DwayneEMTP

+5 Mike

+2 Mike...

What changed you as a medic? I was watching "Combat hospital" tonight. If you've never been to Kandahar Afghanistan, you should watch it. It is so true to life that it freaks me out a little bit... Anyway, I'd been helped into Afghanistan as a new medic, by an amazing friend that I won't name, out of respect to him, but am more than happy should he feel comfortable with it. Two things changed me as a medic forever... The first. I was called to transfer a patient that had a traumatic amputation of his right humorus and left femer. He was 4 hours post op. I was told that he was comatos, yet when I approached him he seemed to track me with his eyes, and when I ran my pen up his existing foot it flinched. B/P 120/90, H/R 130, RR 26, skins moist, diaphoretic. In other words he seemed to be alert and in pain to me. I told the male nurse that he wasn't unresponsive, and that his vitals seemed to indicate significant pain, and asked what he had on board for pain management. You see, our treatment was likely to be the only that he would recieved before he was transferred and died. I was told by a Canadian nurse that, "If he wants proper pain management that perhaps he should show his insurance card!" As I began to unwind on him I was told that I could just manage his pain on my own...I moved him to our plywood ambulance and just did that..but never forgot the look on the nurses face... The second call..only a few weeks into my time overseas we get a mass cas alarm. Expected casualties...400. I've never done a mas cas before that involved more than 3 patients. I call to my supervisor and he says, "Do your job. Call me if you need help." At the end of that radio contact, all of a sudden everything becomes clear. I see ambulance lanes, placement for red, yellow and green patients. I have a gazillion people lined up waiting for me to tell them what to do....And we end up with 4 pts.....The bomb had gone off over the top of a building and though there was a bunch of property damage, very little human damage. But I could have done it...though I might have never known that if this person hadn't had faith in me... Both times, when things seemed really hard, the same person gave me the same advice...if you can guess who, and should he give permission to say, I'll send you something really important to me...a challenge coin from the remote medics in Afg.... Have you had such times? Times that defined you and let you know that you would rather do the right thing than anything else? That you would walk away from your medic/EMT cert rather than violate the morals/ethics as lay down by someone you respected? Lets hear it if you want. I believe that this is the most important aspect of paramedic medicine. Unfortunately, me and my mentors are in the minority....but....what do you say? Dwayne

Agreed on not working this guy longer than necessary to try and correct airway/and verify the PEA. Unless he happened to be ejected onto the ER cot waiting outside of the ER doors, there's nothing to do here most likely. Like Doc said, our drugs are to help correct cardiac/cardiac related issues, this guy has container/neuro management problems. We don't have many tools for that. Also, there are, I guarantee you, other significant injuries other than the facial trauma. Just your description of blood pouring from the roof of his mouth makes a cranial vault compromise almost certain, and it sounds like in a big way in this kid. It took a lot of force to cause that injury (Intuitively speaking, can't back that up). In fact, I would be willing to bet that the CPR was working like a blender on this fellows internal organs from thoracic injuries as well. Kudos to you for bringing this here. And kudos as well for wanting the best that can be given for every patient. Both take balls. Dwayne

Just passing through quickly, but....You're welcome. Also, you are correct on 'stemming' the flow. I'm afraid I've always taken that to mean 'to make it really, really slow' but I've never actually looked it up I guess. The main thing to remember is "Life over Limb." You don't want to worry about limbs until after we're confident that the life is saved, or as close as we can get. But at the higher levels of care you can often do both at the same time. Good questions, amazing attitude, plus, as you can see, your 'simple' questions created debate even amongst professionals. Thank YOU. Dwayne

