croaker260

Only on kids. One of the bigger mistakes in doing this proceedure is not using a long enough needle. Here we cary 10 g , 3 1/4 needles for this very reason, although there are some really obese patients you may not hit the pleural space even then. Steve

The 1st IC is roughly under the clavical. COunt down from there. ALso the OC is easier to palpate at the costal -chondral juncture (near the sternum). May I recommend you also practice your assessment on some of your more attractive female soldiers. You know...to sharpen your skills. In private. SO they feel "safe" with you and your professional demeanor. YOU never know what other skills you may be ...taught. I am of course assuming you can find a willing, able, and conscious female soldier. If not...there is always the navy.

Hey, I was in the 101st in 1992-95, 326th Combat Engineer and 187th RAKKASANS, then went to MEDDAC to go to paramedic school while working the post EMS.

Raaaaaaaaaa - Meeeeenn!

http://en.wikipedia.org/wiki/Talk_like_a_pirate_day And it is associated with the COFSM.... For more information look here: http://en.wikipedia.org/wiki/Flying_Spaghetti_Monster#Beliefs WARNING: If you have overly sensitive religious views, or you are a religious fanatic/zealot who doesnt like it when your god given right to force your religion on others is questioned, perhaps you shouldnt look at the second link.

Or , if you had taken the transport of the unstable patient, then you could have ended u like the medics in the 10 million dollar lawsuit recently.

This case was a (emergency) transfer from one facility to another. They were (wrongly IMHO) found liable for accepting the transfer under EMTLA and COBRA laws, which were originally designed to prevent turfing of uninsured and especially uninsured pregnant patients. Sadly, most medics, even seasoned onees, have no idea about EMTLA, what it REALLY requires, and how it effects paramedics. The really confusing part to me is, and what is left out of the story, is if the sending Doc filled out and signed the EMTLA certification of need, and if the paramedics requested an OB RN to go with. Those two items are crucial parts of this puzzle. There is some debate on this at higher levels, as the verdict would seem to put the responsibility of determining patient stability on the paramedic, and not on the Doctor. Hmmmm..... I believe it is being appealed.

Respectfully, not an apples to apples comparison. 1- Schools (and school districts) are mandated, though the quality is debatable. EMS is mandated too, but not the way schools are. 2- School districts in rural settings receive HEAVY subsidies from both the state and federal government EMS has not since the 1980s when Reagan shut that down. (Still love the man though!!!)There are no subsidies for EMS. This is not a local issue, but a state/Federal one, and cannot be pinned on the locals "not thinking EMS is important". Interestingly enough, most of these agencies subside ONLY on donations, so someone thinks their important. 3- By contrast, EMS is a mandated service for every county to provide , but unfunded by either the state or federal government, a fact we all are of aware of here, nor does the mandate say the county has to provide good EMS. Ironically, many of these rural EMS agencies would get more money if they simply bought an old fire engine, added the words "Fire and Rescue" to the end of their name, and applied for SAFER grants. I AGREE THAT AS A NATION THIS COUNTRY PUTS FAR TO LITTLE EMPHASIS ON EMS IN COMPARISON TO FIREFIGHTING AND LAW ENFORCEMENT...but thats a federal issue. And its not just funding, but minimum standards (when will degrees become mandatory for medics dammit!!!), legislation, and other forms of support too. But thats not the focus of THIS thread. The focus of THIS thread, as I read it, is some feel that the use of ECAs on the ambulance is an EPIC FAIL. Usually (making assumptions here) this is by people with little of no frame of reference to the challenges and start realities of some parts of thsi country. Everywhere is not California, Dallas, New York, or Saint Louis. You dont have a trauma center in every state (Ex. There is no LEVEL I TRAUMA Center in Idaho, ANYWHERE). You dont have taxing districts, or first responders, or even law enforcement when you need it. My point was to provide a frame of reference. RIGHT OR WRONG, these services are serving isolated pockets of humanity with populations less than some of our apartment complexes. There are seem fiscal realities that go with that situation. In these unique situations, staffing an ambulance is a challenge, and using ECA's so you can have an EMT in the back is a victory in some parts of the country. I was curiosu and did some basic research....Looking at the population base of the community mentioned in the OP, the population density, and the median income, this is likely one of those situations. Is it ideal, no. But stomping our foot and demanding that somehow things change wont help it. Demanding that we put more money in the situation and have "Paid" EMTs wont help either when there is no money to put in there. I work with these rural EMTs on many occasions (well nto the rural EMTs mentioned in the article, but here in ID). Sure there are some things that could be improved on. IMHO, the limited $$$ could be stretched way farther with regional cooperatives. But the independent spirit that has kept these communities alive in the face of significant adversity often gets in the way of cooperation. But this is true in many rural communities and even urban ones, not just in Idaho. So my point is that if my service chose to staff ECAs to scrape an extra $$, it would indeed be a fail. But for these communities its not a matter of scraping a dollar, its about getting bodies in the door, and hooked on EMS, so you can get them on to be EMTs later. Other than the use of the term "driver" (which we all universally hate) this is a community EMS trying to recruit and keep their ambulances staffed and on the road. SO, best of luck to them. Again, respectfully Submitted. - Steve

