Ridryder 911

These guys were around when Cain slaughtered Abel.. :wink: I came after Moses... something about a tablet (protocols?) or something. My first exposure to EMS, when I was a kid in the medical explorer program about 1973. Already knew that I wanted to be a physician in the back of a ambulance, after my brother had a major MVC. When Johnny and Roy came out in the t.vshoe Emergency, that was it! In my Senior year, I worked in ER and then the day after I graduated from high school, I started my Paramedic training, could not attend EMT school because they had just finished the program and had to wait to get the EMT after Paramedic... (I know it was backassward) . We had 4 units, all with ALS capabilities, this was in 1976-1977. Proclaimed the first "modular" ambulance, was one we purchased from a funeral home, it was what "modular ambulance" designed their "mods" after. It was an old converted bread truck.. there were 10 federal beacons, one visibar, and flood lights on each corner, clear and blue lights in the back, with lights in each of its homemade cabinets, a 64 gallon gas tank, two sirens, and did a whopping 48 mph at top speed. The EMS director (ambulance) was a chevy low top, with a visibar, and push-bar on the grill (in case they would not move out of your way) and a 3 inch star of life emblem on the door. This was the first unit I responded in. Each unit had a cardiac monitor, a Gould, Burdick, & MRL (physio-control was not invented yet) of none of them had a print out adn they all had the bouncing "ball" oscilloscope, where you had to pull over to see if the patient was in v-fib or not..... no, I am not joking. The Burdick was the favorite because it weighted only 45 pounds, not like the Gould which weighed 65 pounds. Yes, we all looked like body builders. I remember the first time I defibrillated a patient, (yes, we used paddles, and no there was no such thing as defib pads) we carried either the gel (which made it so slick) or a bag of 4X4's soaked in saline. The med's we carried were the usual ACLS (there were no such abbreviation then) of Epi w/4"cardiac needles to perform intracardiac if you could not get an IV, calcium chloride, and NaHC03, atropine, decadron, mannitol, Lidocaine, Dopamine, Isuprel- (of course there were no such thing as pre-mixed). I still remember the the v-fib procedure was 1 mg of Epi, 2 amps of Bicarb, then shock.... Intubation was performed, but we had to demonstrate that we could ventilate with BVM's for at least 6 months using proper manuever's and not getting gastric distention, before the anesthesiologist would sign off. Betadine Helofoam was used for burns, and we carried 6 liter saline bags to irrigate wounds. There were no such things as helo except for military use, and trauma centers was being formed as Dr. R Adams Cowley was just researching the "Golden Hour".. My work week consisted of 24 hr shifts, with at least 12 working in ER between ambulance calls, this was 24 on 24 off then every other week end you had 48 hr shifts. Of course you only got paid 16 out of 24, which I later found out was gracious because they only had to pay us 12 hrs.... :? There were only 2 services that had Paramedics in Oklahoma at that time, Tulsa and us (which we were rural). No one ever seen anybody bring in a patient with an I.V., and boy did the sparks fly from nurses (usually most ER's were staffed by LPN's) very few ER's had physicians present in the ER (except teaching hospitals) and paged physicians for any orders.... no, IV's were not usually routine from nursing staff. There were many times that curtains were pulled in from of me and nurse would grab your stretcher as you entered the ER curtain (usually no separate rooms) and you were informed to "stay out" they would return your stretcher. You were not allowed to touch, perform care, etc. to the patient you might had just resuscitated.. you were not a nurse or Dr. When a physician entered the room usually all stood up and offered their seat. I know of EMT's not allowed to take vital signs in the ER, only to clean equipment and be a gopher or perform tasks. Usually nicknamed "enema maintenance technician " for a reason. Equipment was usually in short supply, and I didn't realize that there was a short arm splint for years..... I thought IV tubing boxes were for that... I do remember ER docs pitching in to get us supplies... When the federal KKK spec grants came through, it was like Christmas. We received our first van ambulance.. a Collins with the unique colors of course... orange and white inside and out. Ahhh... memories, yes some was very memorable, mainly the "guys"... and one of the 1'st female EMT. They were truly dedicated, and I remember them stating "We are the pioneers, one day things will be better, just hope they appreciate the sh*t we went through".. So as you crawl into your $hundred thousand dollar rig, and you hook up your 15 pound monitor, and attach them to the autopulse.. and perform 12 lead EKG's and have the knowledge of interpreting them, have the ability to obtain a accredited degree, remember those that made it possible, it just didn't happen. Be safe, R/r 911

