mobey

That was a one line answer, offered twice! Subtle Doc, but genius!

This is yet another great topic. It has long been the idea that providers taking pics of crash scenes and making statements to the press is some sort of violation of a law that no one can put thier thumb on except to say "HIPAA" or "FOIP". The reality is, to provide pictures of an accident to the recieving Doc is a great asset! I do, and will continue to, snap a pic with my iphone, and email it to the recieving physician at the trauma centre. Now there is a moral/ethical dilemma one must face before spreading said pic to all his friends.... but hey, we are professionals, so that should not be a problem. However, if you do not show a license plate, patient, or give a name.... it is just a smahed up car!

EDIT to add: As I suspected: http://www.ncbi.nlm.nih.gov/pubmed/2039096 MAIN RESULTS: For the blood donor group, mean capillary refill time before donation was 1.4 seconds and after donation was 1.1 seconds. Mean capillary refill time for the orthostatic group was 1.9 seconds and for the hypotensive group was 2.8 seconds. When scored with age-sex specific upper limits of normal, the sensitivity of capillary refill in identifying hypovolemic patients was 6% for the 450-mL blood loss group, 26% for the orthostatic group, and 46% for the hypotensive group. The accuracy of capillary refill in a patient with a 50% prior probability of hypovolemia is 64%. Orthostatic vital signs were found to be more sensitive and specific than capillary refill in detecting the 450-mL blood loss. CONCLUSION: Capillary refill does not appear to be a useful test for detecting mild-to-moderate hypovolemia in adults.

Are you suggesting we tube Patient #1 and send it BLS? Or hang some sort of ALS "drip" on patient #2 and send it BLS? BTW: We can call NaCl I.V.'s a BLS intervention for this scenario... just to keep it comprehensable

Sorry, left out a few details there... Mixed crew, there is only 1 Paramedic on the scene. Fire is not trained medical. Transport time is 30min to a small town clinic. Trauma centre 3+ hrs out. Helo is out of service. (ya... we only have a few here, and sometimes.... well often, they are not avail)

usalysfyre: I agree with your post and would like to add to it if I may. Trismus is not always an ominous sign, it is caused primarily by brain injury (5th cranial nerve with roots in the pons), but can also be a result of a Zygomatic (sp?) arch fracture resulting in "activation" of the masseter muscles, forcing a "clenched jaw. BTW: would that still be true trismus? hmm (forgive the grade-school terminology & spelling tonight). You are dead on with the Versed and MAP thing. I really really like my head injured patients to maintain a MAP = or >80. Why you ask? After much reading, and podcast listening... that is just where I am at. 65 for everyone else. This is where your etomindate, or as we have, Ketamine comes into play. I once assisted in a RSI of a C0 poisoning, we gave 15mg Versed, and had to bolus the otherwise healthy guy back to a normal BP.

We can run this out as a scenario if you guys want, but I am just looking to see who chooses which patient. After your choice, give me your initial stabilizaton treatments and level of cert, I am interested in all level's opinions. Scene: Single vehicle rollover... car unrecognizable. Vollie fire on scene. 3 patients, all ejected No helo out here. Fixed wing 1hr away There is 2 crews responding. 1 ALS, 1 BLS. You can be whichever crew fits your cert level. No more backup (love rural EMS) Patients: Patient #1 21 y/o male, lying approx 10ft from car, UnCx snoring resps. Accepts OPA. Possible Fx left wrist. Vitals normal. Sp02 99, EtC02 33 (sidestream) No other injuries to report Patient #2 19 y/o male lying directly beside Patient #1 (nearly spooning). A&O x4 though lethergic. Complain of parastesia from waist down and severe mid-back pain. No loss conciousness, no resp difficulties. Vitals BP 84/42 HR70 Negative babinski reflex, No pain responce at any level in his legs. Patient #3 DOA So the question is: who goes ALS, who goes BLS?

Ya: 15mg/kg is where it is at for me

Any enlarged lymph nodes? Blood in sputum? Excessive sweating? Night sweats? Up to date on innoculations? I have no idea what you guys are up against as far as disease over there, but I am sure TB is an issue.

Why are you being rejected?

