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You know, even though it keeps coming back to these "I'm sick of these BLS vs. ALS vollie vs. paid stuff..." I have to say, so long as everyone keeps it above the 5th grade playground level, myself included, there is always constructive debate. Its not always a rehashing of the same thing. Okay, a lot of the time it is, but its still good, IMHO.

In response to the "EMS hasn't been around that long" comments, I'll remind everyone that a lot of things haven't been around for very long. Guess what? Even modern firefighting and police tactics are fairly new inventions. Sure, we like to say that firefighting can be traced back St. O'Florian or whatever, but guess what, except for maybe some really backward volunteer squads in New Jersey, bucket brigades and hand pumpers are a thing of the past. Forget thermal imaging and helicopters, even SCBA's have been around for less time than you might think. Next time your driving, look at the road sign indicating a firehouse nearby. It'll show a silhouette of a circa 1950's open cab engine, and given modern home construction and increased safety features on cars, fire departments are adapting to the modern world at rapid rate. Same goes for police work. For a long time a police officer's gear consisted of a notepad, a six-shooter, and a leather slap filled with powdered lead. Mace, tasers, "less lethal" weapons, SWAT tactics, etc. most have not been around for much longer than modern EMS has existed. So, let's not rely too much on the "EMS hasn't been around long" line. Adapt, evolve, or perish.

Nessie, I would suggest going to CISD, but remember, like everything, approach it with an open mind. If you think something they are telling you sounds like BS, then say so. Don't let people tell you how to feel. What you feel and how you deal with it is, in the end, your own business. Let me ask you, straight out, how have you coped with the call so far? Did you cry? Get mad? Get depressed? Get worried about your own family members? Guess what, if you did, that means you're a normal person. These feelings are all normal. It doesn't mean you are a wimp, or unprofessional, or can't hack it, and they are NOT signs that you have suffered PTSD. They are signs that you are a person with a healthy emotional reaction. And, if you didn't punch a wall, go get piss drunk, or wake up in a strange person's bed, you're dealing with it a lot better than many people I know and work with.

Not to stray off topic here, but I think your patient is a good example of why many of us don't like the concept of protocol driven medicine. I wish patient's always fell into a set pattern, but god bless it, there are those who just don't know how to be sick. In a good system, it should be left to the medic's discretion when to start an IO. Restrictions like "in an unconscious patient" or "in a cardiac arrest" bring up situations where considerations that should not affect patient care decisions end up being the driving force. IO's should be started on patients who need them, and those are IMHO, unstable to critical patients where other means of access are not available. To further stray off topic, I recently had a man who presented with a chief complaint of feeling weak and dizzy for a few days. He had a long list of medical problems, including a-fib and CHF, and was taking lasix. He admitted to poor fluid and nutrition intake. He was sitting upright, AOx3, pale, but warm and dry, lungs clear, with a BP of 80/50. His EKG showed a rapid A-fib of around 160 with runs of V-tach occasionally. Okay, so basically this guy is sick, probably dehydrated, and with obvious cardiac irritabilty. My game plan was to try to bring his BP up with a fluid challenge and then administer amiodarone to bring his rate an rhythm under control. My telemetry physician saw it differently. As per protocol, a BP under 80 sys means an unstable patient, so he was an unstable a-fib patient and needed to be sedated and cardioverted. IMHO, he wasn't unstable, but I got trumped. This is why protocol medicine is not a good idea.

The one person I knew who had gastric bypass was morbidly obese, and did really need it, but also, he ended up in a coma for a few weeks after the sutures popped and his abdominal cavity filled up with gastric contents. Sepsis, peritoneal inflammation, he had it all. So, I would highly recommend trying a diet and exercise regimen before going the gastric bypass route. You can start by stop eating fast food, and I don't mean the Subway/Jared diet, I mean staying at least fifty feet away from any franchised eatery. This includes Burger King, McDonald's, Wendy's, KFC, Denny's, Sonic. Carl's Jr, Popeye's, and Pizza Hut. Especially Pizza Hut. Just try visualize that a plaque occluded artery looks remarkably like a stuffed crust pizza, and its not all coincidence. Depending on your height, weight, general level of physical activity, and what you ordered, what you got at Burger King today might very well have exceeded your needed caloric intake for the day. In other words, if you didn't eat anything else all day, you still ate too much. Pack your lunch. Tuna is your friend. So are carrot sticks. And pickles.

Okay I still go ??? Am I missing something? Why was your partner crying?