I was hoping you would catch this post... Band-Aid Patrol.. R/r 911

Well, what do you know we got noticed!.. Now it is a shame that they placed him with apparent idiots to gather some exposure for a real life experience and exposure .. from the article: one of the MEdic describes not wearing gloves : "We were on a ride-along with this guy who had no gloves," Scott said. "We really liked this guy. He had been a paramedic for nine years. He said, 'I don't like not having the human touch. When I'm treating someone, I don't want them to feel like there's something between them and me. I don't want them to feel like this unwanted person" I guess he doesn't want to loose that human touch of Hepatitis, HIV, Community Acquired Pneumonia, etc. as well or his patients receiving all the nasty critters he touched when he touches them as well. Yeah, this is the idiot I want taking care of my grandma who might be immunosuppressed. Thanks buddy for the human touch and diseases as well! No thanks! Granny rather not be on Vancomycin because you want to "feel there is something between you and them... uhhh!!! like viruses & bacteria maybe?... Get a clue... hopefully, whatever EMS this is that employs this moron fires his ass. The makers of Tamiflu and Levaquin thanks you!... R/r 911

What ! Did I forget ??? OOps.. HAppy Birthday !!! I'll call ya' later... R/r 911

I am glad young people are interested in the history of the profession. You can a learn about your industry as well as what the future might hold. One can see history does repeat itself many times especially in medicine. This is why medical schools require history of medicine classes. Actually, EMS was involved in multi-areas, not just California. As well, hearses were still used into the 80's in some areas until Federal specifications was implemented. I am not aware if there are any funeral home that still provides EMS but, I know I had heard of one that was still doing it, and this was the early 90's. So we have cam a long ways since the first EMS units, however; we still have a long ways to go. As humorous as the television show Emergency is some do not realize the impact one show, would make in medicine. I can attest most of the early medics became such after viewing this show, and those probably taught your instructors or instructors instructor and so on.... the series promoted our profession, and without it, I can personally say EMS would still be 50 years behind. Just think, if your EMS cannot provide ACLS, that medical care in that series is still ahead of you and that was 35 years ago. One would think we would had advanced by now, instead of making excuses. I wish that there would be another television show that would compare as Emergency, maybe EMS could finish the involvement. Here is a link for a brief history of EMS and associated things. http://www.rescuehouse.com/content/ems-his...ems-history.php Good luck, R/r 911

I personally believe the Paramedic should have a very thorough understanding of C however; even physicians when discussing the application and use of NTG are not that anal. But one should have a through bio-chemical and pathophysiological understanding. Be safe, R/r 911

A while back Dust had a interesting post about "if you were in charge of an EMS Education Program, what would your entry requirements be". This brought out some very interesting points. Being interested in education, I "Googled" and searched many EMS training and education sites to check vacancy of EMS instructors and faculty openings. Interesting results on the requirements and qualification of becoming an instructor at these varied sites. After viewing several I can clearly see why EMS is in the alarming condition it is in. Inquire for yourself and you will see that a over whelming majority of the programs are taught by part-time instructors only. There are very few "full time faculty amd staff". Out of the several sites, I was only to find two that required a formal education (most of those were for program coordinators). However it appears to be some beginnig to show an interest for at least an associate degree, but alas this was still in the minority not majority. Most only required the "State or National EMS Instructor Course" and preferred to have a state license of that level, and field experience was limited from 3 to 5 years, very few required any past educational experience. The application process was only an application to be filled out. As well, I found very few programs that apparently had "supplemental staffing" such as administrative assistants or lab instructors. So my question is: How are we ever going to resolve educational issues to field personal, when our educational system is in crisis and apparently has a DNR ? How is your educational/training programs requirements ? If you were in the position to write specific requirements or develop programs, what would they consist of ? This is for the educators and faculty positions and associated programs as well. Are you actively participating in your local education arena, such as advisory councils, or hiring/employment committees, etc. ? How is instructors selected in our areas, and is local EMS management involved in the educational system? What can we do to increase the levels or should we even consider it ? R/r 911

