DwayneEMTP

Yikes...and we wonder why the public doesn't know the difference in Cert levels? Craziness.... Dwayne

Heh...maybe, but probably not. What gets me is this, why aren't many basics humiliated to use a term that, to 90% of the TV watching world, doesn't apply to them? Why are they not embarrassed to allow people to believe them to be something that they're not? That they've achieved more than they have and have more responsibility than they do? Do you buy the "I do it because it's simpler" argument Ter? Have you ever believed a volunteer when they said, "Yeah, I love to help, but I can't believe that they make me run all over with lights and sirens on MY VERY OWN VEHICLE! Sheesh...I hate that!" Now granted, I've got a major hardon for people pretending to be something they're not, and I'm not really sure where that comes from, but the mentality that will accept credit that was unearned is truly offensive to me. I've got a...step nephew..in law...or some shit that sports a big Special Forces tattoo. I said, "Wow, special forces huh?" He said "Yeah, I'm deploying with them in Afghanistan in a few weeks..." I said, "Holy shit..that's hard core brother..thanks for looking out for us." Later that night it turned out that due to 'conditions beyond his control' he'd washed out on his 3rd day of training but was still deploying with them "because they want me to go in with em!" I said, "You know what man, tell those stories to my step niece in law...(Or whatever) and to your buddies...but you talk that shit over there and those boys will cut that fucking tattoo off and feed it to you....fair warning.." And I'm pretty much done with him...If he'll lie about something that people die for then he'll lie about anything. And that's how I feel about this. If you'll lie to take credit for something that you haven't earned, if you don't even have the backbone to say that you're not there, yet, then how can I really expect you to be honest about any single thing that might cause you any kind of discomfort. To me, this really isn't any different than any other moral/ethical EMS issue. The whole, "I lie but it doesn't matter because no one knows the difference' is such rah rah bullshit. And that's what I think about that! If you feel differently, or feel offended, give me a call at BR549 and my office will route your call directly to my personal Sat phone...But I can't talk long, I'm on standy today for the White House. Dwayne

What/Who are you disagreeing with exactly? Dwayne

I wonder if there would be less confusion as to the terms if basics didn't refer to themselves as medics? I have no issue in general with who calls who what. It doesn't make me feel less, or hurt my feelings, but I have no respect whatsoever for the basic that identifies themselves as a medic, regardless who they're speaking to. You are lying, and you know that you are. You can pretend all you want that the world doesn't associate the word 'medic' with the heroic bullshit they see on tv, and you can continue to pretend that you define yourself to your friends and neighbors as a medic because it's 'easy' as opposed to trying to piggyback on a burden of education and experience that you haven't bothered to complete yet, but it will still be bullshit. If you've ever said, 'medic' in response to "What do you do for a living?" and didn't immediately correct the misconception when they went 'WOW! That must be so tough!" (As happens to me all the time) then you are full of shit and purposely taking credit that you have not earned. I don't tell people that I'm a Doctor or a nurse when they ask simply because people know what a doctor/nurse is and it's simpler than explaining about being a medic. Why? Because I've not earned the right to be called a doctor or a nurse. When you've earned the right to receive a paramedic degree, then you should tell anyone that will listen that you are a medic. Until then, please stop pretending that you misrepresent who you are and what you do for the sake of simplicity. Ok...There is me getting hung up on titles... :-) Part of the reason that we have so many career basics is that the public doesn't know the difference. If they did, partially by way of US, the EMS community, not pretending that there is no difference, then I believe that they would make different ambulance staffing decisions. While the public believes that they get the same medical care from either person in an ambulance, or from an ambulance or a fire truck, that they all equal "Emergency!" level care, then they will continue to make silly emergency care spending decisions. Because they're idiots? No...because we've helped lie to them. And as long as basics continue to get credit for the work that their partner has actually done alone, then there will be many, many that will have no interest in earning that respect for themselves. And if you're willing to lie about what you do, or who you are, regardless of what any of your buddies are doing, or what reason they use to do it, then you have already filed your petition for moral bankruptcy. Sweat, study, work, pay your dues to become what you want to be...don't piggyback on the first bullshit excuse that comes along and allows you to pretend. Dwayne (Edit, not directed at you MM for your screen name, but certainly so if you do so off of the forums. The difference being that we do know who you are, where you're at, and hopefully, where you're going. Not so with the uninitiated. If they ask, take the time to explain it to them and then perhaps they will make different decision concerning EMS when it comes time to vote next time.)

