DwayneEMTP

Thoughts for peace and healing for those that loved him from the Womacks in Colorado... Dwayne

Good God! Another woman medic! This is bullshit.... Many of the strongest medics I know are women, and every time another chick decides to take the medic path it means the penis people have to step up their game and get smarter and stronger.... It's really friggin' irritating... Welcome girl. I too went from Basic to Medic with no EMS experience and believe that I've become at least a half ass'd medic thanks to my friends here. The important thing to remember is that you won't benefit much here by watching. You have to jump in. You have to show off your cast iron ovaries and participate. That's not always easy, but it's always worth it. Hell, watch the posts by tcripp, and many of our other lady medics/almost medics, every time they talk I feel like a halfwit that needs to go back and take a Basic refresher. The path that you've chosen won't be easy, but don't believe for a second that you can't do it. And when you start to believe that, (and you will if you're in a good program) look back at your clinicals. Remember all of the shithead idiot medics that you saw? Every one of them did it...in one form or another. You will be hit by a ton of dinosaurs (Ok, so they might have a point..it's just wrong is all) that tell you that you will not be able to succeed without previous experience as a basic. That your school must be shit if they accepted you without that same experience. But given a little bit of time you will see that there are many here that took the same path, and many of them have shown themselves to be amazing medics. Of course the others, like...'my friend', that just come to try and get the girls to talk dirty in chat....Just sayin'... Dwayne

Brother, why are you so opposed to learning something other than quick snatches on the internet? I became a basic after seeing a woman get hit by a taxi and didn't know what to do. I hated being helpless. It took me 144hrs...how much easier would you like it to be? With your bags but no real knowledge and practice you will look good, but be nothing more than a pretty ornament when you're truly needed. Also, you keep mentioning trauma. As a Marine, shouldn't you have had at least an introduction to trauma care? I don't mean to piss on this thread, but something doesn't make sense. If you do get the 'big one!' that you keep talking about it's knowledge that is going to save the day, not fancy bags, and yet you keep reiterating that you are completely opposed to any type of formal education in the thing that you claim to hold so dear....What's up with that? I once took an astronomy class because I couldn't explain to my son the stars that he was pointing out in the night sky. Do you mean to tell me that you have less commitment to your current mission than that? By the way, the astraunomy class took more credit hours than becoming a basic. If you want to truly be of help, get smarter, not more encumbered. You need to know triage techniques, how the systems will work so that you know how to support them, know what the priorities are in an emergency. Perhaps you believe that that is all a bunch of 'basket weaving' nonsense the rest of us chuckleheads weren't smart enough to know that we wouldn't need, but if so, you are terribly mistaken. Despite your best intentions and what you may have seen on all of the sexy disaster shows, with your bags, and a head full of ignorance, you are simply another part of the problem, not part of the solution. All of that stuff may convince your neighbors and girlfriend that you are committed, but you will be seen as a poser and removed from the scene on any significant emergency the moment those that are truly committed arrive. You would be better off to get a good set of goggles, gloves, and a shovel so that you can help remove rubble. You say that you don't want to be a 'hero' but the path you are now taking shows you to be no different than any other Ricky Rescue...wanting to have the fancy kit but can't be bothered to spend any quality time learning how to use it so as to do some REAL good as opposed to looking good for the newspaper. You can't learn this on the internet. Along with the knowledge MUST come practice, and practice, and practice. I get the feeling that you believe that practice is nonsense reserved for lesser men, such as myself. Again, you will find that you are sorely, possibly disastrously, mistaken when you want to act. Perhaps this advice will get your panties in a bunch, and if so, well, that's a shame. You needed to hear the truth of the matter. Do you want to do some real good when the shit hits the fan? Get yourself and some of your neighbors together and take an EMT B class. Set it up as a club and then get together at least once a month to practice triage, wound management, and EMS cooperation. You will then have at least basic skills, some idea how to work and communicate within the system so that resources can be deployed to you, and how to manage things as well as you can until help arrives. Right now you have a plan that will allow many, many people to suffer and die, not because help was impossible to receive, but because you'll convince them that you are that help...and you should be shamed by that. If you are/were truly a Marine, then I thank you for your service, for keeping the boogy man out of my families back yard, and I will try and help you in any way that I know how, as will the others here. If you're lying about that....well....Yeah...never mind. My appologies if I've misread you, but I'm still having a hard time with a Marine looking for the 'no frills' trauma skills that are given to every single Marine that I've ever met...and I've met a few. Dwayne