I believe that BLS providers can use advanced airways but should not. Part of being properly educated is knowing what you are capable of knowing and performing and doing those well, as well as knowing your limitations. There are several procedures and methodologies, I am sure I could perform or muddle through, however I realize that I have not been properly educated nor should I even consider attempting, because there is a reason it is not within my scope of education. Again, we have allowed piss poor reasoning and rational to mandate specialized certification and accreditation's. Excuses of not having enough personnel, and poor funding is not valid. Can one imagine allowing "special trained" physician assistants to perform cardiac by-pass or heart transplants because there is a shortage of cardiac surgeons? No, nor should we had considered allowing lower levels to ever perform advanced procedures. One of major flaws and blunders that occurred and continues to propagate, instead of the full level of ALS, in which it was to promote. Unfortunately, EMS will not mature, it can't. Various members and administrators will not allow it to. Obtaining a thorough knowledge is barely visible and unfortunately "training " has been widely accepted as the norm in lieu of education. If you do not know the difference, there is part of the problem. Be safe, R/r 911

I still say the old philosophy of determining if it is wrong or not is if your mate was with you, your discussion and touching would not offend them, then it would probably be allowable. Becoming "too close" is a serious side effect of EMS and never has any advantages. In my past nearly 30 years, I have seen so many "deep or close friendships" end up in affairs. Save the talk, etc. for your mate and counselor. Chances are if you would talk to your mate as well as you do your partner, things would not be as bad. Remember, your partner is your co-worker, and then friend. Unfortunately, we have allowed EMS and the working situation to be a an excuse and blame for problems. In reality, it probably has very little to do with the real problems, the problems were already there hiding. Be the responsible one. I have yet seen any successful "close relationships" at work, within time someone is going to get hurt and everyone will have to pay for it. R/r 911

Actually, I would prefer a Paramedic, than having a system make excuses for itself! It is a shame the citizens of this country cannot at least have a person educated in ALS procedures. One would think after 40 years, the EMS system would quit "justifying" half -ass classes because communities, administration cares so little for human kind to at least give them someone that can administer medications (please not a few or limited) If people REALLY cared there would be only one level... period. Call me para-god, holier than thou.. I don't care! I know at least the patient(s) I attend to can and is able to get what the medication(s), emergency procedures when and if they need it.. If you don' t like it then change it.. go to school, receive an education, pass the boards, get experience and then change the system! One thing about EMS, that has never changed... a bunch of whiners and full of people who want to take the easy way out... don't believe me... look at how many acronyms there are after the letter EMT, or how many First-Aid, BLS, Half-way Paramedic units there are out there. Don't the patients at least deserve a chance? R/r 911

