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Negative, CPAP is used only on alert patients, at least in my protocols.

Sorry flight-lp, but your views on antidepressants are outdated. Antidepressants are used by many healthcare professionals, including doctors and nurses everyday, and there is nothing in our job that is so different as to cause concern when taking them, Modern antidepressants have very view noticible side effects. I would much rather have a medic reach out for help and continue to function well in his job, then one to 'stick it out' and turn to illicit drugs or alcohol to cope. BTW, FAA rules not withstanding, I can bet a significant portion of my next paycheck that many commercial pilots regularly use antidepressants. Its not like you can piss test for them or invade someone's medical records.

I'm on the fence with it, and I'll explain why. First off, I have always believed that EMS should be primarily viewed as an extension of the hospital, paramedics are classified as "physician extenders" and training, ethics, and deployment should be viewed as such. My main arguement against volunteer based EMS systems comes back to this; when you go to the emergency room, you are not descended upon by well meaning unpaid people of varying degrees of skill, you are treated by people who are trained, certified, and compensated based on their competence and skill set. This is how it shoud be for EMS as well. That being said, I don't think the public safety/public service aspects of EMS can be denied. Of particular concern to me is that I know that both hospitals and municipalities will get away with as much as you let them, which includes denying extra benefits to cover the increased risks of working 911 EMS. If, say legislation was passed classifying paid EMS as simply physician extenders working outside of the hospital, you can bet that any service would look to align injury criteria and other benefits to the environments usually encountered by other medical providers. In other words, at the end of the day, if I had to be classified as a public safety provider and have a little extra coverage on my cute little tuckus, or be viewed as a health care provider and have the powers that be give no more thought to my risk for injury than a lab technician, I'll go with the public safety angle. Now, one could argue "Okay, well if you want to be a paramedic, than you just have to buck up and accept the risk," but, I say that if this is your philosophy, than you will only attract those in the population who don't care if they get hurt on the job, and you'll find usually they are the ones who have the 1200 bumperstickers and the stethescope on the rearview mirror. (Now we might have a problem, because as we all know that Dustdevil is always right, it is equally common knowledge that I am never wrong. )

Take your daughter to work day, maybe? "Okay honey, do you want to defibrillate the junkie?"

I guess, for me, yes and no. I try to limit my advice to pertinent medical information, give information or contact for social services, that type of thing. While social service is part of EMS, its not what I'm trained for, I refer them to professionals, and in my experience, those who truly want help seek it on their own terms. The only time I think I make a difference is when I give my "Do you know how stupid you are?" speech to the first time drunk young girl that we bring in. I think with a lot of them I hammer the point home.

