guess, as I've known women that do all of those things that I consider ladies, though none of them would every be offended by my cussing while they were doing it. Can't have it both ways babe. Be crude and aggressive and play with the boys, or act like a lady and, as I/we always do, I'll adjust my behavior to be respectful. But don't be crude and then play the, "you're hurting my delicate sensibilities" card when you get your...whatever...in a bind. Nor I at you, but at the your continued argument that if a posters company has no bariatric ambulances then they have no right to comment on the unsafe transport of an overweight patient. You I like, your argument I simply want to choke to death for it's intolerance, inflexibility and lack of respect for the obese and infirm. And I agree completely, as most of EMS in our country is run by redneck knuckle dragger vollies/paid per call services instead of by professional, paid EMS services. And, as I've said many times before here...justifying an action based solely on the fact that 'others do it too!" is an EMS pathology, and is proving to be terminal. You're too smart to say such a thing or use it as a basis for an argument, but I'm afraid that you've been inside of your services backwards, unprofessional bubble for so long that it's becoming opaque and is sheilding you from any new understanding. And I believe that the compliment is well deserved. The fact that you have an argument that I disagree with, and that you piss me off sometimes certainly doesn't negate the fact that you have the courage to stay and participate. Staying is how we find the truth, and I have nothing but respect for that... Dwayne

Hlpps, the last service that I worked at didn't have a bariatric rig, and it was about 90 miles from the closest one. The next closest, about 200 miles. We'd had units from both to transport patients in this dinky little town..transfers of just a few miles. We had a 900lb patient fall while trying to get to the bathroom. Acute abd, severe lower back pain, unable to get a decent B/P even on her forearm. This is one of the few calls in my career that bothers me as I was, for some reason, so completely, and constantly aware of her humiliation at having fallen before making it the the bathroom and then being unable to get up. I called in our other unit, called in both fire depts, yet we still couldn't lift her really. Our cot was rated at 750#. Finally we managed to get her onto a tarp, with 14 people crammed into her small-ish kitchen we were able to get her balanced on the cot. We used it kind of like a dolly, in the down position, and scooted her out the door, down a bunch of stairs, and onto the floor of the ambulance where the antlers had been removed and transported her non emergent/unsecured on the floor. At the hospital I had the maint guy attach my cot and an identical cot together with ratchet straps, to make one, pretty solid (yet untested/unapproved) cot, and we used that to move her about the hospital. We finally got her into a bariatric bed, but she needed add'l tests that this small hospital couldn't provide. The hospital looked around until they found a bariatric unit available in Denver, 200 miles away and arranged the transport. I think it was 8-9 hrs before they managed to get to the hospital. Pt was relatively stable and moving her out the way that we'd moved her in was unsafe for all involved. Right? Had she proved or appeared to be unstable then I would likely have found the 8-9hr time frame unacceptable and loaded her onto the floor of my ambulance for the transport. It's completely insane to be that your service won't allow those decisions from a paramedic and would even considers hiring a medic that they wouldn't trust with such simple decisions. It seems to me that your argument has been, "Well, if you weren't willing to risk her life and well being to transfer her after she was stabilized at the hospital then you shouldn't have been willing to do it emergent! You should have just left her home to die you hypocrite. Show her some respect!" I had no friggin' idea what to do to get her out of her home, so I made the best bunch of bad decisions that I knew how and hoped that the EMS gods would smile upon me and I wouldn't hurt her further. At the hospital, in their bed, she was much safer than she would have been on the floor of my ambulance when an alternative existed. Now, I have no idea where you live specifically, but I now, and will continue, to disbelieve that there is not a single bariatric unit in your entire fucking state. Keep making the argument if you like, but I don't care how redneck/hillbilly you are, there was access to a bariatric unit. The parties involved simply didn't want to make the effort to make it happen because this fat chick just wasn't worth it to them and/or they didn't want to pass up the fare. Or perhaps your service/community is still somewhat unsophisticated and not used to providing EMS at professional standards so is unused to solving these types of problems. Either way, your inability to see ANYTHING wrong with your argument, despite some pretty intelligent folks questioning it smacks of, 1) you're full of shit when you talk about your EMS experience, or 2) you've worked nothing but very rural/super small volume areas, and/or 3) you work now, and have only worked for volly fire services. The 3rd being my prediction should the truth ever come out. I am though, happy to hear that you were off your game during some of those posts. You become kinda psycho while menstruating! But I'm guessing people have told you that before... :-) Good on you for having the iron ovaries to continue the discussion. There are few on this site that would have. Dwayne

