croaker260

There is an ages old expression... When you have seen an EMS service...You have seen ONE EMS service. Meaning that even services that are right next to eachother or even overlap, can be completely different.

Croakers Sweet Meat ( a pulled pork recipe) Stage one: 4 pounds of pork shoulder/loin/whatever in a crock pot. I have used beef too. Add (all mixed together: 1 can of conc. OJ 1/4 cup of balsamic venigar 1 tbs kosher salt 2 tbs pepper 2 teaspoons chipotle pepper 1 teaspoons red peper 2 shots bourbon Water to cover meat in crockpot (2 cups minimum, but more is OK) Cook on low for at least 5 hours , though I have cooked stage 1 for 12 hours with no problem Stage 2: Drain meat, pull it apart into strips with fork, it should fall apart easily. Then put back into crock pot. Add : Add 1 can of conc. OJ 1 teaspoon pepper 1 teaspoons chipotle pepper 1 tsp red peper 12-24 oz favortite BBQ sause and cup of water Honey and Bourbon to taste cook on low for at least two hours, but it will go as long as 18 hours cooking and be awsome. NOTE: Because of the obvious problems bringing burbon into a station, I mix it up at home , cook stage one overnight before work, do stage two just before leaving for work in the AM, and let it cook in the station until ready for lunch or dinner. Today I left the burbon out of stage 2, it was still very good though the "bourbon" smell wasnt as obvious (as it was last year). At home I prefere it as noted above. NOTE #2: When I use beef, I actually prefere replacing the Orange juice with apple juce concentrate, and apple vinigar instead of basalmic, and use a touch of cinnimin too. I will use maple syrup or pancake syrup instead of honey with the apple. Other than the cooking...which is hands free in the crock pot, the prep takes only about 15-20 minutes tops. Sorry for the typos, its very late.

I like Dubins for an introduction to EKG's, though once you master this there are more in depth books. None are better than Dubins for learning the basics. Guytons pathophysiology is an excellant rescource. Hudaks critical care medicine is good too, but may be too much for just getting through your school. Guytons (or a book like it) should be bedside reading. Walls airway management text for...well ...Airway Management. None better. I think most paramedic texts are rubbish in general for paramedic level classes, though I have used them at the EMT-I/Advanced level. I have used multiple specific texts when I have taught, which was the way my own paramedic school was taught..so I guess I am biased.

Agreed. We used to carry it here in the late 90's, until we decided that it ws far better to intubate them than giving Romazicon. As a general rule , isolated benzo OD's are best managed supportively. If its a poly pharm, then the Benzo's are doing way more good than harm, and again supportive/airway management is the order of the day. similar to narcan, you can cause more problems than you solve with poly pharm ODs and romazicon. A little side note: Anyone know what the ORIGINAL brand name was (before ROmazicon?). Reversed. Say it slowly...Re-ver-sed. get it?

Pink Eye....by a young adult male, while his friends with vehicles played Xbox and he was ambulatory to meet us (while smoking a cig).... He was actually pissed because his friends were hogging his Xbox... Tell me that is not BS. I wont tell you how it ended or what I said ........... but it wasnt pretty

Thats considered cheating for this exercise, and will get you a massive load of ribbing on thanksgiving day shifts by your fellow crews....

Hey I subscribe to Pattons view on cursing, and if I want to curse AT someone, all I have to do look around here without getting online. HOWEVER, if I want good discussion and debate then this is one of the places I would like to go, and in this venue cursing AT each other gets in the way....( now cursing ABOUT SOMETHING is a different thing altogether.... ) Just saying...

OK, at my service, for as long as anyone can remember, our supervisors have coordinated a real on duty thanksgiving dinner. Extra crews to cover while crews ate, deep frying/smoking/roasting turkey, all crews bringing a dish to share as well. This has grown from the "old days" of only a few stations county wide into several different dinners at "central stations" covering around 15 different units. Anyway, the dishes are somewhat diverse with some crew members trying to outdoo eachother. We get some real tasty dishes.... Anyway, with this in mind, perhaps you do something similar where you work. If you do, please share some station-safe recipes. By station safe something you can cook and walk wayfrom if you get a call, or something you can prepare at home and cook quick-like and low fuss on duty. Not simple only for yourself dishes but something for all your crews in a big dinner situation like this. I'll share mine in a bit.