My turn, my turn, my turn! 1. Don't ever lie to us, we will find out. A. Well, while you're at it, use your keen detective skills to figure out when the clutch is burning, too. 2. Girls are petty. Get over it. A. Guys like explosions and large breasts. Ditto. 3. You don't have PMS so don't act like you know what it's like A. On the contrary, I don't even act like I care. 4. If you talk about having a big dick, we know you don't. A. I only bring up the subject of penis with my urologist. 5. A system in your car only impresses your homeboys. A. If you call my friends homeboys, I get to call yours "Bitches and hoes" 6. Be spontaneous. Dinner and a movie gets old. A. Were staying home and watching TV. Surprise!!! 7. We are drama queens. Never forget that. A. I'm sorry, I can't hear you, I'm still deaf from the last yime you broke a nail. 8. We absolutely do not care about trucks, paintball, hunting, or anything else you and your friends talk about. A. A great big ditto for: What your coworker said about you The audacity of Cindy wearing the same shoes as you Shoes, in general Ponies Anything on the Lifetime channel Same goes for 'Oxygen' How the world would be better if women ran it (snicker) 9. Shave! No matter how cool you think your goatee or beard or mustache looks, we hate it. We like clean-cut men. A. Unfortunately for you, the "clean cut" men with the matching trimmed eyebrows and shaved chests you seek, usually aren't out looking for girlfriends, if you catch my drift. 10. We don't enjoy talking dirty to you as much as you enjoy listening. A. You should be glad you found something to talk about that interests us. 11. Size does matter A. Sure does, especially in the butt and boobs area. 12. No matter what you say, your ex girlfriend is a hoe. A. I know, and she f---ed like it, too. 13. No matter what you say, your friends are idiots. A. I'm sorry if we can't all get together for a pint of Haagen Daas, raw cookie dough, seabreezes and a video of "Hope Floats" like intelligent people. 14. If we slap you, you deserved it. A. Ever seen a pair of $500 pumps burn? 15. We don't want to pay. Be a man, throw down the cash. A. Prostitute, definition: A person, usually female, who uses sexual favors in returns for money, goods or services. 16. There are no signs on us that say "Stare at my boobs/butt" or "Grope me, I want it." A. If you advertise, expect people to want to inspect the merchandise. 17. Don't ask for a Guys Night then bitch about Girls Night. A. When guys go out and act like a bunch of teenage hookers, we'll talk. 18. Our friends know EVERYTHING. If we say we didn't tell about your little "problem"...we're lying. A. Good, tell them about my little "problem" with the cell phone bill then. 19. We compare you to our ex-boyfriends...and always tell you that you're the "best" . A. Considering your last boyfriend was the part time manager of a Taco Bell, I sure as hell hope so. 20. Don't expect us to look like Pamela Anderson if you don't look like Brad Pitt. A. Pamela Anderson is 90% plastic and has hepatitis C. Shoot a little higher. 21. We will think you are gay if you wear tightie whities on a regular basis. A. Well, we only think you've gone militant lez about once a month or so. 22. If you want head, give it. A. Why? A trip to the jewelry store works just as well. 23. Playing the guitar will help you get laid. A. If you want me to quit my job, sit around the house and sing about my sensitive side, just let me know. 24. Our Daddy can, and will, kick your ass. A. Not if I don't pay his bail bond, he won't. 25. We fake it. Yes with you. End of story. A. Next time, fake it with out digging your press ons into my back, k? And by popular demand... #26. Please don't ask: "Does that feel good?" If it feels good you will know. Believe us. A. Right, so you can accuse us of "not being communicative and responsive to your feelings?" Nuh uh, walked into that one too many times. ;)AND a new one! #27. Guys, don't EVER say: "Cramps can't hurt THAT bad A. Never ask us to stop for directions and we'll have a deal.

Well, for whatever reason, my sauces always taste better reheated the next day, anyway...

Okay, well, now that we have some answers, here's what happened. First off, the glucometer wasn't hers, it was one of her family members. She didn't take insulin, and according to her family was not diabetic, however, once at the ER, her BGL was 365. Anyway, I prepped to intubate with the BVM, while my partner got the IV, in preparation for transcutaneous pacing. After securing the tube and ventilating @ 12bpm, I noticed her heartrate is now an irregularly irregular 146, a recheck of the blood pressure produces 120/86 and she starts to fight the tube, so we sedate with 5mg diazepam and transport, lung sounds now produce audible rales, and a 12 lead showed some ST depression in II, III, and aVF. I have yet to do a follow up on this woman to find the final diagnosis, I'm not sure if it was purely a respiratory problem or there was some cardiogenic origin, but, the moral of this story is that her bradycardia, evidently, was caused by hypoxia. Prior to this, I was aware that bradycardia in children is almost always caused by a respiratory problem, and that of course hypoxia is one of the five H's in ACLS bradycardia/PEA algorithm, but this is the first time I had seen it manifest like this. The other thing that I wondered about in this case was her initial rhythm, it was a narrow complex bradycardia without P waves. Now, when her heartrate came back up, as I said before, it looked like a rapid A-fib, so I wondered if she was one of our elderly types that usually walks around in a-fib, is it possible a slow a-fib would look like a junctional rhythm? Maybe if I cook Doczilla some bolognese he can tells us the exact relationship between hypoxia and bradycardia and if I'm right about the EKG.