Dust, respectfully , I think I am making that point. We can look at median income, but the math is mind numbing. Basically it is pretty low for needs of the area. Also remember, unless you go 100% tax funded, fee for service is directly Dependant on the volume of runs you make, so run volume does play into the equation. Though due to the size of most of these agencies they contract out their billing (at BLS reimbursement rates), and get only about half of what is collected. Wich, because of the volume of runs, still aint much. Finially, if you tax property, if you only have 7000 homes to tax, no matter how much you tax, you still aint getting much. 7000 x 100K value of home typical Tax ($25) = 175,000 per annum, ANd remember that many of hese homes are trailers, small cabins, though you do have homes that are woth more, its a wash. And this number is for a whole county! Adams county, for example, only has 3k or so population. Not even homes, total population. But lets say HOMES to "round up" so to speak. Assuming all are homes worth at least 100 K after home owners exemption, wich is saying a lot. 3000 x 25 = 75,000 Per ANNUM. And if we say $ average collection for about 100 calls per year total.....thats 25000.....100,000 for ALL EMS expenses. Maintenance, Payroll, Fuel, training, cost of equipment and a warm shed to keep an ambulance, everything! For the whole COUNTY. EVEN IF YOU DOUBLE the PER ANNUM, how can you afford a full crew? And this is assuming you have a taxing district for the whole county, last I heard 14 counties in Idaho do not. So assuming you decide to take EVERY funding rescource for EMS fro the tax base, and fund a crw, You can afford 1 paid crew 24/7. In Adams county of 1,365 miles of MOUNTANOUS Terrain and DIRT FORREST Roads.... where do you put it? In wich of the 7 or so small communities? And what about the rest? Do you say, since you cant afford a "proper" PAID EMS crew, you cant have any at all. Oh yes, you get no funding because we took all you funding....to support a single "proper" EMS crew? You just half to wait for 2 hours or so? There is a point of funding collection that you just cant support paid personnel. You just cant. Even if you pay them minimum wage and no benefits. And you cant tax FEDERAL LAND, wich most of these counties are made up of. Many people live and ranch on 100 year leases on federal land, so technically they dont even "own" their home, grazing rights, or land, though the banks think they do My point is this, in my state no one believes that ECA/Drivers are the best solution, but with limited money to send people for training, If I can send one person (who may or may not be here next season) 1 hour or more for EMT training, or 2-3 for ECA/first responder training and then send the one who stays to EMT later, which is smarter? And in my state you still have to have an EMT in the back with the patient. SO...If I can train 1 EMT and 2-3 ECA's/First Responders or train 2 total EMT's, which is smarter use of limited $$$???

