DwayneEMTP

Hey Kerri, Welcome! Law enforcement and EMS seem to be a really good mix! How far along are you in medic school? Getting a cert or a degree? Jump right in...Like police work EMS is a contact sport, on the streets and in the forums. Don't hesitate to participate! Dwayne

No man, not a pay site. They made the chatroom payed for a while, then not, and I'm not sure of it's status now. Welcome back!! Dwayne

Welcome to the City. Pararescue is a very specific, elite title held by those very, very few people able to qualify for it in the USAF. They are the elite of combat medicine. There is no like civilian title. I keep it on my profile as a lame protest of some asshole giving that title to a bunch of yahoo wannabe medics I've worked with. You need to focus on education brother long before you start thinking about excitement. If you want to be as good for EMS as EMS will be for you then you're at least two years from the "YeeeeHaaa" stage. And you didn't like the politics in teaching? You've made a very serious error deciding to join EMS. I've be around the block a few times, and the reason that I will only do remote medicine from this point on is that it, to a small degree, insulates me from the politics. But you also don't move forward very well in EMS without them. And this is meant to be helpful, not hateful. When you come here asking how you can be Pararescue and/or SWAT before you've even gotten your Basic you put the lie to your comment that you've "Done a lot of research" before making this decision and make yourself look foolish. If you'd done any significant amount of research you'd know what Pararescue is, that flight is not the heroic adrenaline occupation you believe it to be, and there are few things more discussed and covered than how to be a SWAT medic. Try to stop getting your information off of glorious TV shows and it will help you approach this in a more realistic manner. I do wish you the best of luck! Dwayne Edited to fix those typos that seem to magically appear only after I've hit the submit button. No contextual changes made.

Awesome scenario Doc! Thanks so much for doing that! And as chbare said, what a gift it is that you continue to participate with us here. Dwayne

Ok man, I'm calling bullshit on your self pity story. Spell check did not miss all of the errors in your post. And you know what? I don't care if you're sick of it or not, because you can't succeed with the way you present yourself now. Do you think that I have nothing better to do than bag on kids that can't spell like adults? I have a 14 year old autistic son that has non of the benefits that you do, so stop the bullshit whining. Succeed my young friend, or do what you've done so far and fail on your bullshit excuses. It makes no difference to me. I'll care for mine the same way I've tried to care for you. Cry, whine, fail. It's not my issue brother. I've tried to make you one of the family. You have decided to fail as one of the losers. Not my fault. Good luck to you my friend. I'm not aware of anyone that has succeed with excuses in place of results. Dwayne. Edited to change excuse to excuses. No other changes made.

You know, it was 4 or 5 years ago when National Geographic did a special on the 9 oldest skulls discovered in North American... The kicker? They were all Caucasoid. Or, more or less Caucasian. They did a great job describing the battle that the museums had trying to keep the evidence from the "native Americans" as the previous samples that they had given for study had 'disappeared." C'mon..are we really going to consider that we owe the Native Americans when the oldest north American artifacts seem to show that they killed the original 'North Americans?' When do we decide that enough is enough and we move forward? Dwayne

God bless you Kyle, (Despite my religious beliefs) But what I believe is that you are too smart to write like a child and I'm not going to answer any more of your questions until you at least bother to reread them before posting. From your questions I know you're smart, but you choose to just put forth whatever bullshit your fingers happen to land on. Type, run spell check, proof read, then post. If it's not worth your effort to do so? Then it's not worth my effort to reply. Take care man. Dwayne

Hey Max, welcome to the City! No worries about experience. Just jump in here, ask you questions, try and research and answer other peoples questions when you can. Good luck getting into school...Though it's not to late to change your goal to nursing where you can make some money!! Dwayne

Wide qrs is secondary to a LBBB? How wide should the qrs be when it's ventricular in nature? Does there need to be a block to create this tracing? Good on you for catching the 3rd degree. I was curious to see how many were going to jump on brady/block. Dwayne

Yeah!! I love that site! I wished at times that I could argue against some of the answers, but yeah, then I like to argue against just about everything. Thanks Fiz.. Dwayne

At my last service, a private service, we has capnography, CPAP, glidescopes (just recently), Fentanyl and Morpine, non but the Morphine mandated by the state. How does this fit into your theory? Dwayne