Done, done, done. She is making fish faces beneath the NRB, but she tolerates the OPA. As previously stated, she shows a narrow complex bradycardia sans P waves on the monitor. IV is in like flynn with a 250 cc 0.9% NS @ KVO. For the purposes of this scenario, your department is too busy selling T-shirts and making homoerotic calendars to bother buying the ambulance drivers ETCO2 detectors, aside from the plastic doohickeys for the BVM that look like they were found in a box of Frosted Flakes, and ditto for the glucometers. You're on your own, chief. Negative. Negative. Negative. Negative, See above. Yeah, they're all good and stuff. In fact, they're better than good. -Rapid trauma assessment, focus on ABD (?AAA) and distal pulses if palpable (?equal)

No, were not allowed to pour albuterol down the tube, but in some of the asthmatic horror stories I've heard from the Bronx, it has been known to be done on occasion at the ER. Now whether this is something you are actually supposed to do, I'm not sure, but in theory, any medication that can be nebulized and sent through the bronchioles should be able to be dumped in as well. I'm trying to find an article that says one or the other, if someone beats me to it, you win. But, once you are purple and AMS, by in large, aggressive airway is the name of the game. Even in a purple guy who has "I'm a junkie and I'm ODing" tattooed across his chest, as per my protocols, is supposed to be tubed before the Narcan. Now, everyone knows that is a bad idea, but it is what is supposed to happen. I suppose you could, say, go CPAP, nitro, and Lasix for an APE, but at least my protocols say that CPAP is only for someone who is alert. So outside of clearing and airway with the heimlech, or bagging and narcaning, purple + AMS = tube.

You are called to respond to an 82 year old with reportedly difficulty breathing. Wait, a minute, you know, don't the textbooks start out with a little story? Let's make this more interesting. You and your partner are settled in with your plate of perfectly seasoned pasta bolognese, you even went all out and used pancetta rather than bacon and scrounged up some tagliatelle pasta, and the station is still heavy with the aromatics you used in the soffrito. As you tuck your napkin into your shirt, just before the first morsel of pasta hits your mouth, you recieve a call for an 82 year old with difficulty breathing, and you and your partner head out into the dark and stormy night, with the wind howling and the usual suspects lurking about. After a 10 minute curse word filled response, you arrive to find said 82 year old female sitting upright with family, pale cool, diaphoretic, with slow, shallow respirations, who moans when you speak to her, sitting next to a home glucometer. As per the family, she has a history of asthma and a heart murmur. She had complained of mild difficulty breathing and asked to use her inhaler about 30 minutes prior to calling 911, and now is in the current state. The family seems strangely calm about the whole situation. Physical exam: PERRL, lips pale, skin pale, cool, diaphoretic, respirations shallow, slow, negative accessory muscle use, equal chest expansion, lung sounds difficult to hear, but with mild expiratory wheezing, abdomen soft, non-tender, negative incontinence, pulse present, weak in extremities, negative edema, negative obvious DCAP-BTLS. Pulse: 46 and regular, BP: 62/P, GCS: 5, SPO2: ??? (pulse ox cannot detect). EKG: Narrow complex bradycardia with no P waves, probably junctional rhythm. Okay, so the question is, if you decided to say "to hell with procedure and protocol", and your medical control doctor gave you carte blanche, and you could do one thing with this patient, what would you do? A. Sedate and pace B. D50 IV. C. Atropine 0.5mg D: Eh, make that 1mg Atropine. E. Sedate and intubate. F. 500cc fluid challenge. Starling's law, baby! G. Dopamine 5ug/kg/min titrated to effect H: Dopamine is for wussies. Gimme epinephrine 2ug/kg/min or give me death. I. Say "She's 82, lets go finish our pasta"