Absofreekiglutly! This is a HUGE problem that many rural providers and employers are really quick to sweep under the carpet. The old volunteer mentality still exists in some areas and it discusts me. Periodical review as well as strict con-ed format is an absolute must in my opinion... This should have it's own thread

I did not intend for my posts to reflect the idea that a rural provider is "better" in any way. I will admit though, they soon got that way as I was typing through anger in response to the assumption that rural medics have weaker skills or less competence due to low call volume. I think rural and urban providers have very different jobs. For the most part an urban provider faces high call volumes, violence, long hallway waits, and degredation from patients. (feel free to correct me if I am wrong as I have never worked in a city over a million people) A rural provider faces: Treating friends/neighbors on a regular basis, long transfers with/without critical care, lack of resources, living the "lifestyle" of on-call. Of course we each have perks too. The question of wages should not be based on call volume alone, when we obvioustly have such different jobs. The wages must be set for certifications/diploma/degree. If we start setting wages based on calls, based on the idea that more calls = stronger skills, then why wouldent we be paid per skill used per call? The answer is simple... this is not a "trade", this is a profession, and you are paying me for my education.

Wait a minute......

Good then, I'll help you out with this reply as I have put my 3 to bed. I was rushing to type the message while trying to put 2 kids to bed, a 3year old, and a 10 month old, sorry bro. But I do see were you are coming from and I'm all about feed back, it makes a person learn and do better. It would be helpful if you took a college level A&P course to start. Not only will it put you're brain in "student" mode, but will give you the best foundation possible to build your degree program on.

questions for the people who think we should be payed less in the rural, although I am short on tiime: If we are justifying lower wages in the rural setting by saying skills are weaker because of low call volumes, aren't we showing a level of acceptance for the crappier patient care? Is every provider in a rural setting weaker at specific "skills" than thier metro counterpart? Is there any data/studies showing minimum repetition numbers to keep ones skills in the "competent" column? If Metro workers come out to the rural, are they entitled to a higher wage based on the "superiority" of having a history of multiple short emerg calls compared to the rural counterparts? Can a city EMT (especially on an ALS car) be "weak" as far as skillset of competence is concerned? BTW Siff: Rather than tell off a STARS medic, I have a few on Fb. I'll ask them if Metro medics are superior to Rural medics, being sure to mention things like infusions, transport vents, antibiotics, blood transfusions, chest tube complications, you know..... that stuff we see during our long critical transports here in the remote setting. Again, not saying we are superior out here..... just sayin we all have our strengths/specialties. Dwayne: As per your Salary post. Seems as though you are punishing the whole for the actions of a few. Check out this model. Every Medic starts at $25/hr and tops out at $35/hr. There are incriments or "steps" that a practitioner moves up usually annually based on job performance and continuing education attendance. If one does not qualify for his anuall "step" increment, they are given 90 days to correct the deficiency then reviewed and or disaplined as necessary. Yes, this depends on quality management... that is another thread. In this model, those shitty employees get left behind, while others excel. Also, it is fair for all based on education/attitude/competence.

Our system is not unique, just comment on the principal of paying based on call volume Dwayne: I can say that it would look bad if I ran my ass off day in and day out and then saw another medic that runs a few calls a month get paid as much as I do. And the two gigs are so completely different. You are paid to run calls in the city, where rural areas are more buying an insurance policy. They don't expect daily performance, but excellent performance in the rare times it's needed. You're doing it again..... Starting typing before forming a solid opinion, therefore coming very close to contradicting yourself! Also, you gush over the people that have come before you and have made your job and wages what they are yet tell Mobey what a douche he is for doing the same, as you see it as coming out of your pocket. Where do you think that the money came from that increased the EMS standards in your area? Must say that in this job I am at now I: Placed the call to the union and got them in Did all negotiations myself and settled a contract Convinced the employer to go ALS Budgeted ALS, ordered all equipment, stocked the rigs, trained the staff, and scheduled the inspection for license upgrade I am curious as to what exactly Siff as an individual has done to earn these "perks" she is enjoying? I hate any system that pays based on a set salary. Every position should be merit based... Care to explain? Pretty simple solution to your anger really...pack up and move to a rural place. Make the same money for doing much less work and all should be right with the world? Don't make me fly to Mongolia and smack you

I find it interesting that you comment on how it is in a rural service when you've never worked in Calgary or Edmonton. Point taken, The largest city I have worked in was 25000 people, covered by 2 ambulances. How you've described a night in the city pretty incorrect. Firstly, there are very few 12 hour shifts, most nights are typically 14 hours. Secondly, due to the fact that we are understaffed for the volume of calls that are coming in, most 14 hour night shifts average at least 8 or 9 calls now. My record to date is 12. Edmonton for instance is now #1 in the country for murder, and several violent crimes don't even make it into the paper. Thank you for the clarification, my point made remains the same I don't think it's appropriate for you to know or understand what goes on when you've never worked in a city of a million. Point taken...... again. Thank you for reminding me 25000 is not a city Why didn't rural staff try and unionize before? Perhaps those of us who started small and still work small should have done that before. Then maybe we wouldn't have "scraped by". If 3 years ago you wanted to be paid more and realized it wasn't going to happen where you were, why didn't you make the move? Because I do not run from my problems, I progress the profession. I have unionized and negotiated 2 contracts at 2 different services. The last one i did I got us a 40% increase with retirement package and brought ALS to the community. And it's not that there's "equalization" going on. It's that they are preventing several from receiving raises until others catch up, Pretty sure that is the definition of equalization In fact, I've give you my next paycheque if you walk up to one of the STARS medics and tell them their critical care skills are shit. You appear to know it all so it shouldn't be an issue for you. Wow..... just Wow