You gained no relief in respiratory distress, gained 20 bpm in pulse rate, have no report as to its effect on pain, yet you want to continue that treatment assuming only that the bp stays above 90 systolic? You sure? Dwayne

Not sure man, but I used to get them that appeared spontaneous. What is her BGL? DDX at this time for me in order of index of suspicion. MI PE Bronchospasm Anxiety secondary to argument with husband. At this point she's relatively stable. But what would be your treatment options if you were remote and help was at least a few hours away? I wonder if it would make sense to trial Glucagon?...But I think some of these questions would likely be answered by SPO2. Dwayne

Regardless I'd give her 324 ASA now. Until we know the etiology I'm going to assume cardiac in origin though I believe that it does sound like a possible P/E or bronchospasm. The twelve lead certainly can't be trusted to have ruled out a cardiopathy in this patient. Do you have ETCO2? What does it show? Dwayne

Yeah, I agree completely. I've made many, many decisions on scene based on issues that I had previously thought through with my friends here. It's a great way to share information I think. Dwayne

Thoughts of peace and healing for those that loved him from the Womacks in Colorado...

Welcome LB. What is the intended use of this equipment, that may help many help you with what you need to know. Dwayne

Beiber made a reference to viewing the patient from the 'truck', meaning ambulance. I think that that was misconstrued as meaning a second vehicle. FE09, I truly get what you're saying about not blocking the airway, and of course that is a valid point. Sometimes though what will pay large dividends comes along with at least a little risk. After having the injuries more clearly defined I can see that packing wasn't an option, but if backing would have been an option packing, while leaving the leading edge of the bandage tied to the C-collar to avoid losing it isn't a great option, but might be viable if the blood loss is of an unacceptable quantity. I once had my partner hold two big wads of dressing, one on the inside and one on the outside with Magil forceps, of a ragged cheek wound. It wasn't pretty, but I had no other way to stay the bleeding on this unconscious patient, at least no other that I was smart enough to identify. This was a 90ish year old male who'd fallen in the shower. Was unresponsive after hitting his cheek on the metal towel holder while falling. He was breathing on his own, Coumadin confirmed by spouse, B/P around 70ish systolic, about 350 gallons of blood in the tub but only this one wound identified...I just simply wasn't willing to lose any more blood if I could help it. So, though I'm not implying that wouldn't also do what you have to do to treat your patients, I meant that if packing was appropriate, as with the dressing and Magils, then I wanted it considered in a patient that was possibly heading south, hemodynamically speaking. But, as often happens...he only headed south west for a bit before leveling of to due west the rest of the way to the hospital. :-) Good thread...thanks to all for participating! Dwayne

Yeah, and stopping for the insurance information at this point will likely get you fired faster than starting an I/O on a possible stroke/hypoglycemic. I'm getting paid either way my friend... What caused you to choose this blood pressure? Dwayne

That's a good point. I don't see anything so far that would lead me to believe that I'm going to have to intubate. We do need to reassess and clearly define the need for pain management, as it may already exist but has not been the priority, but so far I think we're on a decent path. Dwayne

