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Dee Barns, as far as I know is a singer who Dr. Dre (The rapper, not the doctor) slapped once, which is alluded to in Eminem's song "Guilty Conscience", but I don't know what that has to do with anything. I always consider it an honor when any doctor posts on this board, but especially you, Dr. Bledsoe, welcome. Honestly speaking, my interaction with aeromedicine is fairly limited, as evacs are almost unheard of here in the five boroughs. However, since my unit covers both the east and west side heliports, once in a blue moon we do a stand by and transport the final leg of an aeromedical transport to the appropriate recieving facility, almost all of which come in from New Jersey. The last transport I did had me scratching my head a little, and your post has shed a little light on it. New Jersey has two nonprofit helicopters run by the State Police, Northstar and Southstar, and they were the ones whom I was expecting to bring in the patient. To my shock, I saw it was a helicopter that had the markings of a private, not-for-profit hospital based ambulance group in New Jersey who I was familiar with. The patient was a 50 y/o female with an intracranial bleed who was intubated and sedated with a flight medic and a flight nurse that was being transferred from a local community hospital in NJ to a specialty surgery hospital in NYC. Now, having myself having done a great deal of critical care transports from NJ to NYC at one point in my life, one of which in fact was a smilar intracranial bleed, I was at a loss for why they had flown her. In fact, and maybe you or ERDoc or Doczilla who can correct me on this, I was told once that flying someone who had suffered a hemmorhagic stroke or similar brain injury can actually compound the risk of transport due to the changes in air pressure during the flight. I was unaware of changes in Medicare rules, but after reading your post its starting to make sense, and as usual, I am fairly appalled at what people will do for a buck in this industry. Me, I've never been a big fan of helicopters in the first place. I mean, if I came up to someone and said "Hey, I got an idea, lets land something with a jet turbine and blades that reach supersonic speeds that is loaded with highly flammable aeronautic grade kerosene into a freeway jampacked with commuters," I'd get some funny looks. Yet some people in this field look for excuses to do just that. Someone should take the roll call from the EMS memorial and see what percentage of deaths of EMS providers involved aeromedical operations. I recall doing a quick scan once and noting that an awful lot of them were popping up.

Ummmm, see newspaper article above?

Yeah, as NREMT said, there is no real definite 'critical' number for vitals, it all depends on the context... thats sort of the whole art of medicine thing... which I think nursing school is for... but who am I to say.