Of course this is plagiarized and probably more than anyone wants to know about it.. not to be confused with pulses alternans :wink: ...LOL History: The reduction in pulse volume during inspiration was first described by Lomer in 1669 in constrictive pericarditis[1]. A similar finding was described by Floyer and later by William in 1850 in bronchial asthma[1]. Adolf Kussmaul (Freiberg, Germany) coined the term “pulsus paradoxus” in 1873 in three patients with constrictive pericarditis. The “paradox” was: (1) the discrepancy between the absence of the pulse and present corresponding heart beat and (2) Amidst this irregularity, the regularity with which the pulse disappeared during inspiration.[1] :: Respiratory influences on the pulse volume Under normal conditions, arterial blood pressure fluctuates throughout the respiratory cycle, falling with inspiration and rising with expiration. The changes in the intrathoracic pressures during breathing are transmitted to the heart and great vessels. During inspiration, the right ventricle distends due to increased venous return, the interventricular septum bulges into the left ventricle reducing its size (reversed Bernheim effect), and increased pooling on blood in the expanded lungs decreases return to the left ventricle, decreasing the stroke volume of the left ventricle. Additionally, negative intrathoracic pressure during inspiration is transmitted to the aorta. The relatively higher negative pressure in the pulmonary circulation compared to the left atrium in patients with pericardial pathology causes back flow of blood from the left atrium into the pulmonary veins during inspiration.[2] Therefore, during inspiration the fall in the left ventricular stroke volume is reflected as a fall in the systolic blood pressure. The converse is true for expiration. During quiet respiration, the changes in the intrathoracic pressures and blood pressure are minor. The accepted upper limit for fall in systolic blood pressure with inspiration is 10 mmHg. :: Pulsus paradoxus: what is the paradox? The “paradox” refers to the fact that heart sounds may be heard over the precordium when the radial pulse is not felt.[3] This is due to an exaggeration of the normal mechanisms mentioned above. Moreover, the clinical method of assessment of this “pulse” is by measurement of the “systolic blood pressure”. The mechanisms in various pathologies are discussed below. :: Causes of pulsus paradoxus Cardiac causes 1. Cardiac tamponade 2. Pericardial effusion 3. Constrictive pericarditis 4. Restrictive cardiomyopathy[4] 5. Pulmonary embolism 6. Acute myocardial infarction 7. Cardiogenic shock Extracardiac pulmonary causes 1. Bronchial asthma 2. Tension pneumothorax Extracardiac non-pulmonary causes 1. Anaphylactic shock (during urokinase administration)[5] 2. Volvulus of the stomach[6] 3. Diaphragmatic hernia[6] 4. Superior vena cava obstruction[4] 5. Extreme obesity :: Mechanisms and pathophysiology As a general guideline, pulsus paradoxus will be a result of the following mechanisms operating alone or in combination:[4] 1. Limitation in increase in inspiratory blood flow to the right ventricle and pulmonary artery 2. Greater than normal pooling of blood in the pulmonary circulation 3. Wide excursions in the intrathoracic pressure during inspiration and expiration 4. Interference with venous return to either atrium especially during inspiration In this review the pathophysiology underlying only the major causes will be discussed. :: Constrictive pericarditis and cardiac tamponade Pulsus paradoxus has great diagnostic significance in pericardial disease. The following mechanisms are proposed to operate: 1. Tense fluid accumulation within the pericardial sac impairs left ventricular filling causing an exaggerated reduction in systolic blood pressure during inspiration. Katz and Gauchat found that with pericardial tamponade, intrapericardial pressure did not fall during inspiration.[4] As a result, the pulmonary venous pressure would fall more than the left atrial pressure during inspiration tending to cause a fall in the left ventricular filling during inspiration due to incomplete transmission of the inspiratory fall of intrathoracic pressure to the left atrium. This has been documented in other studies as well. Dock[7] proposed that the inspiratory traction by the diaphragm and mediastinum upon the taut pericardium further increased intrapericardial pressure thus interfering with cardiac filling. Shabetai[8] found that both vena caval and pulmonary arterial blood flow velocity fail to increase normally during inspiration in patients with constrictive pericarditis. 2. Fowler et al[9] showed that there is a persistence of the normal inspiratory increase of the filling of the right side of the heart during cardiac tamponade. If this was prevented, paradoxical pulse did not develop, however severe the tamponade. Guntheroth et al[10] proposed that the normal respiratory variations of a reduced right ventricular stroke volume are responsible for the exaggerated respiratory variations in blood pressure during cardiac tamponade. 3. Pulsus paradoxus may be caused by pooling of blood in the pulmonary circulation and competition of the ventricles for filling within a relatively fixed pericardial space. Few reports have highlighted abnormal movement of the interventricular septum during inspiration contributing to decreased LV volume.[11],[12] Similar respiratory changes in mitral and septal motions and the similar respiratory interaction between the right and left ventricles have been observed during the Mueller manoeuvre. These observations suggest decreased left ventricular filling and left ventricular end-diastolic volume during inspiration in the presence of pulsus paradoxus. Large pericardial fluid collections may affect left ventricular function even in the absence of clinical manifestations.[13] 4. One of the other principal causes for pulsus paradoxus is underfilling of the left ventricle during the preceding diastole. This is the most likely cause of this combination of events.[14] :: Acute massive pulmonary embolism The pulsus paradoxus in this condition results from right ventricular dysfunction secondary to acute right ventricular dilation and excessive pooling of blood in the lungs in inspiration.[15] :: Acute myocardial infarction Pulsus paradoxus in acute myocardial infarction can result from right ventricular infarction, cardiogenic shock or cardiac tamponade. However, it has been described in uncomplicated myocardial infarction due to the differences in the compliance of the left atrium, left ventricle and pulmonary circulation that is further exaggerated by an increase in the left ventricular stiffness due to myocardial ischaemia.[16] :: Respiratory diseases Pulsus paradoxus is one of the ominous signs in acute exacerbation of bronchial asthma. This is the most common extra-cardiac cause of this physical sign. The main mechanism operational in respiratory disease is the unusually great fluctuations in intrathoracic pressures that are transmitted to the aorta. The following theories have been proposed: 1. During increased airway resistance, there is an exaggeration in the inspiratory-expiratory difference in stroke volume mediated primarily by the effects of intrathoracic pressure on ventricular preload. Shim et al[17] found that patients of asthma with pulsus paradoxus had greater airflow obstruction than patients without. Also, it was often present in mild obstruction and absent in severe obstruction. In acute exacerbation of childhood asthma, pulsus paradoxus often correlates with both the severity and response to bronchodilators.