The spirit of the thread is not "What does your service pay?" I would like to hear your opinion/rationale on paid per call, or paid per education. RaceMedic: If the rural service is paying more but still has no volume how do you keep skills? Just to clarify, I am talking about wage parody. Both make the same. A Paramedic is a Paramedic no matter the setting. Ahh yes... skills.... This is another infamous argument made by the urban fans. The problem of skills in the rural setting is a real one. I would love a thread where we discuss the upkeep of skills, and how each service does so. But in keeping with the direction of this thread, I will turn your question around to ask: If a few rural services do not take steps to ensure competence of thier providers, should we hack the wages of all rural employees and label them as having weak skills as justification for taking pay away? RaceMedic: The busier city job is still more attractive do to actually getting to treat patients. Maybe to some, I RSI'd an overdose a couple weeks ago, then transfered her into the city with Dopamine running, pushing bicarb, and continuous sedation/paralytic. The transfer was just over 2 1/2hrs. Don't get to do that in the city. To be fair.... that is all I did in 3 days though Oh, BTW: On the topic of skills..... are we certain that a "inner city" medic has the skills to run critical care transports for hrs on end? How often do City Medics run transport vents for more that 15min? Nitro drips? Initiate blood transfusions? Use PEEP/CPAP for extended periods long enough they can actually do damage if used incorrectly? Interesting. Should the hiring process be different? Oh... You mean like a Profession?

I was recently having a debate with another member about wages. I won't get into the local details, but here in Alberta, the city wages are nearly frozen while the rural wages are skyrocketing. This is a result of the entire province unionizing. Previously, the City's were great paying jobs, and the rural staff barely scraped by. So we are really just equalizing wages at this time, which is really upsetting the City medics. So the opinion that I have found quite common coming from the city medics, is that us rural workers do not do enough calls to warrant wage parody with the city workers. My opinion is: we should be paid based on education and job title, NOT call volume. We do entirely different jobs. eg: A city worker may do 2 ETOH, a code, and a chest pain in 1 - 12 hr shift, then go home and shut the radio off for the night. Last tour I did a 7hr old female with increased ICP that had to be rescusitated, then managed for the 3.5hr transport, then go home and remain "on call" for the next 48hrs straight. True enough, that may be the only call I do, but why should my annual income be any different than a city workers? We do totally different jobs.

Great scenario Gulf thx. To begin discussion I will point out that many many times with pts whom cannot lye supine for various reasons I have used a KED and leave them semifowlers on the cot. I also like it for chest injuries because you can splint the entire chest when you are faces with bilateral fractures.

Oh good! I get to disagree with Dwayne I dont need to comment on the sedation thing because the OP knows the Captain was wrong. An elderly female who spent (probably) all day working to breathe, using everything her intercostal, abdominal, and diaphram muscles had finally becomes so hypoxic and fatiged her body "throws in the towel" so to speak. Intubation (RSI) of this patient is absolutly indicated, those muscle groups are totally wiped out and need some recovery time, not to mention, her fragile old heart is hypoxic and has probably just worked its ass off. I say, Intubate, paralyze, cool, correct the acidosis, and let this patients cardiorespiratory system recover before waking her up again. We are not talking about a COPD exacurbation anymore, we are talking about post-cardiac arrest care with respiratory failure. http://circ.ahajournals.org/content/108/1/118.full

Just wanted to recommend this for any Paramedic out there interested in expanding your knowledgebase. I get frustrated with the "other" ones since it is 30mins of ads and horseassing around, followed by 15min of good info. Emcrit is an ICU Intensivist that works ER. Really good stuff. Anyone have any other fav's that actually provide medical info?

Only way I have ever done it is with humor. There are some good pics out there of boogers flying during a sneeze, as well as a "mist cloud" around a person wearing a nebulizer.

Alot of practitioners I know are taking the one at Medicine hat as opposed to Lakeland. Dunno why, just an anecdote for ya to check into.

I have heard of D5W being infused in dehydration with hypernatremia under the theory that the body will use up/store the dextrose, leaving free water.