New Denis Leary show, Sirens

Why was it more difficult and what made it a mess? Sincere questions.... Though I agree that in the vast majority of arrests that just about any airway will do, we don't really do medicine for the majority do we? We plan for worst case scenario. The over bagged 300lb'er that is going to belch his stomach contents all over the place, the ROSC that is going to vomit, etc. The problem I have with your statement is that by the time you realize that it's not 'working' you will have aspiration and you just can't unring that bell. And I've always wondered, as I've never used the King/LMA, other than inserting a few LMAs in the OR, how well they withstand compression pressure at the seals. Intuitively it doesn't appear that they would do well. Dwayne Note: Posting at the same time as Bernhard, similarities are accidental.

Yeah, upon rereading my response I'm sorry I made it sound like I believed that you were looking for a one fit answer as opposed to polling and trying to generate discussion. You've never been a shallow provider and I didn't mean to imply that you were looking for so simple an answer. Just not well phrased on my part. Dwayne

None really. I went to basic after seeing a woman get hit by a cab, discovered the City, decided I wanted to try and be as smart as some of the people I respect here and try my best not to look like a bigger idiot than necessary. I had no political agenda or significant opinions other than wanting to surgically remove the word 'hero' from hosemonkeys. Soon I'd hoped that the AAS for EMS would take hold and I would work with fewer and fewer shitheads as time went on. No, it's not taken place. In fact working in Southern Louisian I was in a remote medic course when they asked if we'd push MS for an apparent MI and I immediately said, "Sure.." and was truly shocked to find that I was the only 'Yank" in the class, as well as the only person to answer to the affirmative. I even had this hot chick sitting next to me (She moved only moments later) say, "Yeah, so I guess if you think that you're Soooooooo smart that you can diagnose an inferior wall MI and not kill your patient with the morphine then you're just some kind of super medic or something!!" To which I replied, "You don't feel comfortable diagnosing an inferior all MI to within a reasonable enough degree of certainty for you to treat your patients? And you do EKGs?" Not only did the entire Remote Duty Medic Class! claim that they couldn't, but that they wouldn't even consider treating chest pain without first speaking with a doctor. Their local protocols allowed vascular access without medical control consult in major trauma and cardiac arrest only. And not a single person was bothered by that. The further I go in EMS and the more providers I meet the more it becomes clear to me that American EMS in it's current incarnation is terminally ill...I'm not convinced that it's a pathology that we can reasonably expect to resolve. For me, in my experience it's not about helping to move EMS forward, it's about kicking and scratching and clawing....fighting every day with everyone that will listen to try and convince it not to run backwards...it's an exercise it trying to be able to celebrate treading water instead of actually drowning. And I truly have no idea what to do about that until we get Fire to move on to some other hobby. I don't believe that you can teach them to be proactive for change. Some people are leaders, most are followers and though it would be awesome to try and teach the up and coming the political realities of EMS, it will make little to no difference without a strong leadership. I saw one of my personal heros Jack Welch on an interview show the other day. He's considered by many to be the most successful business manager in American history. He said something to the effect of, "In my time in business I've come to believe that most people, to create positive change, need to start with a backbone and then they need someone to tell them that change is ok." Most of the providers I know, despite all of their bullshit and bluster about type A personalities, are followers. And there are just not many leaders out there. And the few that rear their ugly heads immediately find that they will run into job scared supervisors that don't want to listen to their shit and will do what they can to keep them contained...thus allowing themselves to maintain the status quo and sleep..like they've always done. As above. I do what was done for me. Dust, ak, Asysin3leads, and others convinced me to get an AAS as opposed to a cert. I think that they did this because it was good for EMS, but more importantly because it was good and healthy for me. And they were so perfectly right. I try and mentor in that same spirit. I'm going to try and change one attitude today, try and help someone make a better decision or be more proud of themselves. Not because I believe that that will save EMS. But because it's good for them, and helping them be better makes me feel good, plus creates a better environment for me to work in, and that in fact makes be better still. And then...like a pie eyed dumbass, I go to sleep and hope that somehow that attitude will spread, and jump up into the arena of being rare...and if we can even get so strong as to have that attitude be rare, as opposed to almost unheard of, then we'll have some folks that won't allow mediocrity as a standard. Or so I hope... Dwayne