I'm not clear how it was independent, as he consulted the document and the pts family. And I don't get how it was a moral decision as opposed to an ethical one? He's not deciding to allow her to die despite her wishes to live because he believes that she is too damaged to live, right? He's simply saying that though being a doctor is pretty big shit to most folks, me included, perhaps it's still not big enough to override the pts wishes. Though Herbie does make an interesting point. For those of us in the do not intubate crowd...does your opinion change if it turns out that this is a suicide attempt? How about if it's actually a murder attempt and she's been left with additional deficits? How does your opinion differ if it's neither of those but simply a malfunction in her pump? Dwayne

You know, before becoming a medic I spent 15 years as an animal behaviorist. I trained everything from dogs to zebras, and you know what? Each of those things, with the exception or arson, is seen daily in the animal kingdom. Have you never watched the discovery channel? Animal Planet? You're whole point seems to be that "people are evil, people are bad! And if there were not people than no bad stuff would ever happen!" Now, depending on how you define bad, that is just patently not true. There will still be forest fires, there will still be pollution, there will still be theft, and violence if people are gone. I guess I'm just not seeing why it's so important to you to point out that the worlds evils rest with people? If you'll notice nearly all of the world's significant kindness and victory has been created by people as well. Do you have a deeper point or is your message simply in the Chicken Little vein? Dwayne

I have to go with no Doc. She has the DNR, has stated to two close family members specifically not to be intubated. It sounds like a woman who is done fighting, and I believe that she has the right to make that decision, and is blessed to have family members that are willing to fight for her right to do so. I would likely get jammed up on this no matter what service I worked for, but I will not knowingly disregard a persons end of life wishes. Especially this woman, who has fought so hard for so long with these diseases. I'm going to (Maybe) wake her up and tell here that not only has her life been raped by disease but I chose to rape her once more by removing any power she had left by ignoring her wishes. Aint going to happen. Not only do I think it should be honored now, despite what the nurses feel her quality of life is, but she had these wishes four years in her disease's past! Certainly she's much more tired, and much less happy now than she was then, at least from a health point of view. I'm guessing you'll tell us the ultimate outcome at some time? I really, really love the moral/ethical debates. I don't think that we have them nearly enough here... Dwayne Note: How did you determine that the seizure was cause by the hypoglycemia and not the MS? Unless that's best left for another time. I know you want to keep this moral/ethical instead of pathophysiological, so if there is not a simple answer, please disregard this question.

Hey Mobey, I don't have time to search for it now, and I may have posted it before here. There is an online ECG library that has hundreds and hundreds of strips. It's set up in a quick format, you choose to view either 1,2,3,4 or 5 star strips, considered to be of increasing difficulty the more stars, and then it give a professional analysis of the strip after you decide what you think it is. It's awesome! I used to skype with another medic student and we'd argue these for hour and have a great time! I believe it was made for Docs... Also, there is a great site that I also don't have a link for (Had to reformat my drive so lost all of my bookmarks) that just tries to fool you with the 'mimics.' It gives you 4 answers, if I remember right, and you have to decide which one is correct. The trick is that they've tried to give relatively common sense pathologies and then try to fool you with common mimics of those conditions. I liked that one a lot! Sorry brother, I'll try to find them when I have time, but I'm sure I found them both by Googling ECG or EKG or the like. Dwayne Note. I just found this site, cardiology site , and only looked through the first problem, but it looks really good!! Also, if you ever want to make some time to Skype and argue cardiology, that would be awesome!

Oh! You mean the reason for the call? I didn't mean to imply that there was serious debate, just that when talking to an ER doc about it he claimed that it wasn't harmful but not really beneficial with Coumadin pts. Verified with another doc, that he felt the same, but that's as deep as my research went.. I'm always talking to you when you're feeling kind enough to answer... I'm guessing that you don't mean this to sound nearly as clear cut as it appears. I think someone posted something once that shows that relief of pain with nitro isn't necessarily showing cardiac relief, as many of us have believed, as it will also commonly relieve the bronchospasm, and I believe in some cases even muscle spasm, that was actually causing the pain. I have no reference for this though...But I am confident that my index of suspicion is really high for bronchospasm in this gent. Be interesting to see his ETCO2 wave form. I don't think it was harmful, but I would put no real stock in it's benefit regardless of pts reported changes. Placebo, relief of issues not acute, etc could retard your ability to determine any real changes as the things you are trying to effect are completely pt reported. Now, significant 12 lead change would likely shut me up...but not much short of that I think. I think that there is just too much going on with this guy, and too many effects possible from the Nitro for it to be used as a significant diagnostic aid. Yeah, fair enough. I wasn't really questioning whether or not it was appropriate so much as looking to see if you had a physiologic benchmark to be guided by. Sometimes you just do it if there seems to be the likelihood of benefit with very little chance of detriment....I get that. Great discussion from a lot of really smart folk...Thanks to you all for participating! Dwayne