I'm going to jump in here for a sec. Okay, because my eyes glazed over reading the back and forth, I'm not sure if I'm right here or not, but basically, this guy is turning purple and we don't know why. First off: Purple people get tubed. I don't really care why they are purple, barring a grape soda accident, or a recent episode of old fashioned wine making, purple = cyanotic = tube. Yes, the mechanism causing the cyanosis is extremely important, and after I get them to stop turning purple I will use every single Dr. House trick of the trade I know to try and figure out why they were purple, so long as it doesn't interfere with timely transport. It doesn't matter if they are asthmatic, emphysemic, have a pulmonary embolism, foreign body, traumatic asphyxia, pneumothroax, APE, or diaphragmatic hernia, they are getting tubed. Even if they are blue because they are hypothermic, given their depressed LOC, they're getting tubed. The only way they are not getting tubed is if for some reason we have to go to the cric route. Then we can go for our survey, our neurologic exam, etc. In the case of status asthmaticus, yes, you can attach a nebulizer to a BVM. Of course, you can also pour albuterol or even epinephrine directly down the tube if your protocols permit. At the purple stage, nebulized meds, in my mind are like a band aid on an arterial wound, right concept, but not effective enough.

This issue has come up before, and its one of the points in EMS that needs vast improvement, and that is the overall professionalism and maturity level of the service. EMS is a young service and it has its own growing pains, and like insecure high schoolers, we tend to follow the "gossip and backstab your way to acceptance" model. I I realized this is how it works at an early stage in my career, so I followed the good advice that the WOPR computer laid down in the classic movie "Wargames": The only winning move is not to play. Don't consider the people at work your friends, consider them your colleagues. If you are friends with them, great, if not, oh friggin' well. Do your job, take some vitals, treat some patient, stock, restock, and keep it clean, watch some TV, get your paycheck, then go home, where your social and personal life should begin, not end. Now, if the powers at be only selects "the cool kids" for advancement, this can be a problem, but at the end of the day, if you truly have the knowledge and skills needed for advancement, and you are not moved on, you work for some lousy people and its time to work some place else.

Ahhhhh MONOC. Rule #1 of EMS: Don't do anything stupid Rule #2 of EMS: Especially don't do anything stupid while being videotaped.

Aggressive fire response, the hallmark of the FDNY. Not necessarily intelligent fire response, but aggressive nonetheless. The building should have been torn down years ago, but it still stands. The only thing I can say is that the firefighters did not die in vain, attention is now being called to this abomination; who knows, maybe their sacrifice prevented one of the thousands of daily passersby from getting injured or killed. The real story is one we've all heard before, about a government owned building having deficiencies that would land a private owner in the slammer, and about certain unions who insist that buildings are demolished floor by floor rather than one controlled implosion, which is the now standard practice elsewhere.

Ones 911 don't want? Wow, lol, that's some mighty interesting coverage you have there.

As has been posted before, the idea of a medic fly car is good on paper. In practicality, there are many problems. The main problem, of course, is the response of the BLS. If you are in a rare system where BLS is on the ball, it all works fine and dandy, the medics can free up and go to calls that require them. More often times than not, however, BLS is either part of a hit and miss volunteer system (yes, boring old sick calls need to be transported just as bad as the real cool smash 'em up MVA does), or the BLS is a paid service that, well, utilizes, er, many times less than qualified staff, where your check list before transport ends with "checking the to make sure patient's wallet is intact" to finally "checking to make sure your wallet is intact." Basically, what it boils down to is that an ALS transport unit does not tax resources appreciably more than a BLS transport unit does. So, if a system can reliably get a BLS transport unit to a majority of its calls, 9 times out of 10 it can get an ALS transport unit there too, and as a collolary, if a system has trouble getting ALS transport to the calls that need it and requires PRU's, it probably will have problems getting a BLS unit there too.