As many have said, it may go away, and likely will, or it might not. It truly does depend on your your previous experiences and what kind of toolbox you've developed for dealing with unusual stressers. I have never had a hard time with death, not from the very beginning. But I grew up around drugs and violence and prison tattoos. I'm not sure if that is where my tools came from, or if having my particular set of tools is the absolute most healthy way to cope, but I've found that I'm comfortable with it. It's the people that try to convince you that 'you have to be sick after seeing such a thing! It's not normal not to be bothered!" that you have to worry about. I had a non medical driver in Kandahar Afg that told me one night, "You know Dwayne, I've decided to go and get some help when I get home..." I said, "Ok man....help for what?" He said, "Oh, you know...all the dead babies we've seen and all.." I said, "But, I'm the medic on the truck brother..and I don't remember seeing any dead babies.." He said, "Yeah, I mean all the dead babies I might have seen...." I said, "Well....hmmmm......Good on you then...it sounds like get professional help is certainly what you need." :-) (ak, I'll bet you can't guess who this was!) You should have a general 'vibe' about this issue. You'll feel yourself getting better, feel the pieces falling into place as your brain processes this new and disturbing information, or you'll feel that something seems to be broken and you're not getting better, or you're getting worse. In that case find some help. You should feel absolutely no pride in choosing to be in pain if you feel that you need help to alleviate it. In fact, if you have anyone that loves you, you have no right to make such a foolish decision. On the flip side, if you're feeling ok? That's perfectly normal too...Look inside, follow your little internal barometer, and it will all work out fine. Awesome first post Poppy...thanks for participating! Dwayne

Can you say that here? I was also taught to stop compressions to intubate, I've just chosen not to follow that training as it just doesn't make sense to me. So, yeah, if you can do it safely with compressions then I believe that is certainly the best option. If though, for whatever reason, you can't, then the briefest possible pause is warranted. Stopping compressions is bad but trying to be macho and creating airway damage could certainly be worse. I don't believe that this is a 'one answer fits all' question. Dwayne

Yeah brother, I don't know where you're from, but unless they are paying you a ton of money for each accounted hour I'd tell them to blow it out their ass. I am full grown, educated and have a family to feed. You never, ever get my time without paying for it...(Well, unless it comes with a happy ending.) And I can't imagine an employer with any respect at all for their employees ever asking such a thing. have you asked your supervisor, or whoever is in the office how many hours/month they choose to donate? The exception would be super rural where you get paid to stage at home. Smaller amount of money for doing nothing but being ready and then and adjusted rate if you have to run calls. Otherwise, I can't really imagine it... What makes an hour accountable as opposed to non? Dwayne

Following that logic brother then they are also stating a $100,000/run cost for an ambulance response. I'm pretty sure they were speaking of the cost of the vehicles and not the response. (Not busting your balls man, I can see where you got that.) Dwayne