I've found that though Fentanyl doesn't have the hemodynamic effects that scare everyone so bad with Morphine that it's also a wuss where significant pain is concerned. At the doses we were allowed to give it, 100mcg with an addl 100mcgs per med control (This was the only service I worked that had it) that it just didn't have the muscle I wanted for most really good injuries. Plus the hospital will dose them with morphine as soon as you get to the ER anyway as the effective life of the Fentanyl is nearly useless for them and the time that they need effective pain management to do their evals and treatments. It's been my experience that the number one reason that people like Fentanyl is that they're afraid of Morphine, and though I've pushed gallons of it, I've only seen the severe hemodynamic effects less than a handful of times...and of those times simply laying my pt down, or bolusing a little fluid compensated for that without any real drama. I think the Fentanyl is good for mild to moderate pain at the doses used by most EMS, but you'll be disappointed the first time you use it for a significant injury. Now, when I talk to the old guys that had protocols for a loading dose at 400mcg, I can see that having some value, and others that are allowed to mix Fentanyl and benzos, I can see that too..but stand alone at the 100-200mcg doses...I will always choose MS for hardcore stuff. But, I almost always push Promethazine prior to MS as the two together seem to give a nice mellow buzz, plus after the Promethazine I often don't need the MS at all. Dwayne

I didn't see a reference for pain, but perhaps I missed it? I do see where the pt specifically denied chest pain or discomfort though. Also Afib is pretty much a given here as he's 85 AND on Warfarin so the rate is not concerning, neither the high nor the low. I agree that the ASA was a no brainer, (though I believe it's value in the face of Warfarin is questionable, it's likelyhood of detriment is small) based on 12 lead findings alone, even if that's all that you had, but it wasn't. You also had the DOB (difficulty of breathing) and crackles, both pointing to pulmonary fluid, and fluid often pointing to retarded cardiac function? One thing I did notice is that his B/P was pretty high considering he's on a beta blocker, metoprolol, which I've found to work pretty well. (Not terribly so, but work with me I'm going for the zebra here!) I wonder if it's possible that he haden't taken it like he was supposed to, which is very common in my experience for beta blockers, and if he didn't take that, then perhaps he's chosen not, or forgotten, to take his other meds, like Lasix, and his nitro patch? (pulmonary edema exacerbation, possible arterial constriction allowing a cardiac thrombus to cause your ST changes?) Most everyplace I've worked the protocol for Nitro in cardiac pts is 0.4 mg SL q 3-5 mins until pain relieved, or some such. Would you have given the nitro based on the 12 lead changes alone? (forget Dr.s orders) I would have given it to this patient for the crackles in the hopes that it would battle some of the fluid, but I'm not sure that I would have for the BP or cardiac issue. I'm curious on your thoughts here, as well as the others that delivered Nitro to this patient. Would you simply have pushed two or three doses? How would you know when to stop? How would you verify effectiveness of treatment? And as the others have said, pretty certainly a cardiac event, but not just because of the ECG changes. Everything else about this guy screams a heart ready to go, at least that's my thought. I'm looking for your thoughts, as it's more than likely all of the above is simply me talking out of my ass as I have touched 5 seriously ill pts in the last 4 months. I'm going to need to go back to basic school soon... Great call, and giant cast iron ovaries evident in posting it. Dwayne