[18] 2. Hyperinflation of the chest due to air trapping is also plays a role in pulsus paradoxus. Factors other than hyperinflation also contribute to the fall in systolic pressure that occurs at full inflation of the lungs. This is also observed in patients with chronic stable obstructive airway disease.[19] :: Pulsus paradoxus in hypovolaemic shock Hypovolaemia may precipitate pulsus paradoxus in critically ill patients. Its occurrence may aid in the clinical recognition of the common syndrome of occult hypovolaemia in patients with shock and no obvious blood loss.[20] :: Measurement of pulsus paradoxus Cuff sphygmomanometry The patient should be instructed not to breathe too deeply (enough to make the chest movements easily visible). The sphygmomanometer cuff is inflated above systolic pressure. Korotkoff sounds are sought over the brachial artery while the cuff is deflated at rate of approximately 2 to 3 mm Hg per heartbeat. The peak systolic pressure during expiration should first be identified and reconfirmed (when Korotkoff sounds are heard only during expiration). The cuff is then deflated slowly to establish the pressure at which Korotkoff sounds become audible during both inspiration and expiration (when the Korotkoff sounds are heard during both inspiration and expiration). When the differences between these two levels exceeds 10 mm Hg during quiet respiration, a paradoxical pulse is present. Palpation Usually, palpation of the central pulses (carotid) is recommended for the evaluation of the character of the pulse. However, pulsus paradoxus is better appreciated in the peripheral pulses (radial).[4] When the pulsus paradoxus is severe, it may be possible to palpate a fall (reduction in the pulse volume) during the phase of inspiration and rise during the expiratory phase. Arterial waveform analysis In the intensive care setting, where the arterial waveform is available, pulsus paradoxus can be diagnosed by visualising changes in the systolic blood pressure tracing during the inspiratory and expiratory phases of respiration. Pulse oximetry waveform analysis[21],[22] This technique has been found useful in the neonates with cardiac tamponade. In patients with obstructive airway disease since pulse oximetry is available in ICUs and emergency departments, it is a useful non-invasive means of continually assessing pulsus paradoxus and air trapping severity. :: What is reversed pulsus paradoxus? Reversed pulsus paradoxus, a rise in systolic blood pressure during inspiration, was first described by Massumi et al[23] in patients with idiopathic hypertrophic subaortic stenosis, isorhythmic ventricular rhythm and patients of left ventricular failure on positive pressure ventilation. A rise in peak systolic pressure on inspiration by more than 15 mm Hg is considered significant. In a mechanically ventilated patient, positive pressure ventilation displaces the ventricle wall inward during systole to assist in ventricular emptying causing a slight rise in the systolic pressure during mechanical inspiration. A reverse pulsus paradoxus in mechanically ventilated patients is a sensitive indicator of hypovolaemia. :: What is pseudopulsus paradoxus? Salel et al[24] described a patient of complete heart block who was misdiagnosed to have pulsus paradoxus. This was the result of forfituous synchronism of inspiration with the cyclic intermittent properly timed atrial contribution to ventricular filling characteristic of atrioventricular dissociation in this condition. This is termed pseudopulsus paradoxus. This error can be avoided by strictly adhering to the guidelines for pulsus paradoxus laid down by Gauchat and Katz: (1) The pulse must be felt in all the accessible arteries (2) There is no need for deep inspiration and (3) There must be no irregularity of cardiac action. [4],[15],[23]"> :: Absent pulsus paradoxus in cardiac tamponade[4],[15],[23] All cases of cardiac tamponade are not accompanied by pulsus paradoxus. The reasons for this are not clear in all cases, but it is likely that other compensatory mechanisms are brought into play in order to maintain a normal systemic blood pressure. The following are such conditions: 1. Aortic regurgitation (AR): In the presence of AR, the left ventricle can fill from the aorta during inspiration. Therefore, if aortic dissection produces both AR and tamponade, pulsus paradoxus may be absent. 2. Large atrial septal defect: The normal increase in systemic venous return on inspiration is balanced by a decrease in the left to right shunt, resulting in minimal change in the right ventricular volume. 3. Isolated right heart tamponade: This entity has been described in patients of chronic renal failure on hemodialysis 4. Elevated left ventricular diastolic pressures 5. Severe rheumatoid spondylitis or disease of the bony thorax: Wide changes in intrathoracic pressure prevented by the relative immobility of the chest wall. 6. Coexistent condition producing “reversed pulsus paradoxus” [4]"> :: Importance of kussmaul’s sign in pulsus paradoxus[4] Kussmaul’s sign is a paradoxical increase in the peripheral venous distension and pressure during inspiration. The major mechanism is a change in the shape of the pericardium with a resulting increase in the intrapericardial pressure and obstruction to the venous return to the heart. Compare this with the marked exaggeration of the normal expiratory increase in venous pressure that accompanies patients with pulmonary disease. Note that pulsus paradoxus may be present in both groups of patients. :: Approach to a patient with pulsus paradoxus Rule out common, important and life threatening causes first. 1. Careful history of the illness 2. Haemodynamic status of the patient 3. Meticulous examination of the jugular venous pulse – do not forget Kussmaul’s sign and abdominojugular reflux 4. Look for Beck’s triad (distended jugular veins, hypotension and muffled heart sounds) – suggestive of cardiac tamponade 5. Detailed evaluation of the respiratory and cardiovascular systems 6. X-ray chest and ECG may provide diagnosis or rule out some of the causes 7. Emergent pericardiocentesis if large pericardial effusion 8. Aggressive management of asthma, exacerbation of obstructive pulmonary disease, intercostal tube insertion/needle insertion for tension pneumothorax 9. Thrombolysis for myocardial infarction or massive pulmonary embolism 10. The other causes should be treated on their own merit :: Limitations of pulsus paradoxus Although pulsus paradoxus is a valuable physical sign, it has its limitations. The use of the term is not uniform and as it is an exaggeration of a normal phenomenon, a cut-off value is difficult to provide.[25] In patients of cardiac tamponade, studies have shown that when right ventricular diastolic collapse on echocardiography and pulsus paradoxus were compared, right ventricular diastolic collapse was more sensitive and more specific than pulsus paradoxus in detecting increases in intrapericardial pressure during euvolaemia and hypervolemia whereas the two tests were equally valuable in hypovolaemic states.[26],[27] As with other clinical signs, pulsus paradoxus must not be considered in isolation but in conjunction with the patient’s clinical state and with other indices of the severity of asthma.[28] Finally, the absence of pulsus paradoxus does not rule out the presence of a significant pericardial effusion.[13] However, this important bedside sign must be elicited in indicated patients, foregoing which life threatening and potentially treatable causes are likely to be missed by the examining physician ANymore questions on pulses paradoxus...lol