Shoot..no harm in laughing brother! Some of my greatest learning experiences have involved me looking like a monkey humping a football... But you're right..I learned a lot of good lessons that day, and though I partially boneheaded the call there have been many patients that have benefited from that mans discomfort. The ER doc was really cool. I said (As I seem to have this need to go, "Hey! Look at what an idiot I am!" any time I make a significant mistake.), "You know what Doc, he was resting ok, but then I tried to see what was happening and made him really, really freaked out and sick...Could I have verified this another way?" He said, "You know what? Don't play the "I'm a fucking retard" game. At least you bothered to check. Vertigo sucks, you made it suck less..I'm calling that a good run." Of course he didn't really tell me if there was another way to verify it without making my patient wish he was dead, but after that I simply medicated based on vertigo symptoms, or symptoms in the issue specific recent history, and lacking a high index of suspicion for other pathologies and the patients have always sat up within a few minutes, cautiously twisting their neck this way and that to see if they were going to freak out again...so I call that good and leave it the hell alone!! :-) Good thread, if maybe a bit off track... Dwayne

I have the same problem with the experience conversations as I do with the spanking conversations. They can go on for pages without ever defining the terms. What do you consider 'experience?' Getting experience isn't exactly like buying a gallon of milk. When someone mentions that they bought some milk I can have a reasonable expectation that it is white, loaded with calcium, relatively clean and pasteurized, etc. I can draw reasonable conclusions from their one simple declaration. Experience does not come with the same reliable parameters. Very, very few of the people that get their EMT will ever use it, and of those that do, very few will get experience with it in a quality system as opposed to some knuckle dragger service or good ol' boy volly fired dept. Those opportunities do no offer quality, productive experience in my opinion. My last Basic partner was super smart, competent, and I would have trusted him with most calls, but he is not the standard in my limited experience but the exception. Where these conversations tend to go off into the ditch I think is that side A assumes that all basics have gained 100% of their experience at Knuckle Dragger Volly Fire Dept, while camp B believes that all basics are gaining experience in quality systems, like the ones that they work in, and they're both wrong. But again, my experience is that camp A is more often than not more correct in their assumption. I'm all for some experience before moving up the food chain assuming that it can reliably be expected to be good experience, with good mentors and preceptors, focused on moving forward. And I believe that I have a solution to making that happen. Starting the 1st of next year make an EMT cert expire perminantly after two years. Unless proof is given showing that the basic is irrevocable financially committed to an AAS in EMS program. That way we move out the career basics, opening quality spots for the up and coming medics student, and begin to populate the labor pool with people that are serious about EMS and intend to move forward instead of staying as lifelong helpers. People will be less likely to become EMTs simply because it looks fun, employers will be less likely to hire people that they believe they will have to replace in two years, experience will become a non issue, many more basics will have as their original intent a desire for medic school and higher education, the fire depts will run from EMS in droves, (after spending a few years whining about shackling their heros), and soon the country could be populated with degreed, motivated, non fire dept medics. Then we'd have a population that we could use to create real change. It might be ugly at first, but over 10 years, maybe much less, I believe that it would completely change the face of EMS. But either way...as long as the majority of available basic slots will be in systems that are detrimental to the educational development of an individual, it's just really hard to make the argument for demanding it. Dwayne

Despite what his protocol may say, the auto injector is designed for IM, right? And it was an auto injector question? It makes no difference how he defends his answer, auto injectors are designed IM, basics are trained IM, and I could be wrong, but I doubt many have a protocol for SQ. So yeah, he was just being an idjit. Dwayne

Yeah man, it wasn't my intention to make him sick so that I could treat him, but to try and verify what I believed needed treatment was actually happening so that I could justify treating it. Know what I mean? When I was new I wanted to push every drug, provide every treatment, encounter every illness, so that I could add that experience to my mental toolbox. I didn't want to be a cowboy and use things just because I could, but, early on, I needed to prove to myself that I wasn't afraid to use my drug box either. Of course, long ago now I've most everything in there and have more faith that each will do what I expect of it, but early on I had no such faith. And yeah, if a basic crew had such a case with more than a few minute transport time without toning me out, I would seriously question their competence for continuing on the ambulance. Vertigo would still be a diagnosis of exclusions. Dwayne