According to the legends, the paramedics claimed they were given orders to do so, but the doctor later denied giving the orders. I don't know how true that is as I'm pretty sure New Jersey uses taped lines in telemetry conversations. All right, I've actually looked into this now. Apparently this occured on 09/25/1997 and involved two paramedics from Jersey City Medical Center responding to a call in North Bergen, and from the newspapers I can find, the baby actually lived. Here's a copy of the full text of the story: N.J. Paramedics Face Inquiry Over Emergency C-Section By DAVID W. CHEN 9/27/97 The New York Times New Jersey health officials are investigating the actions of two paramedics who performed an emergency Caesarean section on Thursday to deliver the baby of a woman in North Bergen who was in cardiac arrest and could not be revived. The paramedics acted while consulting by radio with emergency room doctors at Jersey City Medical Center, officials said, but state health regulations forbid paramedics to perform surgical operations. The emergency workers said they believed the procedure was their only hope of saving the baby. The full-term baby girl survived but is in critical condition; the mother, who was 37, died. The two paramedics were placed on desk duty, with pay, pending the outcome of the state investigation, which officials said should be completed next week. "This was so unusual," said Dr. Leah Ziskin, the deputy commissioner of the state's Department of Health and Senior Services. "Our review is not complete." But to hospital and volunteer officials, the only thing clear was that the two paramedics were heroes, in spite of the rules. "These two people, a man and a woman, they've gone through probably the most traumatic situation of their professional career, so light duty is more than appropriate," said Bill Dauster, a spokesman for Jersey City Medical Center. "We probably didn't need the state to tell us to do that." The events, according to spokesmen from the Jersey City Medical Center and the North Bergen Volunteer First Aid Squad, unfolded as follows: At 5:30 a.m. Thursday, the North Bergen squad received a 911 call from someone in a residential neighborhood in the uptown section of North Bergen, saying that a woman was not breathing. Two volunteers, who were on the midnight-to-7 a.m. shift, arrived a few minutes later, finding the woman in cardiac arrest, with no heartbeat and no sign of breathing. They tried to revive her, said Mary Ellen Cleveland, the president of the first aid squad. A few minutes later, two paramedics from the staff of Jersey City Medical Center arrived at a house in the neighborhood from their base in Weehawken. The woman had still not been resuscitated; the baby was lodged in the birth canal. "They made a determination that she was dead," Dauster said. "And then they said, 'Oh my God, we have to do this."' In a telephone consultation with doctors at Jersey City Medical Center, the paramedics and the doctors made a "joint decision" to try a Caesarean section, he said. The two paramedics, both of whom were described by Dauster as seasoned, delivered the baby just after 6 a.m. The baby had no pulse at birth but was revived by the paramedics. Another ambulance from West New York then came to assist, and the woman and the baby were taken separately to Palisades Medical Center in North Bergen. The woman was pronounced dead at the hospital. The baby was later taken to Jersey City Medical Center. Officials said they had not yet determined what caused the woman's heart attack. Friday, a woman who answered the phone at Palisades Medical Center said the hospital had no comment on the incident. Dauster and Ms. Cleveland declined to give the names of the family, the paramedics or the volunteer emergency medical technicians from the North Bergen squad. It was the first time anyone at Jersey City Medical Center could recall such a case, Dauster said. But he added that everyone was proud of the paramedics. "What they did was step over what regulators have outlined for them into the moral arena," he said. "Most people are going to view this as an act of heroic endeavor; that's how we're viewing it." The baby, he added, was named Davida by the nurses at Jersey City Medical Center. She weighed about 10 pounds. I've looked everywhere for the outcome and I can't find it, I even looked at the websheet of shame that the New Jersey State Department of Health nicely puts out naming all of the providers who had their certifications suspended or revoked, and while I found the name of a paramedic I knew while working in Jersey got his cert revoked for diluting the morphine in North Carolina, I can't find anything relating to this case. However, it doesn't look like anyone is on the sheet of shame from before 1999, so if they had their certs yanked before then, they may not show up. ERDoc, if you are really interested in this case, I suggest you contact the EMS office in Trenton and see if they can give you the info. They usually are a friendly bunch and obviously revocation actions are public information, so they should be able to help you out. Here's there info: NJ State EMS office Department of Health and Senior Services P. O. Box 360, Trenton, NJ 08625-0360 Phone: (609) 292-7837 Toll-free in NJ: 1-800-367-6543 Our Locations Let us know if you find anything out.

I'm with Dust. CPR and haul ass. There were two medics in Jersey who tried the emergency C-section, the baby died, as did their careers as paramedics. Had the baby lived, well, who knows.

I say.

My advice: First Aid, good, very good. Focus on it as much as possible. CPR... in the woods... off of an ATV trail... eh, not so much. Well, I guess the heimleich/choking stuff but beyond that, I'd say learn to administer last rites instead.

I think NYC got bumped up a notch from 'crappy' to 'sucks' this year, citing improvements in communications. Excuse me for a second. Where's my soapbox? Ah, yes, there it is. Ahem. MY ASS WE'VE IMPROVED COMMUNICATIONS!!! MY RADIO STILL HAS PROBLEMS! SOMETIMES I FEEL LIKE GOING ON CALLS WITH TWO TIN CANS AND A LONG PIECE OF STRING! NOBODY HAS EXACTLY EXPLAINED WHY PD FREQUENCIES WERE REMOVED FROM OUR RADIOS, DESPITE IT BEING CALLED INTO QUESTION BY THE POLICE, EMS, DHS, FOX 5, AND JIMMY BRESLIN WRITING FOR NEWSDAY!!! HECK, WE'RE AT THE POINT OF FILING A LAWSUIT SO SOMEONE WILL EXPLAIN EXACTLY WHY IT HAPPENED! Okay, I'm done. I now return you to your regular scheduled programming.