Well I didnt offer it as a comentary about the parties involved, though that had crossed my mind. I offered to provoke thought on what would be a reasonable and realist circumstances where you may encounter this, and what a reasonable solution would be, without us cussing eachother out in this thread. BTW, I like PA's protocol.

SLOW DOWN EVERYONE, let me share a HIPAA safe incident from a galaxy far far away.... Hopefully this will negate some of the arm chair quarterbacking..... In this galaxy, a couple of medics were working a code. The patients partner/Spouse/SIgnificant Other/etc (NOT THE PATIENT) had a service dog. In the course of the call, the patient had ROSC but was very unstable, intubated, hypotensive, etc and was fully expected to code again. The other party was invited to ride n the MICU (in front of course). The service dog was declined. There was simply no way to safely restrain the dog int he front for the safety of the driver/operation of the ambulance, and the BACK of the ambulance was already chaotic enough without adding an animal. Additionaly, in this case the crew had 3 people in the back and there was physically no practical room in this case. Ironicaly, I believe there wa alternative transportation on scene but the party declined it. A civil rights suite was filed, and a number of policy changes came out of it. ADA sent investigators out and they physically crawled in the back of the ambulance, interviewed the medics, etc. It is my understanding that the inviestigators from the ADA found no specific fault of the medics due to the circumstances, but did recomend that we could offer alternative transportation (i.e. with a supervisor, LEO, etc) should it arise again. I am not sure if the suite was found without merit, or is still ongoing. I have not heard anything further about it so I am Fairly sure it is dead in the water.

File Name: Opioid Review for EMS providers File Submitter: croaker260 File Submitted: 22 Nov 2011 File Category: Misc Files This is a comprehensive overview of Opioid abuse and use, and treatment for EMS providers. Covers what everyone should have been taught in Paramedic school (and probably wernt) and more! Click here to download this file

Approx 22K per year, Our sevice area for each unit is pretty diverse so calls per shift is highly variable. We have both 12 and 24 hour shifts. The most I have ever worked in a 24 here is 18 (the most ever I have worked is 23 at another serivce). I woud say that between 6 and 10 calls a 24 hour shift is average during the winter months (except for the first ice on the highway days, which are stupid busy) and bewteen 8 and 15 during the summer months.

As a side note: Some of the symptoms your son is manifesting also sound stress/depression related. Having a major medical condition, the repeated MD visits, and decreased activity (plus what sounds like some inter-parental strife...just assuming here).. these are all issues that even grown adults have problems with. ….any one of this can contribute to the math issues, the lying, the fatigue, the vague symptomology..sounds like a little counseling may be in order on top of the ongoing medical follow up.

n 1995 before I landed respectable paramedic Job, I had just ETS-ed from the Army and had my fresh medic cert in hand. Needing money I applied to one of the large privates in Nashville. (and was hired, no real interview, no FTO or orientation...my first of mutiple red flags about this company) This company did in the neighborhood of 120 dialysis transfers a day alone. You were issued TWO sheets Each sheet was expected to be good for 4 patients if you flipped them right. If you needed more sheets you were honestly expected to swipe (aka STEAL) them from the hospitals any way you could. Now keep in mind I have worked every day of my life almost since I was 15. I had never walked out on a job before or since. but based on this and other things I saw there my my first day..I walked off the job in 4 hours. I think they gave my still warm and starched (ys , i stood out in that crowd) uniform shirt to the next schmuck who walked in the door, certfied or not. So yes this does still happen I am sure. Is it right, hell know. is it gross Hell yes. If a company deliberately puts you in a position to treat patients like this, get out as soon as you can before your reputation is poisoned by your time there. BTW, up here in Idaho we have agreements with all the local hospital linen departments and simply swap blankets, pillows, etc...no questions asked. Except for the VA. No surprise there.