This is one of those weird things that seems like a no brainer to me but seems like I'm the only one I know that does it, and that is that I want his clothes off before he's strapped to the board. It takes time and sometimes manipulation to get good visualization when trying to cut the clothes off after the straps are on. So I have Fire Ccollar him and hold manual Cspine, his clothes are cut off down to his tighty whities, and I peek into those in front and back for missing or damaged or bleeding parts. I have FE09 supervise the Cspine taping and continue suctioning as I have little faith in my unknown help not to suffocate him with the suction or possibly increase bleeding by being too aggressive, or perhaps not aggressive enough. Are we able to determine where the bleeding is coming from? Is there any way to pack it in the inside of the mouth? Does he respond to being disrobed, or manipulated with any type of pain/indignation response? I'm going with Warfarin as his med based on his statement and the difficulty with managing the bleeding. To me this means that we have to be very judicious with our fluids and do what we can to pack/bandage any wounds with significant bleeding as a 20 minute transport can make a significant difference to this guy. (Yeah, see, here we go again. Likely your protocols say that you can bandage his wounds, but not pack them, so what are you going to do with those that you can't bandage? Let them continue to bleed?) After he is strapped to the board I'm going to load him on the cot with a couple of blankets stuffed behind the right underside of the board so that his airway will drain. (Right underside is only relevant so that he will be tilted facing me, instead of away, when I'm on the bench seat.) Does he struggle on the board? If so trying to clean him up at this point enough to get a decent set of electrodes placed to see if a cardiac issue may be occurring is likely a waste of time. His resistance is going to queer any of my results as well as take up a lot of time for very little benefit at this time. Two 14s preferable both on the right arm, one a blood Y, where they will hang out of my way as I'm confident that we have abd bleeding already as evidenced by the distention/guarding and possibly falling B/P. (Not sure as of yet, as two readings does not make a trend, but combined with his overall assessment it seems likely.) We may also be managing a pneumo/hemo before transfer of care and it leaves me less obstructed access. It also helps avoid any of our 'helpers' from pulling them accidentally. I need to get really, really good vitals, and really, really good breath sounds at this point, monitor his mental status and I'll certainly intubate him if/when be becomes unresponsive. I know many might believe that I should be focused on his head injury, but as long as he can keep his airway clear, other than stopping the leaks, there is little that I can do for anything in his head that might be going to kill him, so I will prepare for the things that I believe are going to go wrong before transfer of care that I may be able to influence. IVs TKO, constant monitoring of his airway, PMS x 4 regularly, lights and sirens and best safest speed (Which means we ask a fireman to follow in the police car and have cop drive us) while I call the hospital and tell them to wake up all of the expensive people. Dwayne

First I'm going to retreat and get PPEd for this guy. I don't know if he spit on me on purpose, but with continued bleeding in his mouth it's a fair bet that he is going to continue to spit all over the place. It's just what they do. No fire or volly or police are to approach this patient without a minimum of goggles, mask and gloves. No question that this will be reported later as an exposure so lets try and not have to look any dumber than necessary by having to report more than my partner and I. Also, I am going to report me and my partner for a failure to properly protect ourselves and suggest remediation with BBP (blood borne pathogen) education. As you go back to your ambulance for PPE, what is the patient doing? How is he behaving? Is he trying to stand? Holding his head up or letting it droop? Trying to speak? Aware of the things going on around him? What does the bystander say happened? I want my partner to go ahead and set up the back of the ambulance for a trauma, which for me means meant two 14g IV set ups, one 10ggt, one blood Y, intubation kit set out but not opened, NRB mask attached and running, though it doesn't sound like we'll be using it on this fellow, stethoscope hanging on the grab bars, 3/12 lead ECG set out with patches applied. While s/he does that I'm going to re approach the patient with the Fire guys with a C collar, long board, soft restraints, suction, and trauma sheers. We need to get this guy naked, boarded/collared, (leaning on it's side to keep the airway clear) so that we can figure out how badly he's damaged and how we're going to manage it. From your above description is sounds as if we're dealing with mostly cranial trauma. It's possible other than O2, and lines that we may do little more than this depending on the answers to the above question regarding trauma centers. Either way, we need to be moving quickly, though intelligently, towards a higher level of care. Dwayne

I was waiting to see if someone was going to jump on your for considering the above separate steps separately. I can't tell you how much I respect that you consider your initial impression, separated from your more thorough exam. You can learn a lot in the minute or two that it takes your partner to get an 'official' set of vitals. Also, man, you think that you have your head up your ass? OP poisoning and PPE didn't even enter my mind. Yikes...I was thinking of intubating so that I could quite screwing with his airway and wondering if I could remember how to mix dopamine at about the same time that you noted SLUDGE. That's cool as hell on your part, not so much on mine. Outstanding scenario as well as assessment! Man, this thread is really strong...It's truly the best of what's good about the City. Dwayne Edited to make me look like an even bigger idiot that I did when I originally posted. No significant changes made.