WARNING WARNING WARNING EXHAUSTIVELY LONG POST AHEAD. ABANDON ALL HOPE, YE WHO ENTER HERE. Requested for BLS intercept on what was initially a "minor injury" call type. The first rule of EMS in my neck of the woods is that BLS does not call ALS for trauma for almost any reason. Given the fact that you are rarely more than 10 minutes away from a hospital, coupled with the fact our BLS defines themselves, their families, and certain parts of their religions on working trauma victims leads to this phenomenon. So, if a BLS is calling for ALS back up on a trauma, something very bad is going down. Arrived to find 19 year old mail in large pool of blood laying on numerous large shards of glass. Patient apparently somehow went through a 1/2 inch thick, roughly 6ft x 6ft sheet of exterior pane glass. Patient is in underwear, fecal incontinence noted, seizure considered, as patient is AMS and extremely uncooperative and combative. After much work avoiding getting cut to ribbons on the glass, give up on the idea of attempting to secure him to backboard and remove patient to stretcher, left arm has major injury to it, EMT bandages before I can get a good look at it. No other major injuries found, partner gets 14 gauge IV access while waiting for elevator, patient promptly rips it out. Did I mention this call is a mess? Initiate rapid transport, enroute, try again for an IV while EMT attempts pressure on arm. Again, get IV access, again, patient yanks arm suddenly and violently, and IV access is lost. Lungs clear bilaterally, confirmed no other major injuries, BP:100/P RR:22, HR:140,GCS:13 (patient using incomprehensible words). Now turn attention to the arm, which has completely soaked through the bandage. Upon removing dressing, left arm has found to have complete transection of all major structures of the arm except for the bone. I raise the arm up to attempt direct elevation (hope springs eternal), and also to get what is left of his biceps brachii to stop noodling out of his arm. I apply direct pressure to the arm, keep elevation, and then go for my approximation of the pressure point for the brachial artery. I then hand off this task to the EMT while I get the materials together for a splint, and I am starting to wonder if I will actually have to tie a tourniquet on this guy. Lucky for me, we arrive at the hospital before I can get to that point, and into the trauma bay he goes. Patient now has a BP of 90/P and a HR of 150. ER doc orders O negative and calls in a patient in Stage III hemmorhagic shock. Patient is sedated, stabilized, and sent to the OR. All right, so I'll admit it, this call caught me off guard. I've dealt with extremity injuries before. I've had old ladies deglove their hands and I've had overweight women with their leg fully amputated mid femur from a subway, and I've had patients on coumadin put holes in their legs, and up until this point in my career I've thought it was rather hard to exsanguinate from an extremity injury. I was wrong of course. Its never a good feeling being wrong. But, when I'm wrong, I go back and I learn as much as I can so I'll be better prepared for the next time. I reviewed my A and P for the upper extremity. Given the location of the injury, it was safe to say there was damage to the brachial, deep brachial, ulnar recurrent and radial recurrent arteries, which ultimately lead back to the brachiocephalic trunk that comes directly off the aorta, they are of course major structures which carry a lot of blood. An older physician at Roosevelt Hospital told me about a patient who was brought in on December 8, 1980 who despite being only 13 blocks away from the hospital when he was shot four times in the back, severing his subclavian artery, suffered 80% blood loss and died. (Plus five points if you can name the patient.) So, I'd like to weigh in with the EMS veterans here. If you wanted to sedate this guy, which drug would you prefer? Is there any anything else we can do for this guy short of tying a tourniquet? Is this type of blood loss excessive for this type of injury? If so, what kind of factors could lead to this? Actually, any input from anybody on this matter, I'm feeling much like someone who just got there basic patch in the mail about now . Dustdevil, my man, I'd love to hear your input on these types of injuries.

DT4, when I said the law no longer applies, I meant it as my own personal mindset. Of course the law applies always, no matter what. In these extremely rare situations, Flight 93 would be an example, or if some 250 pound guy has his hands around my neck and I see that cold black cloud coming down, I will do whatever is necessary, regardless of what the law says. I'll do the stint for manslaughter, I'll smile in the courtroom if the family brings a civil suit, but I won't be dead, and to me that is the most important thing.