Geez this is not rocket science.. are they not teaching how treat patients anymore? The question in the initial scenario is a lot different than having a specific or isolated injury. I did not watch the video nor do I want to, too many idiots in action. Each patient and situation should be guided by the incidence, the mechanism of injury (MOI), the potential injuries and the findings of the detailed assessment. If there is potential injury, pain, paresthesia, they get immobilized.. period If your service has field clearance protocols and the examination, MOI, meet those then use them. But, even those usually are vague enough to state, "when suspicion, or possibly indicated, err on the behalf of the patient"; if they don't they should. Please if you are going to post or cite journals as well be sure they are pertinent to the case. This article was not for initial spinal precaution (s) , but eluded to the length of stay and having patients remain on LSB. Anyone that works in ER should know that removal of CID and LSB should occur ASAP (after clearance, preferred x-ray or CT) to prevent pressure sores, neuropathy, and other potential injuries. All this material should had been well covered in the basic curriculum and in detail in PHTLS or a BTLS course. R/r 911

I agree with the exposure. From most of my experience and observation of larger services there is so much "cookie cutter" type medics, with emphasis on policies and protocols rather than individual assessments, and techniques. So much pressure is placed o "following it their way as well as scene time, etc. very little is autonomy and individualism is sometimes discouraged. Yes, the volume will definitely "hone" your skills as well as get bored, after a while. That is why I suggested part time, hopefully at a urban area, one can provide more autonomous care, and focus those associated skills at the larger service. I suggest the same in nursing. Be safe, R/r 911