You never heard of the baby drop test?

I think once 3 rescuers get killed, you say enough is enough.

Anyone know how the feds got the 21 year statute instituted in the first place? Although it was the time of Ronnie Raygun, who was supposed to be all conservative and in favor of a smaller federal government, basically they trampled on the 10th admendment by threatening to revoke the federal highway funds of any state that didn't comply. A couple of states banded together to fight the pretty much outright extortion in court, but they didn't win. I think Louisiana up until fairly recently was the lone hold out who said "keep your f---ing highway funds", but the rest of them caved. In case anyone fell asleep in social studies class the 10th admendment is the one which leaves all powers not spelled out to the federal government in the constitution in the hands of the states, and the constitution says nothing about age limits for drinking. Of course, it doesn't say anything about slavery either, and I guess some states had an issue with that too, but, well, we all know how that went.

Personally, I think that anytime you dial 911 you should get somebody who is municipal based. Sure, the government is generally incompetent, wasteful, and corrupt, but some things they are in a better position to provide for than private companies. Personally, as much as I love capitialism, and I do, trust me , I never thought healthcare and capitalism were a good mix. I mean, if you sell someone the extra Scotchguard on their new car, that's just good business, but if you convince someone to get a surgery they don't need or to take a certain drug because of your advertising abilities, I think that's just really wrong. Private ambulance companies put profit first, patients second, and employees last. No one, except maybe the shareholders or owners, makes out well. The thing about EMS as a municipal service, despite it being far cheaper to run than a police or fire department, is that the benefits to the municipality are not readily apparent. A police force increases commerce and property values, as does a paid fire service which also usually gets homeowners a break on insurance policies. EMS, well, as said before, ambulances are seen as a nuisance, and the community doesn't benefit just because we happen to keep their population from dying untimely deaths. However, in the long run, I do believe that a properly run municipal based EMS service provides the best, most efficient patient care with the best accountability.

I say take it down at night, but only after a full flag lowering ceremony with a bugler playing taps and a color guard procession. After a few nights of this someone will break down and buy a damn light.

Etomidate works well for facilitated intubation, and by some weird quirk of law, its not a controlled substance. The two biggest prehospital concerns, in my opinion, are its viscosity and its relatively short duration of action. If you look at the bottle, the solvent is propylene glycol, which is also used in antifreeze. As per my medical director, this makes it even more viscous then D50, so, in other words, make damn sure your IV is good before administration. The second is its relatively short duration of action. I can't rattle the duration of action off of the top of my head, but from anecdotal experience, it is not very long. In my opinion, a person should not be intubated without a following dose of a benzodiazipine. When we first got our etomidate, as the story goes, a telemetry doctor granted the etomidate but not diazepam, and, well, the story ends with a paramedic nearly losing his finger to the teeth of the patient. Otherwise, its good stuff.

Be forewarned, this test is part of one of my insidious plots, and anyone scoring above 85% will be targeted for termination...er I mean...reeducation.

I haven't taken the NR paramedic test yet, but I'm going to get around to it. I did read through a NR prep exam however, and there wasn't anything mind bending about it. Practical testing is always the b**tch. They don't test your knowledge or skill, but only how well you can memorize the sheets. I could make the procedure for making a cup of coffee difficult if I wanted to, it doesn't mean its a particularly difficult task. I think the majority of veterans who fail the practicals are of the "I know how to do that" mentality, and you know what, they're right, they do know how to do it. Knowing the NR's BS about when to reassess the distal vitals and maintaining of this and that, well, that takes some practice I mean if a practical test was really a "practical" test, board and collaring would be something like 1. Maintain head stabilization. 2. Apply collar. 3. Move patient onto board carefully. 4. Strap down. 5. Fix any screw ups. 6. Transport. Instead I think the skill sheet is like 10 pages long by now.