I just think we should clarify a few things, because we've got apples and oranges all mixed up. It looks like there are three distinct scenarios we are talking about here, and what is needed and what the law allows are distinct for everyone. Situation 3: Violent or uncooperative patient needs to be restrained and taken to hospital involuntarily. The "continuum of force" should apply here, first should be professional or authorative appearance, etc. The more people, the better, a person will much more likely take a swing at two people than 6 people. Try to keep your emotions out of it, remember the person is (generally) sick, not a criminal, treat them accordingly, minimize injury to patient using soft restraints but remember safety of the crew is paramount. Situation 2: Physically confronted but not really in danger. I.e. while operating at a scene a drunk guy gets in your face then grabs you by the shoulders. This is the whole reasonable and necessary force thing. You have the right to pull him off you. You probably could even get away with kneeing him in the groin or smacking him in the face, but then you need to extricate yourself and call for appropriate resources. You don't have the right to then hold him on the ground and pummel him. A few weekend courses in self defense or non-combat martial arts like Akido can be useful for this. Or you can just get off your ass and hit the gym so you have the upper body strength to get people off you when need be. Generally speaking, things like kubtaons, mace, or retractable batons will only get yourself in trouble in situations such as this. Situation 1: Imminent danger of death or grievous bodily harm. This is a situation, in my own personal opinion, in which all bets are off. The law no longer applies, the only rules is to survive. Remember the mantra, eyes, throat, knees, genitals. Don't play fair. Do what it takes to survive, whatever consequences come later, you'll be alive.

The firefighters are standing around with a look of confusion mixed with terror is never a good sign. Nor is it when you hearing screaming and arguing in a language you can't even place let alone understand coming out the front door. Nor is it a good sign when five drunk guys come stumbling up you trying to give their version of events.

NREMT, between the volunteer squad cults, and the ALS provider monopolies, and not so brilliant ideas like Hackensack's trauma unit on wheels, Jersey's system is one of the most flawed in the nation. I've written several posts about it in the past.

Whit, I believe the theory is that since we don't have x-ray vision, a "near-drowning" should be considered a "complete drowning", i.e., water has entered the lungs if rescusitation efforts are unsuccesful, and so the Heimlech maneuver is attempted. That would be my guess. I also believe modern theory is to start CPR as they've found chest compressions provide as much or almost as much success as chest thrusts.

Okay, so now that we've made the difference: The legal way: The law provides for the reasonable and necessary force needed for a reasonable person to extricate themselves from a situation that provides an immediate threat to life and/or health. The other way: Male, 29 y/o is laying on a hospital bed in cuffs blowing blood from a broken nose all over the ER, next to an injured paramedic who is nursing nasty bruises to his person. Cop: "The subject was violent, intoxicated, he fell prior to EMS's arrival." Me, to injured paramedic's partner: "He fell, eh?" Partner: "Yes, prior to our arrival." Hope everything is clear. Stay safe.

WannaBe, you have to be a little more clear. Are we talking about what the law allows or what actually occurs if a patient attempts or succeeds at assaulting myself or my partner?

There may have been an error, there may not have been one, the sources aren't quite clear. What is clear is that in the event of an error, we would have taken immediate, direct action, and would have brought the error doers to justice.

You know if there is a t-shirt like this around there's a mullet and a gap tooth smile not far from it.

Thats it, State EMS director Michael Garvey is now on the list of short sighted and ill informed people that we shouldn't listen too. Rare heart conditions, I love it, yeah, I'm quite adept at treating hypoplastic left heart syndrome. It what I do in my spare time. This arguement has been done to death. Education is a good thing. You want the person working on you to be educated. Training is for the known, education is for the unknown, the current paramedic curriculum barely touches on the core levels needed to properly care for the sick and injured in the field. Extolling the virtues of the EMT-I program is simply a way for greedy, soulless people to bill ALS rates without paying ALS providers. I pray on everything holy that Michael Garvey breaks both femurs and has a two hour extrication time while his mother goes into cardiogenic shock while only his precious EMT-I's abound. That'll show him.

If you want my honest opinion, simple is always better. If you want to really make your artwork meaningful, in my humble opinion, look past the eagles and skylines and flags and such that we've all seen before, find something that really connects people to the event at a human level, and go from there. I think the idea of the patch is a good one, as it symbolizes the New Jersey response, some symbols of EMS might be good, steth, ambulance, etc. I think having an image of someone with one of the patched displayed helping one of the evacuees would be a good way to go.