MOI, restrained, driver, air-bags.. yadda..yadda. PMHX, type of pain .. parathesia, tearing?.. prior tx. Usual H & P R/r 911

I agree with Dust.. I have never worked but at one service that had turnout gear... ( and that was a Police EMS, and they provided ALL rescue). Not a very common thing if you are not fire based. R/ r 911

I have always described that attitude is the difference between me and them... going the distance and trying to the best one can be. Good luck in your career! R/r 911

Yeah, she keeps her gender symbol as a male. Congrats on geting such a great work benefit ! ... R/r 911

It all depends upon your intentions. If you intend to do this for some time and really administer patient care with detailed care, I suggest more rural settings. If you want volume, I suggest a large metro area. I disagree with starting out in large cities. I suggest rural for learning medical care and then work city for increased skills levels. Most I have seen come to rural areas are used to high call volume but very little treatment modalities. Having a drug box with 40 -50 med's, is very unexpected, as well as spending maybe an hour or two with one patient. The other point, so many city medics presume because they have a higher call volume they perform better care and have a better EMS. This is usually far from what I have seen. In fact most flight services I have worked with preferred an urban setting, because f the diverse care the Paramedic performed, as well as continuous treatment. Both areas have their weaknesses and strengths. Again, one needs to weigh what their goals are. Good luck, R/r 911

Both are excellent books. The Dubin's is the master of learning EKG's as well as Bob Pages Multi-Lead medic and XII lead book. I personally feel Bledsoe has produced the new "Bible for Paramedics" in the Critical Care Paramedic; this textbook should be mandated for any Paramedic program. He and his authors really has hit the nail on the head, with this book. I can actually say this is one of the finest books I have seen written in the past 30 years. Every Paramedic should have a copy and read through it at least once a year... This is ideal for those who want to know more than the general Paramedic, and have at least a basic understanding of emergency and critical care medicine. For novice Paramedics this will advance you a couple of years ahead, by reading and investigating the text. No, I don't get commission.. just an oddity to see such a great textbook. Be safe, R/r 911