Hey all, I almost went back, read and tried to catch up on this discussion, until I saw the last few posts.....I am afraid that if I do my head will exlode based on some of the hate I see it has generated. So if I repeat what someone else has said, I am sorry. Our agency has a rather liberal RSI protocol, though at the same time a bit old fasioned (no ROC, etc). Our pre-medication includes any and/or all as apropriate: Opioids (Morphine or Fentanyl), Benzo's ( Versed or Valium, Versed prefered), Short acting sedatives (Etomidate),Lidocaine (for CVA and CHI) and Atropine (Peds). We use Succs for actual paralysis. We do not use a de-fasc dose of vec (though I have very seldom seen fasciculations when I use versed in the pre-medication phase). Though our orders allow us to place an ETT without actualy using a paralytic (sedation only airway management) if the situation calls for that, both the evidence in the literature and the medical directors preference is for using both sedatives and a paralytic whenever the situation alows. For post intubation management we also have Opioids, Benzos, and vec. To improve out success at ETT we have the Bougie when needed, and for rescue airway we have Kings and BVM's. For the Cant intubate/Cant ventilate situation we have the options for needle/surgical/quicktrach crics. To answer your question regarding IM, yes we have that option, though with the advent of the EZ IO (and quite frankly we have pretty goood success with IV's - unlike some of our ALS first responders who see fewer patients). As an alternative to the RSI with IM medications....we also have the option to nasaly intubate, and we practice this in our bi-annual critical skills labs as well, though it is truely a lost art from. Anyay, here is our SWO appendix on the RSI/MAI portion of airway management. FWIW, we have seperate protocols/documents for the various flavors of ETT, advanced airway, and crics, so this is not a stand alone document but instead fits within our larger SWO's. http://www.adaweb.ne...B8%3d&tabid=798

Hey all, As an FTO, I frequently have to teach a new employees and paramedic preceptees how to do EMS Documentation. I have a number of recources, documents, etc as well as war stories of documentation gone bad. I wont torture you with all of it. That said, as I hit the 21 year mark, I am stil a huge fan of SOAP in one form or another. For me it is the gold standard by wich I measure al naritives regardlessof format. One of my first PO's (probationary employee...AKA a preceptee in an FTEP program) had a lot of difficulty in charting. She took copious notes on our informal discussions and then added it to a little EMS website she ran at the time (long defunct now as she passed away from cancer several years ago). I have since copied, adapted and otherwise used what she wrote and turned it into one of the first handouts I give my new PO's. It wrks as a good starting point for discussions and teaching on charting. The documet is attached to this post. I hope this helps. SOAP Report Guidelines for EMS.doc

RIP Dust. Guess your running calls in a better zone now. Steve Cole Ada County Paramedics Boise Idaho

These arnt cards, but they will help anyway: http://www.adaweb.net/Paramedics/Pages/SWOTableofContents.aspx At the bottom are our current drug profiles. We are adding Zantac soon as well. I have the old ones on file for a lot of the ones we dont carry anymore, like phenergan and brytillium if you need those too. BTW, Strong recommendation for writing your own drug profiles over and over again. I teach paramedic students and I will give a blank drug profile as part of a queze...just to prove a point. I am sure your instructor will too. Steve

Our protocols not only allow medication of abd. pain, it encourages it. From our protocols, I quote:

Hey all, I certainly agree with most of what was said already. I am, however, I am going to offer a slightly different perspective. This is based on my experience in our hiring process and then over the following months training the new hires in our FTO process. For what its worth, our FTO process is a minimum of 4-6 months long, typically being 6 months to 9 months for a brand new medic. It is based on the law enforcement San Jose Model and we have used it for about 15 years with very good results. Anyway, Over the years I have seen multiple students from these "medic Mills" (we have a couple in the area" come and intern, and then come and try to get hired. Over the years we have had a number of graduates from the year long medic mill courses get hired, though I cant recall any of the "fast track" (6 months) medics actually completing the process. I will say that as a general stereo type the ones from the medic mills tend to test poorer, and subsequently tend to have a steeper learning curve than their more traditionally trained counterparts. The knowledge gaps are larger, but most importantly the typical students who tend to fall into the propaganda traps of these schools tend to be students coming directly out of their EMT courses and have no previous experience in EMS. This also contributes the many challenges they face. That said, we have many who have done quite well at our service, but it definitely takes them longer to get there. I attribute this directly to our FTO program. An organized, structured, professionally ran and validated FTO program can overcome many of the gaps and challenges that these students will face. The front line in this is of course the FTO's , how you select them, how you train them, how you retain and motivate them...but that is a different discussion. For you, in addition to all of the above answers, I would suggest seeking out a service with an actual FTO/FTEP program (not just a glorified preceptor or orientation program) and try to get on. Your learning process will be greatly accelerated, and this in turn will help your professional development.