Lisa, hang on, don't go this route just yet. I don't think anyone was slamming you per se because of the mnemonics you were being taught. People we re discussing the mnemonics here and there, making their own conclusions, and if anyone was having a problem it wasn't with you it was with your course. Its what we do. If you really want to learn and grow, you need to take into what people say, even if it makes you mad. Thank you for explaining the PASTE acronym. I still think it's unnecessary though. Most of it is already covered in the OPQRST questioning portion, and if there is one acronym I still use, OPQRST is the one. Onset: Did it come on rapidly or suddenly? What were you doing when it occured? This takes care of P in PASTE. Association is also taken care of in S: Severity, are you having pain, on a scale of 1-10, how bad? S: Sputum is taken care of in "associated signs and symptoms", T, talking tiredness is one, really not necessary in a rapid emergency interview, but is also mentioned in P: Provocation, does anything make it worse? The same goes for exercise intolerance. Learn what you have to pass the class. Just be aware that there are disagreements as to what to learn and how to learn it, and it isn't anything personal. Don't treat your class like its your church, its possible they may be wrong on some things.

Talking tiredness? Exercise intolerance? Here's an acronym: WTF? What exactly are you planning on doing for this patient? An echocardiogram and a stress test? Should I assist the patient in taking their thallium? Christ, lets focus on simple things, like getting bleeding control or splinting right. That takes a lot of practice.

Sometimes it isn't worth arguing. It just makes you mad, brings you down to their level, and the person remains just as ignorant as when you started. Dwayne, I really applaud you on how you handled the situation. Sometimes though, as crass as it may sound, the best response to "Yeah, the problem with you new medics..." is "What the hell did you just say to me?" That usually stops the conversation right there.

I'm glad that some others touched on what I was getting at. I have found that 99 out of 100 times I hear a "EMT babysitting their medic" horror story, its a matter of the EMT really wanting to believe their training made the difference on a critical patient rather than any basis in truth. Its kind of like the mall security guards who go on and on about the robberies they've single handedly foiled. We're sure you made a difference and did some good, but at the end of the day, how much can you really do with a flashlight and thermos full of coffee? However, to prove my point, after a few days I finally realized what was missing in incognitogirl's saving the day story. Maybe you found a bleed an maybe you didn't. I wasn't there. I can't say what happened. But what I can say is that according to your account, all of you actually screwed up big time from the get go. The way you put it, the patient was hypotensive after an MVA. Because the medics were too busy trying to get an IV, they did not expose the patient. Because of you "reminding" them about exposing the patient, a critical bleed was found, the patient was uptriaged, and rather than going by ground they went by air, and the world was better place. So let's back up. I'm not sure what state you are in, however, critical trauma criteria tends to vary little from place to place, and in almost all of those places ANY patient. whether they have that all important life threatening bleed which can only be found after exposing the patient or not, if they are hypotensive after a significant mechanism of injury should be a high priority, rapid transport to begin with, and the reason it is set up that way is because most hypovolemia secondary to trauma comes from an internal injury, which many times cannot be easily identified. Anything but a very low speed car accident is a significant mechanism of injury, and the fact he was hypovolemic ALONE pretty much made him a critical ipatient. Whether you exposed him, started an IV, sang Dolly Parton to him, as soon as that BP came up someone should have been calling for a helicopter. Remember that next time you tell your story. (Oh yeah, and for 10 extra points, technically speaking, you should have checked for life threatening bleeds before even boarding and collaring him. One of the few things we do for critical trauma's while on scene. A...B...C..... you know the drill.)

Oh, give me a break sister. First off, you nicely missed my point, AS USUAL, which is that I hear these stories over and over again, NOT because they are ACTUALLY HAPPENING, but because stupid ass EMT's with more hours spent watching MASH then being in the field think every single time someone has blood on them its a life threatening bleed, and as soon as the value of saline replacement was called into question, every single person who couldn't pass static cardiology said "YEEEEEHA! I DONE TOLD YA THEM MEDICS WERE NO GOOD ON THE TRAUMA!" and the stories about the life threatening bleed and the trauma, and the IV came about. In short, its BULLSHIT. But I guess my irony was just a little to subtle for you. Oh yeah, and until you can quote me Starling's Law, hematocrit, or tell me where the femoral artery becomes the popliteal artery, don't start in with the "blood turning pink" or "blood turning to Kool-Aid" crap. If you don't want to go to medic school, fine, that's your choice. But don't try to act like there is some value in having less knowledge about your job than others do. There isn't. Maybe in the movies, the day is saved by the folksy hero with some sort of homespun bit of wisdom, but in real life, things get done by people who studied, practiced, and persevered. I reiterate, this is what drives me up the wall about my job. Its never "Hmmm, these guys actually worked really hard to better understand prehospital care. Let's listen to them." No. Its "DAAAAHHHHH YEAH THAT THAT LARNIN' AIN'T NUTHIN ITS ABOUT HAVE A KEEN EYE AND A FOOT FER THE GAS PEDAL!" Or something. I'm going to use my diploma and certifications to make a big doobie and then sew some more patches on my uniform. Maybe then I'll know what I'm talking about.