Welcome back! How ironic to have a double post in the Deja Vu thread? Deleted the other, thanks for the heads up. Dwayne

You know Brother, it may seem that folks are just bagging on you, but they're not. You want to run IV fluids, right? The problem that arises as you begin your new medical career is that you see people run them all the time on TV, and you see medics starts lines and run fluid all the time on scene, so it appears that anyone can run fluids. I get that, but it's really a false view of what's going on. You did well by coming here for advice, but then you stopped participating after you didn't get the easy answer. But you know what? There isn't an easy answer. There is a short answer... The saline is added to try and match the electrolytes in the fluids to the electrolytes in the body in an attempt to approximate a homeostatic relationship to try and prevent radical fluid shifts into or out of the vascular/interstitial systems. Do you think that I tried to make up big words and make that as complicated as possible? Truthfully, that is the simplest explanation that I can think of. And I'm easily one of the dumbest people here. If that is all that you know about running fluids, or why there is salt in the water we push into people's veins, then you have to stop pretending that you want to do medicine and admit that you're simply an ignorant whacker that wants to look like a hero in front of the chicks and his buddies. Be better than that. Show that you actually have the balls to participate in EMS instead of simply pretend to participate. Come back and explain the paragraph above to the best of your ability after doing a bit of Googling. Not cut and paste, but in your own words....we'll walk you down the path, help you all that you need and more...but you've gotta pay to play man... We're not jerking you around because it's fun, but because it's good for you. If you really want to be an EMS provider prove it by doing the real work on this subject as it is vital. Of course, you've probably already gone to one of the other sites where they gave you the answer and told you what a hero you are for wanting to help people...If so, I'm sorry for that. They lied to you, and cheated you out of an opportunity to be better today than you were yesterday. If being better is not your goal then get out now my friend because you'll always be ashamed of yourself when you work around people that are truly dedicated. Because those people have been trying to be better today than yesterday for weeks, months, years, some here, even decades. That is what makes them really good medical providers. You want to knock the socks off of your teacher? Show the class that you came to play and that they'd better amp up their game if they want to keep up? Then understand this presentation when you give it instead of just parroting a bunch of crap you found online like everyone else is going to do. I look forward to your thoughts and I hope that you stay to participate. There is nothing at all foolish or stupid about your question. Many here can learn from this discussion. Show that you have a true EMS spirit...don't cheat them out of it... Dwayne Edited for poor grammar and typos. No significant context changes made.

It sucks? Not busting your balls man, but I'm not sure what you're looking for. There's really no information other than the fact that those investigating either chose/or were forced to release a news statement admitting that they are/were investigating a Dr.s office for questionable biological control practices in some way. What is it that you're looking for? Dwayne

I think what most are saying, at least in part, and tcripp brought this to my mind as she does many things, is that not only did you show for the call, but cared enough to question your behavior, and then still enough to seek out answers....and that is in the very finest spirit of EMS. You've got nothing to worry about. As Toni said, stick with it. If it's not your bag, you'll figure it out and have new skills to show for your time spent in class. But I'm willing to bet that you're going to be really good at this... Dwayne

I'll give you a dollar if you tell her to blow the buck fifty out of her ass and report back... Two bucks even... Dwayne

Excited for you too Brother...If you bring all of the kindness and passion to your relationship, as I know you will, that you bring to EMS, life will be a breeze... Good luck.... Dwayne