WAY to general of a statement. Example, I am proud to say I believe I work in one of the top 10% of EMS agencies in the nation here in Idaho. We serve an indigenous population of about 350K with a transient workforce of about 75-100K from out of county, and are a pleasant mix of suburban, rural, and even a little bit of urban thrown in, with median income from near zero to over 1 mil and everwhere in between. Sounds great, right? HOWEVER, you go north of here into the mountains, where most of the land is federal or state forests, The populated areas are small barely sustained communities of less than 1000 people....and these are the the "LARGE" communities,and are separated by mountainous terrain and snowed out roads in the winter for WEEKS at a time. This is not the natural disasters you see on CNN. This is the NORM. These communities are unincorporated, and have no tax base to speak of, and the EMS lives of the generosity of donations. The Counties they live in are little better. These community first responder/transport units often get less than 20-50 EMS calls a YEAR. Some examples: Valley County Idaho- Population 8000 total over 3678 square miles. An average population of 2 people per square mile. Yet most of this population lives in three communities along HWY 55, and are SEASONAL populations. the REAL population once you get off the HWY into the 6 or 7 uncooperative communities is closer to 0.25-0.5 people per square mile. Custer County Idaho: 4,166 (and decreasing BTW)in 4,937 square Miles. Less than 1 person per square Mile, and most of this population is in CHALLIS (pop 909), McKay (pop 500), STANLEY (pop 100) and other communities with a population of about 25-50. , Population is very seasonal, and mostly around red fish lake. The remainder of this population is spread out among 4-6 "smaller" communities. Many of these communities are vacated (except for 1-5 families as caretakers) during the winter. Adams County, Population 3400 over 1,365 square miles, most are seasonal with a ski resort or between two small communities each with less than 900 and 500 respectively. The remaining are scattered through out the mountains and along the river, many are "off the grid", and real population density is about 1/square mile or less. These are typical Idaho counties in MID/Central Idaho (where the Mountains and Valleys are). Hopefully you can see the budgetary issues, not to mention the personnel shortage this causes. Making a system out of a seasonal workforce and without a decent tax base is neigh impossible. In Texas, I only found one or two counties resembling this demographics on simple square miles (brewster for example) , They were agricultural in nature, not necessarily seasonal as we understand it here, and arent ISOLATED like we are for weeks or months at a time. Most had counties less than HALF this size, and population densities far exceeding what we have here in rural Idaho. THATS the REALITY here. And there are similar areas in OR and WA too, and in other parts of the country (SD, WY, and MT for example) You seem to imply that these comminities simply are to lazy to do anything other than volunteer EMS with an EMT and A "driver"/ECA. You seem to imply that if they wont do it "right", they should not do it at all. Yet without their own volunteer EMS, they would be HOURS in winter from anyone getting in by snowmobile or snow cat, or 4x4. If you have a population of say, 1000 (wich is the upper end of the LARGER communities, amy have populations less than 100). and you have an unheard of rate of 2.5% voluntarism, than thats still only 25 volunteers. In this state fully half of those will go to a first responder course and be a "driver", as long as there is an EMT in back. Then , if they stick with it, the service will find a way to send them to a EMT course, many will have to travel an hour or more to get that course in the summer. Now the state requires an EMT in the back, and at least a driver in the front. Most will run with 2-3 man crews on call from home. Usually the same people will be on call for weeks at a time. In the summer, they ONLY have to manage the patient for 20 minutes until air medical can get there, if they can get there (mountains are tricky to fly in).......In Winter, due to weather, white out, and other concerns, it may be hours to ALS or a facility thats more than a clinic and a PA/NP on call. In these areas, called FRONTIER, or SUPER-RURAL by medicare, ECA/First Responder/Drivers are the brutal reality, and the step to EMT in areas with no budget and no support. I am all for "doing it right", but in the rural parts of this state, every certificate that is issued is a victory, and everyone that re-certs, is a triumph. You have to see these beautiful, scene, and terrifyingly majestic areas to appreciate the isolation you can find here. I have volunteered my time to teach in some of these communites from time to time. It is way more rewarding than doing it in the "Big City" of Boise... (I have to laugh when I say that). And these guys are wanting the training. They just dont have the resources. In some places, "Doing it right" is simply doing it. Respectfully submitted. P.S. There is a push by the state to legislate counties into taking a more active role in supporting and funding these communities EMS and forming SYSTEMS....., and in forming taxing districts to support those "systems"......but guess who opposed it. The various FF lobbies. They dont want to be told how to run EMS by anyone.....)