A long time ago I wanted to be a doctor. Everyone who knows me says I should be one, but the truth of the matter is that I know what doctors do and go through, and honestly, it just isn't for me. Being a doctor kinda sucks. Ask any doctor. Sure, you get to have "MD" after your name and wear a cool white coat, but is putting up with residency, bitchy nurses, sleazy administrators, and then the stresses of patient care really worth it? I say, nope, not for me. Some people have an attraction to power and responsibility, but I never have. I take all my responsibility seriously (I do, really, you there, stop laughing), but the desire for more power and responsibility just isn't there. My father is a doctor. I see what he goes through. He works long hours and has a lot of stress. So, being a paramedic is just fine for me right now. I'm always attracted to learning and I love working with my hands, so there is probably some medical/technical something or other in store for me down the line, but I doubt MD will ever be there for me.

There right answer to this scenario is that there is no right answer. In a political philosophy course I once took, we discussed different ethical models for priniciples of government. One model that should be familiar to anyone who has participated in MCI planning is "The most good for the most people." That is, whatever decision provides the greatest amount of good for the greatest amount of people is the correct one. An example of this would be what the pilot of New Jersey's Northstar Medevac once told me about take off clearance: Just because they may get a critical call does not mean they get immediate take off clearance out of Newark. Just because someone somewhere in the Garden State needs to get to a trauma center doesn't mean that you can jam up the take off and landing schedules of all the flights on the eastern seaboard. The needs of the many outweigh the needs of the few. In this case, even if say we were succesful and didn't get fired after doing our pericaridialcentesis doesn't mean we are not going to at least knock our unit out of service for a good long time while the paperwork storm clears. As EMS providers we not only have a duty to our immediate patient but to all of our patients, and potential patients, to keep our units in service and running. The needs of the one (pericardialcentesis) cannot always outweigh the needs of the many (access to ALS services). The flip side to that is that you can't always justify everything that way. If you did, it would be perfectly ethical to execute an innocent man if it brought a sense of justice to the masses, the needs of the one (the innocent man) would be outweighed by the needs of the many (justice for the masses). Sometimes everyone else will have to just wait so that one person can get the treatment they deserve. Heck, I pride myself on causing some major traffic jams on that principle. This is why rules are so important, if rules were in place allowing access to pericardialcentesis in the field, then we could address the needs of the one without hanging ourselves and our unit out to dry. So, like I said before, there is no right answer, its someplace in that grey area in the middle. If you always follow the rules you'll end up sharing a seat at our next version of the Nuremburg trials, and if you break the rules and go with your heart whenever you feel like it, I'll see you shirtless and sporting a mullet on the next episode of Cops. Life is complicated, do your best.

For me, what it would come down to was how comfortable I was with my own abilities and what my relationship with the doctor was like. If he would be willing to guide me through it, and I knew the doctor and had a great working relationship with him, I probably would. When you talk about ethics and morals in this context, you really are asking whether it is ethically superior to always follow the rules or to not. There are many people out there, the police officer or soldier being a great example who would say "It doesn't matter what I think, it doesn't matter what is good in this situation, these are rules and as a member of society or a member of a profession, we are duty bound to follow them." We can come up with a great many excuses to justify our behavior when we break the law or break the rules, but honestly, when it comes down to it, breaking the law is breaking the law. Its wrong, always, end of story. Sure, you can bring up civil disobedience or whatever, but that is a different case. So, someone could make a great case in saying "If she dies, she dies, people die all the time, she had a medical condition that could not be treated in the field under existing protocol, and she succumbed. It happens all the time, every day, there is no reason to go above and beyond your scope of practice just because you think it might work." So, when I say I probably would, its because of my own personality, not because I think there it is ethically superior, but because of my own problems in dealing with the fact that I am not applying skill and knowledge that I possess to help someone who is dying. I, personally, could not live with myself if I didn't. I know it would be wrong, I know that I would not be doing anyone except maybe the patient a service, and I would do it anyway.

Does he seem hypoxic? Is the blue appear to be a cyanosis or a pigmentation?

First of all, give your brother my thanks for keeping us all safe. Secondly, from what I know, an EMT-B course can be compressed into as a little as three weeks. I remember my EMT course met I think like 3 times a week for 4 hours each, so it took about 10 weeks for the 120 hours. If you spend 6 hours a day and met every day, you'd bang out the 120 hours in 4 weeks. Please send him my best.