Actually, they all seem like things that might be touched on but not covered in a first aid field guild for the novice. And I'm not sure by what definition of a troll this poster would fit? Polite, respectful, responds directly to every statement directed at them without being an ass.....what about any of that is trollish? For your question...yeah, I have used tourniquets, am positive that I will use them again in my career, but their use is very, very rare in EMS and a really bad idea for the novice. The problem with them for the novice is that there is so much adrenaline and so little education that a lot of damage can be done with a tourniquets. You see, you only want to stem the flow of blood, not stop it. If you twist a tourniquet tight enough to completely stop the flow of blood there is a decent chance that you'll damage the vessels under it as well as starve everything after it. In the earlier levels of first aid you often have people that can only see "Bleeding=Bad", therefore, anything that stops the flow of blood=Good, and that's not the case in most instances. Many, yes. Most, no. At the paramedic level we have to worry not only about life, but limbs as well when we can. Saving a life while needlessly losing a limb is the worst kind of bad medicine. Dressings and bandages are good because they avoid rescuer added vascular damage that tourniquets can produce if put on in the wrong place or too tightly. Also, dressings protect the wound margins (The edges of the wounds that the smart people at the hospital may be able to use to close/repair the wound if we haven't damaged them in some way.) and keep them moist. So, if you have a big wound, dressing and HARD pressure, if it bleeds through, more dressings WITHOUT EVER lifting the first, and then more. If you see someone with their arm cut clean off...dressings or tourniquets? Dressings if possible...we want the blood to continue to feed the wound ends without causing a significant continued loss of blood. How about two legs and one arm amputated with blood spurting everywhere? (Reference 2c4s post above) Tourniquet, tourniquet, tourniquet. See what I mean? This dude is hosed anyway, but you just can't manage him with dressings on that many severe wounds. If you're not sure if you should use a tourniquet or not? Don't......It's a good rule of thumb. Dwayne Edited to correct a typo. No other changes made.

I can't remember if I mentioned that I once started an I/O for a diabetic coma...? I once sutured a head laceration with the patients hair, that's cool, right? I couldn't get permission to use sutures as it was an Afg national and they didn't want to create an OSHA recordable event, and I was still a big enough pussy to ask before I did the right thing. One of the guys had a Special Forces field guide so we looked it up in there and..... Walah! He wasn't a happy camper...But he has a nicely closed laceration. Dwayne

Hey man, Welcome to the City. Yeah, being a medic pretty much guarantees that you will have way more people die in front of you while there's little or nothing that you can do than ever before. But that's the gig brother. At least now, if you're in a good program, you'll have a better understanding of why. You should feel more comfortable knowing that there was little you could do, and for some, it's simply their time. But, those patients are rare in the Grande Scheme of things. Good to have you here man...jump in, be brave, ask, answer, debate....just don't be a baby... :-) Dwayne

When I first got to Afg I was fortunate to work with a bunch of medics, some really good, others just shiteheads, but we all worked in a meat grinder. It was mostly clinical medicine but we each saw 15-30 patients/day, day after day after day. I was able to listen to a gazillion assessments, from all types of providers. One thing I noticed was that it was really common for a medic to ask a few questions, decide s/he knew what was going on and then lead the patient the rest of the way down that one narrow path by asking only the questions that would validate their assumption. I don't think that they did it on purpose most times, but just out of habit. It was evil because doing so not only would often lead them down the wrong path, but because the patient didn't really know what was wrong they were happy and the medic was erroniously led to believe that he was a rockstar because it looked like he was right on his first guess every time. I hated that... So, understanding that I'm not better than the other medics and worse than some and thus no less likely to fall into the same traps I developed a plan, that turned into a habit and now is just second nature. It's really pretty easy. Begin asking questions centered on the apparent issue, then focus your questions based on the answers until you are confident that you are on the right path, and then begin mixing in questions that are almost certain to derail you if you are on the wrong path. Know what I mean? An oustanding example is being dispatched for 'drunkenness.' Mr. Jones, have you had anything to drink today? Fuck yeah! A quart of tequila! (Wife appears drunk also, both smell of tequila, you know the scene) Skin flushed/greasy, a little tachy at 118, B/P slightly elevated, speech slurred and irritated, zipper down. No question that this is a drunk. So now prove that he's not. If you can, then he's more than drunk and you can congratulate yourself for being an above average medic and patient advocate. If you can't, then he is what he appears to be, at least as can be discovered at our level of care and you've done your job and should feel really good about that. Mr. Jones, do you have any pain? Nothing hurts but my fucking legs...and they are always hurting me! Do you mind if I take a look at your legs real quick? Will just take a second... You pull up his pants legs and see that his ankles and lower legs are swollen..the skin tight and the skin condition dry, flaky and bruised looking....(Yeah, I'm not going to take all day to turn this into a diabetes/CHF catch, but you get the point.) I think most times with any significantly ill/injured patient you will think of questions that you'd wished you'd asked. Just the fact that you're thinking of your patients after the call bodes well for you as a provider in my opinion. But just like drugs...Gather symptoms until they lead you somewhere, not the other way around, and then when you get where you're going, try and prove that you're lost. If you can't, then you're usually golden, if you can, then you've discovered that you're off in the ditch and need to start asking more questions. Either way is really good...Though of course, sometimes, we're just gonna screw the pooch despite our best efforts. Super over simplified of course, but your post makes it obvious that you're plenty smart and don't need to be spoon fed, so I'm sure you get it. Great question man...it's good to have you here! Dwayne