Holy shit Andrea, I'll tell you what, the way you present yourself here bodes well for your paramedic future.. Smart, introspective, you evaluate each piece of advice and accept or reject it on what appear to be very rational, logical premises removed from your personal feelings. And your 13 years as a nursing assistant? Are you kidding me? You had very little, if anything to gain from Basic experience, so if there is any of that nonsense floating around in your head, let it go, you have more important things for those brain cells to do. I feel like I'm in the twilight zone these last few weeks, watching you, and Beiber, and....damn it, their names escape me at the moment, but you'll know who I mean when you read their posts. (Speaking of which, where the hell is Ugly?) You all are like, what, about 12 years old? Smart, strong, super committed! I'm not sure if it's the rash of "Screw the grammar nazis! I want to spell like I'm 6!!" that has caused me to lower my bar a lot or if we are just being blessed with a bunch of wickedly smart new folks? I guess it doesn't matter in the end. Anyway... Another thing occurred to me from Herbie's post, and that was about being useful. I decided just for shits and grins to jump on the rooms of the nurses that seemed to be more inclined to teach, clean and decon them as soon as the pt was out if I wasn't busy doing something else on the theory that if they had less other work to do then perhaps they would have more time to teach me things. And it worked out just that way for me. I was soon being called to push meds, or insert IVs, etc, etc. Now, the danger here, is that it's not your job to clean rooms and you need to not allow anyone to come to believe that it is. I did this simply by ignoring anyone that ordered me to.. :-) I would clean like crazy for sweet nurse A, Asshole nurse B would say, "When you're done with that one, get my taken care of quick." But I just couldn't hear him/her. It really wasn't very long before many learned that the way to activate my hearing aids was to teach me something...anything! Within my scope, outside, didn't matter...It worked perfect for me. Also, I don't know if you have to deliver babies during your clinicals? We had to be present for a minimum of two live vaginal births. I didn't go to this clinical until later, not sure why, but I got to see most of my classmates come to hate it as they would sometimes have to go 5-10 12 hr shifts to have the vaginal births happening, and have the mother consent to allow them to watch...I was dreading it. But, I got really lucky. At the time I smoked, and I went out to smoke and noticed most of the expectant fathers were coming and going on a pretty regular basis, so I would watch for them to go out to smoke, follow them out, and say, "Hi! Hey, isn't it your girl that's giving birth inside? Yeah? You know, I"m a paramedic student and we're here to observe deliveries as it's out job to give lifesaving care to the mothers and new babies if they deliver outside of the hospital. But man, most people don't like to let us help. They don't seem to think that someday it may be their wives or kids I'll need to be smart enough to care for.." And every one said, "Well, do you want to watch our delivery? That would be great!" Then we'd go back into the hospital where the hubby would introduce me as some kind of mother/child saving hero that they should feel obligated to help educated, and all were. I participated in 5 live vaginal deliveries in my first 6 hrs of clinicals including one woman screaming the whole time to the doctor, "If he's never dropped a baby let Dwayne do it God damn it!" Which of course didn't happen, but I appreciated her vigor. Anyway, in my terribly long winded way what I'm trying to say is be creative. I've not seen you in a medical discussion yet, or one on morals and/or ethics, but I'm really looking forward to it as you're obviously smart. This is another game, just like medicine. Step back, take a look, think it through and figure out how to win it. There is not question in my mind that you are absolutely capable of doing so. Good luck. Keep posting, keep participating, you're going to be really good at this... Dwayne

LOL... Current comedy keeps trying to replicate those ol' play on words skits but just don't seem to be able to pull it of... Dwayne

Yeah, morally and ethically this is completely unacceptable from the point of view of your service. And I just simply to refuse to believe that you're service agreed to delay response times to give a bunch of fire basics the opportunity to practice. It's bullshit brother, truly. My guess would be that whoever makes that decision for your service, assuming that there is no chance that you are incorrect in the things that you state above, is so far gone that your best bet is simply to run away from this service before the whole fucking thing comes tumbling down. Cause I'll tell you this....If my wife and son die on the side of the road waiting for EMS so a bunch of hosemonkey basics can "practice" their 140hrs or training? I'm coming visiting and there will certainly be changes then.... And come on, if they truly care about the patients, if they truly want to participate in EMS in a meaningful way, the answer is not terribly tough, right? Go to medic school. You will then have all the skills you need to care for a patient from first contact to transfer of care whether that should be 5 minutes or 2hrs. It truly is the answer. But they don't really want to participate, they just want to get paid. That's not meant to bag on them, only to keep these comments in what I believe to be a real world context. I'm grateful for you posting this scenario, but if you should knowingly allow treatment to be withheld from the people that you are tasked to care for? Then you are participating in the travesty, and you should find that unacceptable. You don't have the power to make change? Untrue, you don't have the power to make change without taking a beating for it...those are two different things, right? What do you suppose would happen if your local newspaper decided to compare current ambulance response times to those logged before your new posting algorithm? I"m guessing things would change.... Tough spot, but your Fire buddy is yanking your chain most likely. Occam's Razor says that the simplest of two competing theories is most often correct, and the simplest, most likely theory here is that the hosemonkeys want to make you look like an incompetent asshole while their new ambulances are being painted. Good luck man... Dwayne Edited to fix a few spelling errors. No contextual changes made.

I'll tell you what, ak dancing to anything, it doesn't matter what, is one of the most purely joyful things I've ever seen. Truly... Dwayne

Hey John, welcome back man!! Since '05? Yeah, that's been a few days...It does sound like you've done it all and have been around for ever, man, it will be awesome to hear your opinions! Where are you in LA? I'm deployed with SMS on the oil spill down in Leeville at the moment. Maybe we can manage a cup of coffee when I drive up the bayou to fly out.. Dwayne