Yeah man, it sounds like you've had some good calls, plus there are a couple of good scenarios going that it wouldn't hurt you to think about... Good to have you back..now stop being such a slacker and come and post! Dwayne

Yeah, sometimes called Top Shelf Vertigo as looking up will trigger it. This was actually the first Vertigo patient that I had. They explained their symptoms, I thought, "Holy shit! I think I know what this is!!" I had them on the cot, they were speaking and talking comfortably in a sitting position, so, like the rocket scientist I often am I said, " I want you to look at the ceiling for me.." What I expected was a response of, "Oh hell...that makes me really dizzy and kind of sick to my stomach...." What happened was, this full grown man immediately grabbed both sides of the cot with white knuckles, his head started swinging from side to side, he yelled, " Oh fuck man! Oh fuck man!" and ceased answering any more of my questions..Withing a few seconds he was vomiting across his legs, crying, begging for me to make it stop! I actually had the thought, "Oh shit..I hope he's sick enough to forget that I started this in the first place.." At least I'd already had access before starting this mess, so I pushed 12.5 IVSP/diluted Phenergan and with about 3-5 minutes he calmed down (I think, time was pretty relative at that point) And before long he was asymptomatic at rest...though I wanted to, really, really badly, even I wasn't a big enough idiot to ask him to move again to see how complete the relief was. But at the ER during transfer to the bed he chose to stand and move himself and seemed, other than a little dopey from the Phenergan, to be symptom free. And as said before, if I'd not messed with this guy I might not have needed to medicate him...but I wanted to! I was new and wanted to 'cure' stuff...But now of course I want to do what's right way more than what's new to me.... Good posts all! Dwayne

I would be willing to bet that every one of those agencies had a protocol for Vertigo, they just hid it under the N/V heading. They have one for N/V, right? Spinning that is sometimes relieved but returns with even the slightest movement, uncontrollable vomiting. These people will truly be trying to become part of whatever they are laying on so that they limit their movement to the least possible. Nearly asymptomatic if motionless in between bouts of vomiting, but remaining motionless is of course nearly impossible for more than a few seconds. Give them Phenergan. If you carry it I'm guessing you have a n/v protocol for it, and these folks will fit it. I've had several vertigo patients that I am aware of, and I can guarantee you that those that are questioning whether or not to treat them have never had one. Questioning whether to treat them is like questioning whether or not pain management is appropriate for a femur fracture. There is no question. 12.5-25 mg Phenergan IVSP/diluted and it has in each instance been akin to a miracle. Vomiting stops, pt states that they can breath and move without head spins...One of the most significant interventions I've ever provided. Please man, tell me that you are not advocating that we withhold pain/mitigation of suffering because doing so will limit the number of fakers we have to respond to?? Dwayne