Didn't someone post a study/studies in the last year or two that, opposed to showing any type of benefit with Morphine, that there was like, a 50% increase in mortality with AME/MI? I can't remember for sure...but I think so. I can't seem to find it now though... Dwayne

tniugs, possibly one of the most intelligent, informative, eloquent, and certainly one of my favorite, posts on the City ever. I wonder if SD will see the kindness in it? Dwayne

Nah, he probably just did it for simplicity sake... Dwayne

Man SD...I've tried to get on board, I truly have, but I'm calling bullshit on the medic title. I'd bet a weeks wages that you're a basic trying to fit into medics clothing. And I'll tell you why... If you are an ALS provider during your normal work day, leaving all the rest of the crap aside, what possible use could you have for an EpiPen on your person every day? A medic would know that you almost never run into the situations that a laymen would have need of it, and a medic would know that he would have access to it within 30-60 seconds from the ambulance any time s/he needed it so carrying it in a pocket would just be stupid. Also, I know of no medic that would put up with the crap that you've put up with in this thread and yet you continue to defend the ultimate whack pack...That just doesn't add up brother. Every thing in your personal vehicle and on your person, with very few exceptions scream poser. Believe it or not I hate to type those words as you're posts have used proper spelling/grammar/punctuation/capitalization and have been very respectful, and that is a gift the we rarely receive here. But we're not the badge bunnies and teenage bible study group that you're used to impressing with all of that nonsense. We do this for a living, know what can and should be done most often, and you've just gone so far down the whacker path that I'm not sure how to help you find your way back. Get proud of who you are, learn to do good medicine and be proud of that, then I think you'll find that you don't need to try and show off with a bunch of extraneous shit. I would like to see you stay and grow, but for that to happen you are going to have to come clean, and I just haven't seen any sign of that happening yet. Dwayne Edited to add text in italics.

Here I disagree. There was no external mechanism possibly, but turning his neck may have been all the mechanism necessary to create a traumatic injury. Like coughing in a "spontaneous pneumo." (I've always thought of that as an oxymoron). Coughing is still the mechanism, right? Despite no external trauma being delivered. Not busting your balls brother, just throwing that out there for discussion in case the debate may have some educational value. And I hate longboards. There is not data to support them, at least non that I've ever been exposed to, and tons to use to hate em with. I never use one without a quartered blanket on it which, when I was working the streets, meant about 50% of the time garnered scorn from the non physician ER staff and about 90% of the time from my coworkers as 'not real immobilization.' I finally just quit having the argument and let em bitch. I never once, that I can remember, got a complaint from a Doc for it. Still no idea what is going on but I'm leaning towards an electrolyte imbalance maybe. The pop...maybe inner ear? No friggin' idea really. Dwayne