Uh huh. Like I said, I saw this coming. Sure, I got a little annoyed, so here it is again, after a good night's sleep. I have heard this story before, many times, from many different EMT-B's, and it's always the same. It's always the medics who missed the life threatening bleed because they were too focused on the IV, and it always ends with an oversimplified version of fluid replacement with Normal Saline for hypovolemia is inadequate without bleeding control. Anyway, I'm really glad to hear that once again, having a keen eye and all that trumped professional, physician directed training and education. Now that I said that, after this bleed was noticed, you immediately applied pressure at the femoral pulse point right? And constant pressure was held until surgical intervention at the trauma facility? Or did you just give up and tie a tourniquet? Just wondering how it turned out.

Okay, you know, this is what really pisses me off about this fucking profession. I will take all the of the "you're anti-EMT-B" brunt that goes with this, but here is my little rant. People here have posted some really intelligent, well thought out, well researched posts, and mixed in with them is this crap. I mean, what use is it training for years and years and years, suffering, struggling, studying, years of trying to be the best prehospital care provider I can be to friggin' be put in the same boat as people who think that by their "exceptionally keen eye" alone they found the problem? At this point I am really sure there is a factory somewhere that issues the mystical "medics too focused on X to see condition Y" to every EMT-B in the country, because if I had a nickel every time I heard this same exact line, right along with the "ya the saline don't do nuthin' iffin' the bleedin' ain't controlled" line, I could retire. Maybe I'm just blessed. Maybe I am in such a good system that even the dumbest medics I have ever worked with would have immediately snapped to finding a bleed when they saw a lower blood pressure on a traumatic patient. Maybe my paramedic course is the only one in the fucking country that made me go over diagnostics and mechanism of injury until my eyeballs fell out of my skull. Maybe that's it. I assume that after you found this bleed, a tourniquet was tied right? Because, in my mind, the only thing that could stop a bleed that has gotten to the point of actually managing to lower the blood pressure would be one that could only be controlled by tourniquet in the field. I also assume that the person was cool, pain, diaphoretic, with altered mental status? Because usually that is what happens when you have a really bad extremity bleed, and usually, they are fairly obvious. Or maybe this is exactly what is wrong with our field. Maybe this is exactly why medics have the attitude they have when it comes to who's in charge. Maybe there are people out there with patches on their shoulders who have such a lack of basic knowledge about medicine that they don't know what they don't know. Maybe that's it.

Not saying that incognitogirl does this, but I just think its amusing that for SOME providers, volunteering as an EMT-B is NOT about the money but about helping others and serving the community but going to medic school IS about the money. I just scratch my head sometimes.

The doctor must have finally gotten my dose right because I'm going to try and make peace here for once and not take a cheap shot. First I'll say something that actually goes against something I've said in the past. Which means, could mean, could reasonably be construed as insinuating that I was possibly maybe incorrect on a previous instance. Maybe. The way we can avoid the typical name calling and mud slinging that goes on this thread is by doing what EMS needs much more of, going about it rationally and professionally. Basically your post states that you've seen mistakes that a higher level provider has made and you are wondering about how to handle it. Fine. Good. Perfectly acceptable question. However, when you start using terms like "Babysit", that's when people start going to the mattresses. Anyway, with a really big qualifier, despite what I've said in the past, I'll say it IS acceptable for a basic or any other lower level provider to question a paramedic's decision. If a janitor sees a doctor punch a patient in the face, he has full right to report him, and I hope he does. The qualifier, however, is simple, do it the right way, the professional way, and be prepared to take it as far as it needs to go. If you don't feel confident enough with your concern to sit in front of the medical director with who you are accusing and repeat your concern verbatim as you did on the scene, then plain and simple, shut the f--- up. The real problem is that we have petty little whiners on this job who want to nit pick everything but don't have the balls or female equivalent to stand by their convictions. If you think I'm doing something wrong, tell me why. Go ahead. Challenge me. Tell me why the medication I'm giving is wrong. Quote me the protocol. Tell me the anatomy and physiology, pathophysiology, and pharmacology of what is occuring and tell me the flaw in the logic of my conclusion. Don't roll your eyes, elbow your buddy, and then write about it on a message board, write a statement, send it to the medical director, we'll go over it. If you feel that strongly about it, be an adult, be a professional, and do the right thing. Commander Hunter of the USS Alabama gives a great example of what I'm talking about at about 2:12 or so in this clip. Watch and learn.