You know what they say...the devil is in the DETAILS.

For what its worth, I had a course audit of our PALS and ACLS courses., There are some new changes coming down that should ramp up the intensity (a little) and the standards (a little) of the ACLS and PALS. The only problem I see is that the Training Centers dont monitor and enforce things like this as they should, and many instructors will continue to succumb to pressure and pencil whip the courses In Short, the problem is the instructors as much (or more) than the AHA.

Just becasue I am a stickler for the tiny details.....This device actually provides Active compression-decompression CPR (ACD-CPR), as opposed to traditional CPR. I have not used it, HOWEVER, there has been some research showing increased ROSC with it, and some showing no difference when compared to traditional CPR. IIRC, the research that showed increased ROSC was slightly flawed because this device was used with another device called the ResqPod (same company), and therefore increased ROSC could not be attributed to one or the other device (or both in combination). Quoting the AHA: Results from the use of ACD-CPR have been mixed. In several studies61–66 ACD-CPR improved ROSC and short-term survival compared with conventional CPR. Of these studies, 3 showed improvement in neurologically intact survival. In contrast, 1 Cochrane meta-analysis of 10 studies involving both in-hospital arrest (826 patients) and out-of-hospital arrest (4162 patients) and several other controlled trials comparing ACD-CPR to conventional CPR showed no difference in ROSC or survival. The meta-analysis did not find any increase in ACD-CPR–related complications. There is insufficient evidence to recommend for or against the routine use of ACD-CPR. ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb, LOE B ). TAKE HOME MESSAGE: DOES NOT HURT (when used correctly), unclear if it helps. If you use it, consider using it with the ResQPod too. You still have to do excellent rate/compression/decompression CPR regardless of how you do it. Some of the studies: Cohen TJ, Goldner BG, Maccaro PC, Ardito AP, Trazzera S, Cohen MB, Dibs SR. A comparison of active compression-decompression cardiopulmonary resuscitation with standard cardiopulmonary resuscitation for cardiac arrests occurring in the hospital. N Engl J Med. 1993;329:1918 –1921. Plaisance P, Adnet F, Vicaut E, Hennequin B, Magne P, Prudhomme C, Lambert Y, Cantineau JP, Leopold C, Ferracci C, Gizzi M, Payen D. Benefit of active compression-decompression cardiopulmonary resuscitation as a prehospital advanced cardiac life support: a randomized multicenter study. Circulation. 1997;95:955–961. Plaisance P, Lurie KG, Vicaut E, Adnet F, Petit JL, Epain D, Ecollan P, Gruat R, Cavagna P, Biens J, Payen D. A comparison of standard cardiopulmonary resuscitation and active compression-decompression resuscitation for out-of-hospital cardiac arrest. French Active Compression-Decompression Cardiopulmonary Resuscitation Study Group. N Engl J Med. 1999;341:569 –575. He Q, Wan Z, Wang L. [Random control trial of the efficacy of cardiopump on pre-hospital cardiac arrest]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue. 2003;15:292–294. Mauer D, Schneider T, Dick W, Withelm A, Elich D, Mauer M. Active compression-decompression resuscitation: a prospective, randomized study in a two-tiered EMS system with physicians in the field. Resuscitation. 1996;33:125–134. Stiell IG, Hebert PC, Wells GA, Laupacis A, Vandemheen K, Dreyer JF, Eisenhauer MA, Gibson J, Higginson LA, Kirby AS, Mahon JL, Maloney JP, Weitzman BN. The Ontario trial of active compressiondecompression cardiopulmonary resuscitation for in-hospital and prehospital cardiac arrest. JAMA. 1996;275:1417–1423. Goralski M, Villeger JL, Cami G, Linassier P, Guilles-Des-Buttes P, Fabbri P, Venot P, Tazarourte K, Cami M. Evaluation of active compression-decompression cardiopulmonary resuscitation in out-ofhospital cardiac arrest. Reanimation Urgences. 1998;7:543–550. Skogvoll E, Wik L. Active compression-decompression cardiopulmonary resuscitation: a population-based, prospective randomised clinical trial in out-of-hospital cardiac arrest. Resuscitation. 1999;42:163–172. Schwab TM, Callaham ML, Madsen CD, Utecht TA. A randomized clinical trial of active compression-decompression CPR vs standard CPR in out-of-hospital cardiac arrest in two cities. JAMA. 1995;273: 1261–1268. Luiz T, Ellinger K, Denz C. Active compression-decompression cardiopulmonary resuscitation does not improve survival in patients with prehospital cardiac arrest in a physician-manned emergency medical system. J Cardiothorac Vasc Anesth. 1996;10:178 –186. Nolan J, Smith G, Evans R, McCusker K, Lubas P, Parr M, Baskett P. The United Kingdom pre-hospital study of active compression-decompression resuscitation. Resuscitation. 1998;37:119 –125. And the Meta-Analysis: Lafuente-Lafuente C, Melero-Bascones M. Active chest compressiondecompression for cardiopulmonary resuscitation. Cochrane Database Syst Rev. 2004;:CD002751.