The Acetabulum, part of the Hip. Q: The purpose of rotating venous tourniquets?

Appreciate vs Understand: Semantics. I believe it was Raising Children in tough times, it was my mothers. And , I have read articles and books wich have referenced his other considerable work. My grandmother, who was a 40 plus year school elementary teacher with a masters in Education thought it was a crock as well, though that was a much later and different conversation. I can easily say that if my grandmother hadn't taken charge of my education, I would probably be wearing a prisoner number right now. From my point of view, all the anti-spank group seem to think that the world is made up of parents who beat their kids senseless at the drop of the hat, producing bullies and brutes that would be perfect members of society if only the rod had been spared. On the other end are the pro-spank parents who see a world out of control and children with no consequences bullying the world at large while protected from consequences by the misguided intentions of the anti-spank touchy feely groups. Obviously we both fall at different ends of the spectrum but let me share my perspective. And you will note, I will do it WITHOUT calling you lazy, ignorant, or similar terms, which is more than you have done. When we speak of the military, I believe I am comparing apples to apples, because I was talking about the military school approach to educating children. My military school took in children from 6th through 12 grades. My tenure in military school, and in the military afterward, was far from scientific. It is the simple evolution of some practices that worked and some that possibly did not, but in the end it prepared me for real life. Punishment was harsh at time, without a grievence process, and was administered by fellow cadets or soldiers as often as it was by the "chain of command" (peer pressure can be a powerful motivator). It simply taught a deal with it and move on attitude, self petty curling up in a ball and hoping that someone else will fix your problems approach doesnt work. My upbringing in this system was at times harsh and unpleasant. But my coperal punishment was as often harsh physical labor (ever shovel coal for 8 hours?) and physical conditioning and rarely actual paddling. But the knowledge was ALWAYS THERE that if i didnt comply, if I didnt do my part...there was always one unbendable, unavoidable punishment at the end of the day. Todays schools dont have that, and without a "buck stops here" attitude, no amount of well reasoned rewards systems of hugs will work. And suspension is not it. To many kids suspension is a vacation, not a punishment. Its street credit. Its time off. Its a (in a twisted sense) a reward. And they continue this pathway until they are 18. Now there is a "final punishment", Prison or Death. And they are often unprepared for this new life paradigm. And we as a society are at fault now. Because we did not train them as children for the harsh world that exists, and these problem children, we actually encouraged on their problem path though this touchy feely approach, and act surprised when they continue it in adult hood. You asked "Why are you choosing to punish a child for reacting to the environment that they are forced by law to be subjected to?". ( sense a pro-homeschooling agenda here, but I will let it lay)The solution is simple, As adults they are forced into an unfair, harsh and unforgiving reality. Do we say to the murderer.."I am sorry, your street environment was harsh and unforgiving, and it is not fair that you are forced to live in poverty....so we will give you a pass on this?" No. Teach them consequences now and they will be better prepared down the road. NOw I am not saying that spanking is the solution, or the ONLY solution, but it needs to be in the process. Because a little temporary pain now (wether in the form of spanking, push-ups, laps, physical labor, or just extra homework) now as children will definitely prevent prevent permanent pain (in the form of prison, bullets, or the well deserved street level beat down) as an adult. Thats not science, and it doesnt fit in with todays thoughts of what reality should be.....but that IS reality. As my old PA in the army once said...Pain builds character. And that is perhaps what our arguments are really about... building character.