I think there's a couple of issues here. The first issue is one of a person being overweight, or not in sufficient shape to perform the tasks of EMS and the second is not conforming to what people expect of you. Particularly for women, there is a big difference between being "large" and being "obese". Being a large person means that you might be taller, have broader shoulders and a more masculine type frame. Since this does not coincide with certain people's expectation of feminine forms, so they are labled "fat". This is not obesity, it might border on being overweight, but it is not obesity, and so long as you present a professional appearance and can perform tasks adequately, of course there is no problem with it. In fact, I'd far rather have a female partner with a build like this, rather than the shiny little petite ones who claim to have mystical powers that allows them to "hold their own" in situations that would have a state trooper sweating and panting. On the other hand is straight out obesity, and lemme tell ya, America is having a real problem with it and I am really getting sick of excuses. I see what people eat, I see their lifestyle habits, I see what they feed their kids and it is really doing them damage. The problem is given the current state of EMS, a person of lax physical standards is often paired with someone of better physical standards, causing the person of better physical fitness to risk injury and overexertion due to their partner's state of fitness, and whether its being the aforementioned petite who is trying to prove something or someone who is positively obese who is already sweating before they make patient contact, its not right and I believe it is one of the many things that make EMS worse, because it provides negative reinforcement for those who keep physically fit. Why should I keep myself in shape if its just gonna get me more work for the same pay as someone who does not?

The best way to escalate the situation is to look the trooper in the eye, take the keys to the engine, toss them in the bushes and say "Fetch, asshole!" There will be much problems after that.

Get help, then find a new line of work. If one arrest is going to affect you as much as this one has, I would really suggest that health care in general is not for you.

The easy answer is for people to start being cognizant of their provider's hygiene practices an to stop being patients of people who don't comply. I've noticed that people's deep seated religious beliefs tend to take a back seat when they start losing money. Orthodox Jews are an interesting example of adapting your religious needs to modern life. For instance, at Mount Sinai hospital, on the Sabbath the elevators stops at every floor so that observant Jews don't have to violate sabbath rules about using electricity. But see, this is the key. They adapt their beliefs to work with the modern world, the elevators keep running, no one has to use the stairs, and they keep their faith. Its a good system. My view is that people can follow whatever cultural practices they wish, but if you want to live in the 13th century, then stay there. Don't expect modern conveniences if you don't want to live in the modern world. If you want an Ipod, modern medicine, and TiVo, then you have to give a little. Otherwise I'll be perfectly willing to send you a hookah for your entertainment pleasure.

For traumatic arrests, ours is pretty clear. It says in big letters "RAPID TRANSPORT IS THE HIGHEST PRIORITY" What I was getting at is personal theories about what the cold is going to do as part of our decision whether to remove or not is a good way to get your card ripped up. Stick with what you know, not with what you think. The doctor is going to not like your answer about exsanguination. He'll have read the headline in the local paper which says "MAN DIES AS EMTS STAND AROUND" and respond appropriately. He'll remind you that you BELIEVED that he might be tamponaded(?) by the truck, but you had to have KNOWN that anyone with this type of injury needed to be transported to appropriate facilities as quickly as possible, and in any event, ALS was not going to be able to help. Look, ALS is not going to be able to do anything about compartment syndrome of any consequence. Like I said before, normal saline, high flow oxygen, even high dose steroids, these are spraying down a house fire with a garden hose. He doesn't need ALS, he needs surgery. Put him on a snowmobile and haul ass if you have too.