The new 2010 ECC guidelines and supporting evidence clearly show that FASTER is better than SLOWER. Specifically, it states " To provide effective chest compressions, push hard and push fast. It is reasonable for laypersons and healthcare providers to compress the adult chest at a rate of at least 100 compressions per minute (Class IIa, LOE B " This is different than the 2005 guidelines that recommended a rate of about a 100. The guidelines also state: "The number of chest compressions delivered per minute is an important determinant of return of spontaneous circulation (ROSC) and neurologically intact survival. " The studies that support this are: Abella BS, Sandbo N, Vassilatos P, Alvarado JP, O’Hearn N, Wigder HN, Hoffman P, Tynus K, Vanden Hoek TL, Becker LB. Chest compression rates during cardiopulmonary resuscitation are suboptimal: a prospective study during in-hospital cardiac arrest. Circulation. 2005; 111:428–434. and Wolfe JA, Maier GW, Newton JR Jr, Glower DD, Tyson GS Jr, Spratt JA, Rankin JS, Olsen CO. Physiologic determinants of coronary blood flow during external cardiac massage. J Thorac Cardiovasc Surg. 1988; 95:523–532. The first study showed the following ROSC rates based on compression rate 40-72 compressions/minute : 40% ROSC 72-87 compressions.minute: 58% ROSC 87-94 compressions/Minute: 76% ROSC 94-138 Compressions/Minute: 75% ROSC Considering that this is the total compressions delivered in a minute, not compression RATE (as in, this is the total compressions delivered even accounting for pauses, ventilation, scratching ass, etc) When you count the ventilation pauses and a goal of 20% hand off time or less each minute...if you screw up at all you will drop below 87/minute total compressions each minute. The take home message is this: You will not decrease ROSC by going to fast, but you will significantly drop it if you go to slow. So.. a little fast (up to 138 min) is perfectly OK. I hope this helps. Could not disagree more. Respectfully, the evidence is more compelling that ever supporting the change, and with the stuff I have seen being done, expect even more changes coming out in 2015. Oh , and FWIW, the updtates are every 5 years. And for what its worth.... the evidence is clear that WE (Health care providers of all levels in and out of the hospital) are as much at fault for the poor outcomes as anyone. WE became to focused on toys, and not on quality CPR. And for what its worth, ROSC rates are improving. Both in places like Seattle, but in smaller services too. Seattle just broke the 50% ROSC mark for VF arrest (the holy grail for the past 50 years of resuscitation science). I have a large portion of the science documents if you are interested. Or you can look at my science behind CPR lecture if you want too. Its on slideshare.com.