In my opinion, in my experience, it will tell you little to nothing. This is just not a reliable enough sensor and without labs to back it up we can't draw any hard and fast conclusions. What I hate about this sometimes, as with SPO2, is that as this value is near 'normal' then this little man shouldn't have any of the symptoms that you are reporting...but that is obviously not the case...So once again, 'normal' doesn't apply. Yet still it's common to hear medics talk about chasing this number around... Not sure what you were looking for here brother, but I don't think that you can define the relationship between the two with the data provided. Even if we can trust 32 as an accurate absolute ETCO2 value, (And with Os running, we can't trust that it's even very close) we still need more information not available in the ambulance, at least not any that I'm aware of, to draw an accurate relationship to PCO2. Or, I'm just talking out of my ass...I probably should have Googled this to see what the newest thinking is as I've not messed with it in over a year now... Dwayne God Damn it...I wrote that above, and then did in fact Google it, and found... http://emscapnograph...-in-asthma.html Concordance between capnography and arterial blood gas measurements of carbon dioxide in acute asthma. Corbo J, Bijur P, Lahn M, Gallagher EJ. Ann Emerg Med. 2005 Oct;46(4):323-7 In this study, 39 Patients, 37 Classified as "Severe Asthma," received simultaneous measurements of arterial carbon dioxide and end-tidal carbon dioxide. The mean difference between Pa02 and PetCO2 was 1.0 mm Hg. The median Difference was 0 mm Hg. Only 2 patients were outside the 5 mg HG agreement (1-6, 1-12). "In patients with acute, severe asthma exacerbations, we conclude that concordance between PetCo2 obtained by capnography and PaCo2 measured by arterial gas is high." Bottom Line for EMS: End tidal CO2 gives a good indication of the arterial blood gas level and can help a paramedic evaluate the severity of an asthmatic's condition. So, as not to be a bigger pussy than usual, I'm leaving the original and have added the above. The problem that I have with this is monitoring a person on O2. Either delivered by canula or NRB I've found that I can drag the numeric ETCO2 value all over the place with a change in flow rate and often with relatively small changes in the positioning of...anything. But I'm also guessing that the above quotes come from in hospital testing as well as more highly trained providers, so perhaps I'm not completely off in the ditch....not sure though. Dwayne

Outstanding reference Tim! It makes both arguments thoroughly it seems. At least for the part that I read. I look forward to reading it all later when I have time. Thanks man.. Dwayne

Oh.....My....God! That may be the gayest thing I've ever heard you say...(he's got a hot wife, he's got a hot wife.....ok..ok... then....I'm better now) But if you insist on anatomically correct terms and you define the entry sounds then don't you also have to define the exit sounds? I'm thinking your friggin' PCRs have got to be miles long... I'm probably going to be sorry I asked, but no epi? How come? I would have shot the epi while I was prepping the Mag sulfate in 250cc of Saline...(In theory of course..pretty easy to manage this call when I've had two days to think about it.) But I would have done everything in my power to avoid intubating this munchkin.. and not just cause Vent scares the shit out of me these days, thus my reason for ignoring the RSI stuff before.. Dwayne Edited to add a missing word..if that will really help in that mess...No other changes.

Tracheal tugging? Where did that come from? And surely you've heard lung sounds before that were moving so little air that the sounds you could hear returned no useful information? I've rarely, but have, put 'lungs are silent to auscultation" in these situations. Dwayne

No further information on why he was at the docs? You said that he didn't follow you as you walked into the room, how obtunded is he? Stridor? Did you percuss the thorax? What did you/might you have heard? Do you have him on ETCO2? Before or after we began bagging? Is it the canula sensor? What is the wave form? What is the numerica value? If you're going to neb him you need to bag it in. I'd be putting epi onboard before I worked an IV unless it's possible for you and your partner to do both at the same time. I think the steroids are going to help, but he needs relief faster than it will bring it. Depending on the results of percussion, the short term, 30-60 second effects of the meds/assisted vents, I'm wondering..again, if we find that he's constricted and not blocked, of maybe a gram of mag sulfate too? Might wanna run that one by the doc...in his condition I have no faith that it's the right thing to do, but something better work or we better pull a rabit out of the hat. I don't have another rabit per se, but I have the mag sulfate guinnea pig..and it may have to do if we're going to avoid intubation. But based on the above, I'm not confident that this isn't a/or several slowly developing pneumos...I''m really not confident about anything else though, either, so there you have it... I'm thinking RSI probably won't be necessary with this kid..if we can't open him up in the next few mins he's going to crump and probably be easy enough to intubate.... Dwayne

The entire thread, post LSs post, has been about patients that are alert enough to verbally and physically refuse transport.. You win man. I'm not smart enough, or have enough time to try and block every bullshit rabbit trail you can create for each time you get jammed up. Thanks for the discussion. Dwayne