And I think that this is how we remember such things...by talking them through, deciding what is important, and why, giving our brain more complex context hooks to hang information on. You probably didn't need a thump on the head, but it's usually what it takes for me... :-) Good thread. Dwayne

Man, what a treat that would be. How educational would it be if only you could have an intelligent way to follow up on interesting patients? It sounds as if this is very close to what Celtic is talking about. Man..this would be so good...which means that the fire dept would most likely not let if fly for one reason or another. Dwayne

Though it's cliche I do believe it is valuable, "this is not my emergency." My previous partner grabbed my collar once and jerked be backwards onto my ass as I was walking around the side of the ambulance and the extended side view mirror on a pickup doing about 80mph missed my face by an inch, maybe two on the outside. That did it for me! I've never had to call in a scene report unless I needed additional medical resources, and then just to explain to dispatch briefly what was going on so that they could make intelligent decisions on where to draw the resources from. I also believe that if you are patient focused first that other things are being missed too. If you focus initially on the gasping patient in the front seat do you still remember to ask all involved how many people started out in the vehicle? Do you remember to send fire to look for possible ejections? Did you notice that the passenger side door is open? Who opened it? Did an injured passenger wander off? Tunnel vision is really good for one patient, its unethical, immoral, and unprofessional for the group. And if you run many calls, you will absolutely miss patients at some point, and I know that that is not something that you would be able to live with very well. The first thing that MUST be done at the start of every emergency is....Nothing. You have to pause, breath, see what things look like generally, then more specifically. What resources are available? What are they doing and can you trust them to do other things? A dispatched call is like Valium to me. I get mellow and relaxed. It used to make my partner batshit! He's say, "Give dispatch a call and see what the nature of the call is." I'd say, "It doesn't matter, right? We're supposed to be able to handle anything on 3 minutes notice." He'd say, "Yeah, yeah, whatever, just call." I'd say, "I don't want to know, it's almost never accurate." He's say, "God damn it! I don't care if you want to know or not! Will you PLEASE call the fucking dispatcher and ask for the nature of the call!!!" So I would, and they'd report a 'fall with hip pain" and we'd show up to find an arrest. I just don't like to get stirred up. I don't do good work when I'm stirred up. I'm willing to bet that you're the same. How do you remember that? You don't need a note girl, you just need to remember why you're there. To take control of the scene and all patients as well as possible patients, and you can't do that with blinders on. You're responsible for every person on scene, even the other responders. On every single call you have to remember to do the entire job...I friggin' hate that part...I mostly just want to do medicine, but that's not the only reason that I was called. You have some of the smartest posts here..I'm confident that a visual reminder wasn't needed so much as to refocus on your total mission. All comments meant in the spirit of friendship. I absolutely do not mean to imply that someone like me needs to teach you basic EMS, but when you want so badly to be a really good provider it can be easy to lose focus of the entire scope. Unfortunately being scene focused initially means that some people will suffer longer than they might have needed to while we assure that everyone, the healthy and damaged are accounted for and protected. Dwayne

I got the feeling that he was asking more about training together, helping one hand understand more fully what the other hand is doing, rather than dispute resolution. And I think that it's an awesome idea. So much of the bullshit that goes on between medics (Paramedics) and nurses is caused by misunderstandings. I've met a ton of medics that truly believe that they are smarter than any nurse could possibly be, and a ton of nurses that were shocked to discover that a medic can start an IV without permission. Continuity of care would be accomplished at a much higher level much more smoothly I believe if these myths were vanquished. But, to answer your question brother, other than a program at one service that allowed us to go and get tubes in the OR every quarter, the only representation between EMS and ER was secondary to conflicts and that was management alone. Though in the small town we had a great relationship with most of the hospital staff, whatever the level, but I still believe something formal would have been very beneficial. Dwayne

Excellent answer. Truly. Now your transport time is 30 minutes. What do you think? It's 60 minutes now? Same answer? I have a little trouble with your opinion that this patient isn't critical. I had this exact patient, only with a penis, showed Hi, only I was able to easily obtain access and run a ton of fluids. Labs showed a BGL of 1500 at the ER and he died before the next morning. And though Beiber may not have meant me, I do think that folks take I/Os, and EJs, way to seriously. Some patients need fluid or meds, others will simply benefit physically, mentally or emotionally from fluids or meds..to deny any of these folks any of these things because you (general you) are afraid of more aggressive access should get you fired. Or, as I've proved at least once...giving it to them may get you fired too. But I think that your logic is awesome. A couple of pieces of advice, meant friendly as I'm already a fan. Could you break your posts up into smaller paragraphs? It makes them much easier to read...easier on the eyes, and much more likely to generate responses. In my opinion. Also, having the balls to post a case review before you have 20 posts? Yeah man, I'm confident that I'm going to remain a fan. Also, you're not a hosemonkey here, so sir isn't necessary. Every now and then Babs says it, and it friggin' rocks! But it sounds to me that you've earned your place here. There's no hazing, there's no 'noob' hoops to jump through. All are judged on their heart. commitment and logic. Good on your for the respect, but take it brother, don't ask for it. I'm grateful that you're here. Many here like Paramedic Mike and Herbie are so old they won't remember that you were nice to them anyway. Thanks for participating.. Dwayne