I'm with Dwayne. If you let this guy lay in -35 degree weather for 50 minutes, you're going to have a lot of explaining to do. We are not going to sit in front of a doctor and say "Well, we thought maybe the cold would help." We don't go with our personal theories in the field. We have operating procedure. We have rules. We have rules that are not open to interpretation, personal intuition, gut feelings, hairs on the back of your neck, little devils or angels sitting on your shoulder. We're all very well aware of what our orders are and what those orders mean. They come down from our Commander in Chief. They contain no ambiguity. MR. HUNTER, I'VE MADE A DECISION, I AM CAPTAIN OF THIS BOAT, NOW SHUT F--- UP! Ahem. Sorry. Get the guy out of the cold and snow, get some tourniquets on him, and get him out of there. End of story.

Bigfire, I have to admit I've never visited Midvale, Utah. It sounds like a nice place. Apparently you have a very forgiving populace. Apparently, when you're in front of the city council answering questions about your response times "The reason we were delayed responding is because we had stopped the fire engine and/or ambulance to help with a flat tire" is an acceptable answer. I applaud your population's altruism and concern for their fellow man. Or maybe you've just never been in the situation where you have had to defend your actions on a run. Maybe you get to live in fun firemanland where kittens in trees need saving and we can use the tower ladder to trim Ms. McGurk's hedges if need be. Maybe you've never visited a friend in the hospital who was struck or injured at an accident scene. If so, congratulations, you have a great, wonderful, happy life and I hope it continues that way. For the rest of us here in mean realityland, remember, the first rule of operation is know what you are doing. Know the risks, and know the consequences, particularly if you are off duty. As for customer service, the way I see it, the public pays us to treat their illnesses or injuries, put out their fires, or arrest their criminals, and as much as we like to play the big burly big brother role, which we can, and help out here and there, it is not our primary responsibility and once w start putting that over our duties, ourselves and our patients and populace start to suffer.

I'd say either way the guy is f---ed in the a-- with a big rubber d---. ALS or no ALS, if he is going to exsanguinate from wounds that can't be controlled, then he is going to die. 50 minutes to a trauma center in the air means approximately 120 mins before he even sees the ER trauma team, let alone surgery. I mean, I've had people with these types of injuries die enroute to the hospital after an ALS team and an emergency response physician respond and treat on scene and the transport time is less than 10 minutes. This guy is pretty much dead. Large bore lactated ringers or normal saline won't help. High flow oxygen won't help. Tourniquets might help. If you want to be perfectly morbid about he whole situation I would say wait for ALS so they can give him a load of painkillers to get him nice and doped up before he meets his maker. Otherwise, pick 'em, pack 'em, and fire it up.

Not for nothin', as they say across the river, but I find a good knowledge of pathophysiology, pharmacology, anatomy and physiology, psychology, first aid, CPR, airway management, ambulance operations, and assessment skills usually are what's best for a patient. Not that having a good heart isn't a prerequisite, I'm just saying...

This is a fairly easy situation to deal with. I know that if you live in a smaller, close knit community and rely on XYZ volunteer rescue squad for patient care and transport that going the formal route is frowned upon, but in situations like these, it is absolutely necessary. First off, just because she is the captain of her squad doesn't mean anything. My joke about someone claiming to be captain of the squad is "Yeah well, I'm treasurer of my Dungeons and Dragons club, you don't hear me bragging about it." Don't let the titles fool you, the person responding is a state or nationally certified EMT, nothing more and nothing less. That means they answer to generally the State Board of Health, though you might want to check in your specific state, sometimes a state will put EMS under transportation or something silly. The bottom line is that the medical provider who responded to your 911 call was rude, uncooperative, and displayed a lack of knowledge of recognizing and treating extremity injuries in addition to failing to recognize the changes the aging process brings on the body, all key components of the EMT curriculum at all levels. This needs to be reported. Report it professionally and stick only to the facts, and then let the state take it from there. However, before you do, you might also want to check to see if you are a mandated reporter for elder abuse, and if so, make sure you file appropriate paper work about what you witnessed and what the patient reported before you file your complaint with the state. I know that we try and adhere to working things out without going the pen and paper route in EMS and probably the rest of the health care field, but as I get older and crankier, I find that it becomes more and more necessary. Yes, I have a duty to try and work out problems at a personal level with other providers, but I also have a duty to protect my patients and also to perform CYA procedures. I'd rather be the bad guy than hang for someone else's attitude or mistakes. The way I see it, you are a nurse legally responsible for the care and well being of the patients at your facility. You've pretty much written an account of witnessing poor patient care bordering on elder abuse of one of those patients. I would use that as your jumping off point, and let that supersede who is captain or married to which chief.