Bear: I think there is a world of difference between inserting a Combi/King?PTLA/EGTA and inflating until you cant no more, and inserting a Blakemore and carefully monitoring the pressure. The last Blakemore tube I transported we kept saline in the bladder instead of air, although that as mainly due to thats what we did with ETT's when we flew them back in the day. Not sure if that was overkill or not. This was 9 or 10 years ago.

I think you need to appreciate the school enviroment that schools have to deal with these days, with kids throwing complete fits at a very young age disrupting the whole class, kicking teachers and getting away with it, etc.. Suspension just moves the problem elsewhere, it doesnt correct it. Either call the parents in to spank them themselves, or swat them and sent them back in class. Im for spanking. In school and out. I am also for Jr. High and High schoolers working out their arguments "in the ring" with a pair of boxing gloves too. And sending them out to run laps, and putting them to work sweeping the hall on their break for bad behavior. But then I went to a military boarding school for high school, so I have a special veiw of these tatics, wich I think work. The age of Dr. Spock has destroyed our society

The Combi tube is the LAST thing you want to use, as is any similar device. It will only rip the weakened esophagus wide open. If you read the literature it is specifically contraindicated. Lethal intervention. I admit these are some of the most dramatic medical calls to go on, there can be blood everywhere! But unfortunately prehospitally,theres not a lot we can do. Fluids, airway control, and tincture of transport. Mortality in these cases of actual rupture can be high In hospital they will sometimes use a blakemore (sp) tube, which resembles a low pressure foley cath where the bladder runs the entire length of the tube. I have not seen any service carry them prehospitally, though IIRC they arnt much more difficult that an NG tube to place.

I am 100% in Dust's corner in this one, although in the past he will often come across as ...well...a self defeating bung hole. (Nuthin' but love Dust, Nuthin' but love) Administering any drug that has a vasoactive effect on the body is serious business. Its time that we as educators impart the seriousness of the situation on the EMT classess, and divest them of the illusion of safety, give them the same healthy respect for the drugs they should have for speeding code 3, and guns. Of course some paramedics could learn that same lesson too.

Hmmm, I have had the opposite experiance...but lets not sideline this discussion..... For what its worth, if anyone is interested, here is one of my canned presentations. I hope that some of you may find it useful. http://www.slideshare.net/croaker260/child-abuse-389911 Now, in my experiancre, having dealt with a number of cases, I have found that pediatric cases are sometimes more difficult since I have young children (a boy and a girl) simply because if I dont force myself to ignore it...sometimes I se emy little kids in their place. The closer they are in appearance the harder it is. Thats the hard part. Doesnt make much sense, but what can you do? But I have 19 years in this buisness, keeping focus is what we do. And I get the job done. Thats what we all do if we are worth our salt.

I have this book, its not bad at all. I do not have the otherone you mentioned.

I guess we have different techniques of doing these proceedures. If both Provider A reached for the blade/tube and Provider B reached for the combitube at the exact same time, then my money is on the incision being made before combitube cuff inflation and the first ventilation. Hence my argument that truely doing them simultanously is less than optimal. But then again, perhaps we are just visualizing two different sequence of events, which must be the case. Now if you are argueing for "prepping" for a cric while your partner does/attempts the rescue airway, then I have no problem. But I was invisioning the truely simultanous attempts like they used to teach with retrograde intubation....and IMHO, I can cut the neck (and have) pretty quick.

I am familier with the worthy text by Walls and the algorythm, but I think you misunderstand me. I was using the example of an ETT as a reasons why doing a cric and an ETT simultanously is counter productive, and comparing the ETT to the supraglottic airways (wich use higher airway pressures) to explain that doing a cric AND a supraglottic airway simultanously is even more counter productive. In short, the alteration of the integrity of the lower airway will render the supra-glottic airway ineffective. But if you are going to do both a cric and a supraglottic airway, then focus your rescources and just do the cric, because you will have the first incision before you get the supra-glottic airway out of the package. Again, not what I would reccommend, but once you cut into the trach, the supra-glottic airway becomes useless. Do the supraglotic airway de jour quickly, and if it is ineffective, or contraindicated, either BVM them or if that is not an option, then chose to do the cric... quickly. That is my point. Thank you.