I always find it amusing of those that do not really understand EMTALA. Even EMTALA can be revoked if their are plans in place, such as Trauma Regions, Medical By-Pass agreements, even state triage guidelines and protocols. One might want to be careful of transporting patients to a facility, just because they want to go there. There are some regions to possibly implementing fining EMS/medics for not adhering to local policies of proper and most appropriate hospital rather than patients choice. EMTALA is for the purpose of not receiving patients from non- medical facilities, or care. Mainly introduced for O.B. patients, that used to be denied. Be sure not to confuse EMTALA with COBRA, again a whole different topic. R/r 911

Shhhhh.... that makes too much sense! R/r 911

There are several factors that could cause such an event... 1) Inaccurate blood pressure findings (be sure to check both arms) 2) A period of sick sinus syndrome as well any arrythmia, that caused poor cardiac output and maybe has regained itself in pulse wise or I have seen patients in SVT with only a perfusion pulse of 60 and their ventricular rate was 180 and of course hypotension... 3) Poor or bad perfusion/ output.. R/r 911

I understand where you are coming from; however not all states have trauma centers and would be very surprised how many truly verified Trauma Centers there is : (http:// www.facs.org/trauma/verified.html ) and of those that claim to be one. As well in a lot of rural and smaller locations, it is not unusual to see physicians be on the code team. This maybe surgeons or O.B. etc.. so yes, they are bound to secure the airway, establish a central line placement etc.. Just because they are a specialty group does not exclude them of general knowledge and practice of a physician. Do the hospitals not require them to have BLS and ACLS?.. and as well, they are not required to maintain their resuscitation skills?.. I am sure if you were to pull up their credentials for privileges and procedure abilities you would find that it would be checked off .. I doubt that they excluded themselves when applying for accreditation and privileges at that hospital (s). Again, would like to see ACEP or another credible group perform a study on comparisons). Similar to the recent study of Lasix administered prehospital to that in hospital. After the hBnp & CXR was performed the medics were criticized for misdiagnosis... wow, who wouldn't be >90% with those diagnostic tools?.. It would had been more informative to see a study of using the same diagnostic of assessment skills of the Paramedic, Physician, and then with the use of diagnostic tools. Like I stated, I am all for progressing, but I believe there is a lot of bias allowed. Not being able to have an EMS advocate I believe is slanting the studies. As well, unfortunately many do not read into the studies in-depth to see if the study was truly valid and statistically correct, and take many studies at blind faith. Like I described they are usually all good until the next study performed.... such is medicine. R/r 911

Yes, M & M reviews are excellent on increasing the "whole scope" of things. However; there are some words of caution. Be sure not to use such as a "witch hunt" and one need to point out the good in moderation as well. The difficulty in performing a M & M for EMS, is prehospital care is such a tiny part in the patient care and sometimes is overlooked. Good luck! R/ r 911

Apparently Nate, they do not work in a busy system. It does not take a rocket scientist to examine a "toe pain for 6 months" these type of calls, do not require EMS transport. Not only is it abuse to the system, but you are not being a patient advocate as well. Sorry, unless they are medicare or medicaid, they do not pay any or part of my salary. Even then if they are Medicare or Medicaid only up to 80% of the EMS call are paid by them (if it is justifiable and warranted). So meanwhile while you are transporting this "toe pain or toothache...etc." you have a MVC, pediatric arrest, true AMI patient.. be sure to tell them why your additional 15 minute response time was warranted.. because you were on a non-emergency patient and they deserved to be transported just as much as their loved one. Anytime, you are able to place or the patient warrants setting in the lobby for triage, abuse occurred, and apparently EMS was not needed or justified. The patient could had and should had went by other means. Be safe, R/r 911