Let put a C-collar on him, no board as the cost benefit isn't there. I know the ER is likely to laugh/bitch at me for having a patient with a collar and no board, but I want to remind him not to move his neck. It sounds like he's damaged his C-spine in some way and though the benefit of the collar is questionable at best it will help him remember to stay still. I did think CNS decompensation from the initial mention of the 'pop' but the vitals don't seem to speak to that. No tachycardia, B/P holding well. I went back to see if these values were maybe being controlled chemically but didn't see anything that would lend itself to that. Perhaps there was a previously undiagnosed osteopathy, or a damaged ligament or tendon caused swelling that is intruding into spaces reserved for the spinal column/nerves. Not sure. Though I'm a pretty big advocate of relieving the discomfort of patients I'm not going to give an anti-emetic at this time. Not because we're so close to the ER, but because I don't really have any idea what's going on with this guy and I don't want to steal symptoms from the ER. The severity, quality, and possibly other descriptions of the nausea that might not mean anything to me but might mean something to the physician. Now, should the nausea increase and I believe that vomiting may be eminent, compromising C-spine management, then I may be forced to treat it. If we were, say, an hour out I would call the Doc and consult. But at this point I won't likely even get him on the phone before I'll be going through the ER doors. Otherwise I have no idea what's going on. I'm going to transport with the current interventions in place unless something changes that should push me into a certain direction. Awesome, intelligently presented scenario man....thanks for taking the time to do it. I wish I had better ideas... Dwayne Edited to correct a spelling error only.

Yeah, Mike, you need to talk to the Grande Pubah...it sucks that we can't give positive points to moderators. You're reply was spot on. And LB, none of it is bullshit. Most of the people that I have come to know and or love here have at one time or another sent me packing with their boots so far up my ass that I couldn't poop for days. I'm not saying that getting beat up is good, it's just that sometimes we take good advice as abuse. And even when it is, if it's truly good advice, it's still worth the price. I have nothing but respect for the plans that you have made. I have the pantry from hell...not because I'm worried of earthquakes in Colorado, but because I'm terrified of getting hurt, or fired, and not being able to feed my family before I recover. I've never needed it...but it's never hurt anything that I can see either. I look forward to your thoughts... Dwayne

You're welcome. Now, live in the scenarios forum when you're bored. It's your chance to run your calls through your head before you have to do so on the street. Plus, it's fun as hell...even when you make mistakes. Get busy girl... Dwayne

We know immediately that the presentation doesn't match the vitals. This guys could be in trouble, so lets look at other possible causes. Of course he could just be playing with some dope he's hiding from his wife. I'm going to lift him from the car, no walking for now. Take the automated cuff from the fireman and cut off the friggin' hose off and get a new set of vitals on my own. We are going to need a better history than we've gotten so far. Is he compliant on his meds? Does he have the bottles on him? Lets verify that the remaining pills match the dosage/prescription date. I want an IV on him right away, I'll ask my partner to do that. Pupils? You state a rhythm strip shows no cardiomyopathy, yet a rhythm strip wouldn't show such things. Did you mean a 12 lead? If not, then he needs one right away. What is his pulse quality? I guarantee you that there is something that this guy isn't telling us regarding this situation...we need to figure out what it is. Dwayne

Yeah, man, I'm not getting the wanker vibe from you...But something that you really must understand here..Someone coming here and asking the type questions that you were asking and them NOT being a 'wacker' (wannnabe hero without having any interest in education) is about as likely as...say...spitting into a truck full of Marines and expecting them to say thank you. In fact, your odds might be better with the Marines. It just so rarely happens that we lose sight sometimes that it's even possible. We do get tired of people that want to carry all of the sexy stuff they see the bullshit heros carry on TV, but don't want a personal investment. I misunderstood that to be your position. Last apology for that. Sorry. The EMTB class will run from around 120-160 hours, give or take, including some small shifts on an ambulance and maybe in the ER. Both of those will likely help you with what you're looking for. The classes often run 3-4hrs/night twice a week. Mine was Tuesdays (1800-2200)and Thursdays and all day on Saturdays (0800-1630). I took mine while working well over full time at my regular job, and I had a lot of fun with it. I truly believe that this investment of time and money (The GI bill will probably cover it?) is exactly what you're looking for, and I also believe that it will change the way that you plan for a disaster as well as make you much more valuable to your family and neighbors as well as an asset able to interface with EMS when they finally do get there. That sounds like what you are asking for, yeah? It will teach you basic emergency care from the bottom up (hopefully) and you will learn many, many things more important than trauma care. How do you know if your neighbors gas line broke and he's been poisoned by the gas? What should you do? How should people breath when they're unwell? What do you do if they don't? What should you do with someone unresponsive but breathing in the middle of 20 other people just like that? How much blood loss is to much? And a very important skill...Triage. How to give the most help to the most number. There will likely be modules explaining how the emergency disaster plans work, and how you can volunteer within them even if you'd like to. It will cover allergic reactions, snake bites, trauma/broken bone management, etc, etc. Sorry brother, I've been away from Basic education for quite a while and my perspective is queered. Those are the things that come immediately to mind but I will be more than happy to answer any other questions that you might think of, though there are many here that can guide you on this better than I. Thanks for hanging around man... Dwayne