I'm thinking vent may or may not be able to back me up on this, but here are my thoughts.... I know that the concept of using a rescue airway or attempting ETT at the same time as cricing seems like a good use of limited time, and in some cases it would be, such as laryngeoscopy while attempting a retrograde ETT.... But I also know that in the case of a fractured larynx you must intubate PAST the fracture with an ETT. And the airway pressures for a supra-glottic airway are even higher. Therefore I think that altering the integrity of the lower airway with an attempted cric, and using a combitube or a LMA (or a king, PTL, EGTA, what ever) instead is a recipe for (at the least) SQ air; if not very poor ventilation or even complete airway obstruction. The airway pressures for a supra glottic airway must by nature be higher than that of an ETT to provide effective ventilations, so the concept of doing both seems like something that "sounded good at the time" but actually isnt. At least if you use the ETT, you an advance it past the incision and still ventilate until the surgeon can repair the incision (this is what a friend had to do with a Fx larynx one time on a ped) Finally, if a combitube (or what ever) was a realistic consideration (or BVM) then I would have some strong thoughts about even attempting the cric. IMHO, the cric is strictly reserved for the known CICV situation. I hope this is making sense....good discussion.

The LMA was never intended by the original designer for a rescue airway, but it may serve. Combitube I like better for this situation, but it also has limitations. Having done crics, I can say that the worse situation I can imagin trying to do a cric (other than prone) would be sitting in a car with poor lighting, inability to extend the neck, and limited access to the patient. WOuld I do it if I had to, of course. But chosing a cric over an attempt at a digital...nahh probably not. Remember that a cric is for when everything else goes horribly wrong...not something to be taken likely. I have seen, and I am sure Vent has as well...crics gone wrong. A cric is something we should move promptly and decisively to when needed, and idealy in less than 10 minutes from 1st ETT attempt...(and refractory to BVM, rescue airway, etc) but not recklessly. Far less complications with a rescue airway, or a good old fashioned ETT (placed however you place it) than a cric. Vent, very informative post on pediatric digital ETT. Kudos. Myself...I have never had to do that, and honestly probably wouldnt have thought of it. But...I will tuck that away in my mental bag of tricks. Thanks. I have found most of my tubes in small children, even those with some life left in them, easier than some adults. But alas we trained on cats in school...something you dont see anymore.

Jake is correct. Tamahawk = Sky-hook = Pick-ax. Different names, same approach.

We had another thread on this earlier I think. We had one of the cases here outside of Boise last year. We were lucky the victim posted warning signs all over the car.

The utility of this procedure is intubation in confined, awkward entrapments where you cant get full access to use a traditional visual approach (or foward seated approach- Sky hook) intubation and nasal intubation is not an option. I have had two opportunities in 19 years to do this. Both were trapped patients sitting in a car, roof was not flapped yet , dash wasnt pulled yet either...so extrication and traditional seated intubation (sky-hook) wasnt an option. Neither case turned out well in the long run, but neither died for lack of airway control . I was thankful my paramedic instructor insisted we practice this method on a sitting dummy over and over and over. And for the record, neither had IV access, and one would not have been a good candidate for IO due to entrapment and orthopedic injuries. Not that we had adult IO's back then. That said, I too have fat fingers (big hands...means I ...wear big gloves ) I have found that teaching this over and over again, that since we added the Bougie to our tools, the Bougie combined with digital manipulation makes this MUCH easier over digital manipulation of the tube. As a side comment, I have also found that mastery of the Sky Hook (AKA Pick AX, or Tomahawk) method of intubation should also be considered and essential skill for these awkward situations as well....and is also seldom taught in most schools. P.S. To answer another poster....I prefer nasal ANYDAY over digital. But I started before the era of RSI, and Nasal was a mainstay of paramedic practice back then.