I send the CNA for the RN, informing her that the patient is not going anywhere until I speak with her. I also inform her that I need to see the nursing home's POA. Pt informs me that her daughter is her medical POA. While I wait for the RN I call the daughter who claims that her mother has always been 'sharp as a tack' and asks that we make no decisions until she arrives, approx 15 minute ETA, and can be walked through our assessment. RN arrives and angrily claims that she has the ultimate authority on the patients transport and insists that she be transported immediately! She refuses to participate in further assessment. ER doc is contacted but is unable to consult secondary to other responsibilities. ER RN states that he has confidence in medics judgement. Pt continues to claim that she is 'fine... Just tired' and additional assessment fails to confirm previously CNA statement of stroke like symptoms. Dwayne

Hey Steve, welcome to the City man! I think that you'll find though that for many, like me, the term 'medic' and EMT are not synonymous. I look forward to your thoughts man... Dwayne

Ok, first of all, stop pretending to be a hosemonkey. I've rarely heard a fireman speak of EMS with such passion and I don't like you teasing me, trying to make me think that it is possible! It's not funny! Second. Very, very few new medics are good at ped dosages and drug calcs on the fly. It takes time and experience before you will come to have them in the front of your brain when you need them. First you will have to push some drugs so that you're not afraid of them. (Don't tell me you're not, we all were I believe) Then you will have to study them, review them, run a million calcs from scratch, and become confident enough to realize that nearly every doctor that I've brought a ped to has asked for a Broslow tape, so you can too. There is no shame there. Know how I know? My very first call as a medic (in the U.S.) was a 7 month arrest. I couldn't remember one single friggin' dosage. I called and received that Broslow tape, and misread it. I ended up pushing adult ACLS drugs to the ER, no tube, the most amazing cluster fuck you've ever seen. Got pulses back and everyone thought I was a stud. Ridiculous. You won't know all of the answers, all the time, when you need them brother. Every decent medic that I know has a 'Man...if only I could have remembered' or 'if only I'd thought of' story. But not preparing is not the same as sometimes failing despite your best preparation. I know work in a 100% adult world. No chance at all of ever coming into contact with a ped but I take PALS every two years just because I love it! It makes me think differently. Reminds me that not only the patient, but the scene is going to be different with children, as well as making sure that I remember that I won't always have this job...and I'm responsible for all human beings, not only those that I will most likely encounter. Man...I dig your spirit...you're going to rock if you don't let the hosemonkeys convince you that that all this 'silly book learnin' is for the non hero crowd only. Thanks for participating, and welcome to the City...I'm really excited to see your future posts. Dwayne

Often those new to the forums take this type of advice as a brush off. It is anything but. It is truly the best advice that you've been given so far. Understanding blood borne pathogen risk is the life blood of responding to emergencies. If you have a family, or anyone at all that loves you, if you plan to be in this business for any length of time at all with any type of peace of mind, you will follow this advice this week, and then again at least every year you treat patients. Excellent question, and some terribly good advice. You've shown the balls to post, and participate. Now show that you have the balls to continue to do so. Let us know what you learn from your class... Dwayne

Pt states that she was awakened by the "need to pee' and that the CNA seemed irritated at her being up and began questioning her as to why she didn't pee before bed or wait until morning. She has no complaints other than being treated "rudely" in her opinion by staff and being kept awake when she would like to go back to sleep. Only the CNA was present for the 'episode', it seemed to have resolved before the RN arrived. The on call Dr didn't answer his phone. CNA states that pt had slurred speech, is pretty sure that the right side of her mouth seemed 'weird', and that she answered questions slowly. CNA helped her to pee and then returned her to bed, calling the RN after. By the time the RN arrived the symptoms had seemed to be resolved. She ordered her taken to the ER for eval. RN is called, refused to return to the EMS/pt, per CNA. CNA reports that RN states that EMS is required to do what they're told. CNA asks that you please take the patient to the ER so that there won't be trouble. Pt only wishes to go to bed and tells you to "Please just let me go back to sleep..." Dwayne