Fair enough brother, perhaps I misunderstood this statement and it colored the rest of my response. I read it to mean that this was not the kind of advice you were looking for, but can see now where I may have read it incorrectly. My apologies if that is the case. I don't have the time to get more in depth now, but would be more than happy to talk to you about this at any length that makes you comfortable. Thanks you for your service....And thanks for participating in these discussions. Dwayne

One interesting point, or at least it seems to to me as I've not looked it up in several years and can't remember how valid it is... Only twice I used Amiodarone, even after we began carrying it I used Lidocaine only because I was more comfortable with it. But the first time I used it the ER doc lectured me, kindly, saying that it was the lesser choice because it crossed all of the cardiac drug classes and made in hospital management more difficult unless it was continued as opposed to switching to other more appropriate choices that had been queered by it's use. I have no idea of the validity of this argument, though the next time I used it I delivered my patient to the same doc and got the same lecture. The few times I've needed to choose since I've used Lidocaine based on that. Simple and foolish I know..but there you have it... Dwayne

Yeah man...craziness. So much of what we do now relies on trust; A complete separateness from law enforcement. 80% of the high risk populations for drugs/alcohol/child issues won't give me the information that I want/need if the line is blurred more than it is already. Oh, and there's the fact of course that it will not happen and if it does, simply won't work. This is as bad of an idea, as say, wearing handcuffs on scene? (tongue partially in cheek) Dwayne

Hey Amanda, welcome! If you're goal is to be a nurse, why waste your time becoming a medic first? It will be almost a completely wasted space of time towards your goals. Right? And trust me...read the threads here and elsewhere before even thinking about a bridge program..for the vast, vast majority it is a horrible choice with very limited employment opportunities to follow. And where is James? Don't tell me...to be a firefighter he doesn't need all of this silly learnin' and networkin'...? Good to have you....both? Dwayne

Man, SD, I'm guessing you're not impressed with the responses that you've gotten here, but it's just so foreign man, the way that you think. I've been a medic in Afghanistan, in a rural town of 10,000 that was redneck/meth/ETOH heaven, in the city, on the oil spill in southern LA (redneck/Cajun/Coonass heaven) and now in the oil fields and I've not seen the issues that you are preparing for. I think the thing that goes unsaid here is that there is a reason that you prepare for so much trouble, and it might be your scene management skills. Serious questions, not busting your balls... Why do you want to carry handcuffs? What situations are you having/have you had that warranted the need for, or even more confusing, the desire for them? What can they do for you besides impress the badge bunnies and create a bunch of liability that can't be resolved as well with soft restraints and Curlex? If you're truly an expert in martial arts, then you know the reason that most reputable systems don't advocate carrying weapons upon your person is that it causes you to follow a different decision tree, right? Causes you to think weapons/martial aids when you should instead be thinking diplomacy? And please don't burst my bubble by saying that that is true for most people, but not for you. Though your posts are polite, well written and respectful, too much of the things that you claim to believe are in conflict with what I believe the reality of EMS to be. You seem intelligent yet many of your theories come off as a Basic pretending to be a medic wanting to compare L/S for your private vehicle. I'm just having a hard time, as it seems many are, getting a bead on you. Non of my comments meant to be insulting, but only specific, so that you can see how you appear to present here, at least as I see it. I'm glad that you've stuck around! That shows major balls as this hasn't been a free ride for you by any means... Dwayne