croaker260

Im just impressed the FD actually did something about it. Seriously. If it was one of our local FD's, they would have given the FF a medal for heroism during a technical rescue.

We had one of these about a year ago in a rural part of our county, but near a recreation area. Fortunately the vehicle was well marked. It was a Haz Mat nightmare though.

Well, first understand that this area of rescusitation is based on consensus, there just arnt that many clinical studies in this situation, most dating from the 50's when we used to cool them that cold on purpose. The worry with medictions at temps <86 degrees F. is that at temps that low they will simply stagnate in peripheral vasculature, yet once the body is rewarmed, and you have "afterdrop" from cold stagnate acidotic blood released from the peripheral circulation to the central circulaton, now you will have several rounds of several different drugs released as well. And we dont know what the result will be. Additionally, metabolism functions significantly differently at colder temps. and medications actions may be unpredictable. With Cardiac Arrest between 86-93 degrees, there is no clear guidance that I have ever seen on paper (I could be wrong) as to what conistutes an "extended interval", but in practice I have always extended the 3-5 minute interval to 10-15 minutes. Not that any of us have these calls every day. Steve

3. NREMT Tennessee Idaho And Many Many years ago...Kentucky.

I had this very discussion about 14 years ago with a doctor, a General Practitioner from Rural Tennessee, who for MANY YEARS was the only FT doctor in this county...who still worked the "ER" (Three total beds- Major 1, major 2, and Hallway )in the small clinic. His very astute assessment is that while there are more tools available today, todays doctors are so dependant on them they for get the most important tool...the assessment. Especially the SUBJECTIVE assessment. According to him, and I have heard it repeated elsewhere, 80% od the DX is derived from the SUBJECTIVE ASSESSMENT. I know that when I teach, I stress this point, that the assessment is as IMPORTANT as the monitor, the glucometer, or the CT. In short, we dont teach our EMT's , Medics, or even Doctors, to talk and interact to patients anymore, to assess them beyond a few basic steps. We belive that they will learn it on the job, and saddly they dont, or at least not quick enough not to have some purely avoidable mistakes occur. Like the one discussed above. I would stand right beside you and say that anyone who intubated a diabetic unconscous and hypoglycemic patient should have to explain themselves...but I would also say that there are cases where that same hypoglycemic , unresponsive diabetic patient should be intubated too....and that the total assessment, not just the glucometer, tells the whole story. To use your xample....while ultrasound/CT will prevent some surgeries, an assessment will prevent unnessessary untrasounds and CTs, and catch the need for CT's and Ultrasounds that a lesser practitioner would have missed. Yes, its not perfect. But thats why medicine is a PRACTICE and an ART as much as a science.

While I agree with 90% of what has been said about the fire service, I want to point out WHY they chose CAR WRECKS and critically ill.... Car Wrecks...Let me guess, NV is a mandatory insurance state...better chance of REIMBURSEMENT. Critically Ill: This means the increased chance that these are the older and insured (under insured, but insured)population, where medicare is the most common payor. And since these will likely be "ALS II" bills, the pay out is more sure and increased dramatically over ALS I and BLS calls, even with "bundleing". In short ....$$$$$$$. Its a numbers and volume game. By taking these two significant portions for the EMS Fee revenue stream, you leave the patients for whom reimburesement is less certain, and the payout margin less...for the privates.

We have Benadryl listed as an option if more traditional anti-emetic are contraindicated. We currently have both Zofran and Phenergan, though Phenergan is going away.

I am making a couple of assumptions. 1- Since the complaint presented was not an altered mental state, etc, but chest pain, I am curious why the provider didn't go..."Hmmm this BG isnt adding up in this overall picture"... (as in treat the patient not the ...monitor/glucometer/tool) and at least second guess it. Re check the BG or the equipment. Not saying that a BG wouldnt be pretty standard in my assessments, but a profoundly low BG in an otherwise normotensive, dry, alert patient without a history if DM should make one at least make sure you didnt switch your BG over to mmol. 2- As mentioned , elevated BGs have been associated with increased mortality. Viscosity is an issue. So is immune function too. 3- We all make mistakes, as one poster mentioned, learn from it. What ever you do, don't minimize it. No body can be perfect its true, but striving for perfection and having ridiculously high personal standards is what separates the world class professionals from the amateurs. Food for thought. As a side note, I had 2 diabetics last night who had unexplained and atypical hypoglycemic episodes, one was completely NIDDM. We did sort it out, and both got glucose in one form or another, but both were atypical presentations from dispatch to end of call. So Im not saying you should only give D50 to textbook cases, only that a healthy bit of self skepticism is an essential paramedic survival trait.

Too bad, we just hired two weeks ago. We are not a registry state (Idaho) , though having your registry makes it Soooo much easier. I for one do not believe its a racket, BTW, but thats another discussion for another time.

I read this article, its a thought provoking one. What is known...(or widely believed) that the sympathetic dump that occurs in traumatic situations, also known as epinepherine scarring, is a key component of PTSD. This is why techniques such as "stress innoculation" , intensive training, and "combat breathing"...all of which either help blunt the synpathetic response or stimulate the parasympathetic system....are believed to help in PTSD. (recomend "on Combat" by Dave grossman as interesting reading) It only makes sense that pain relief would be a part of this as well. Beta Blockers woiuld also be an interesting study as well, though counterproductive in a traumatic injury situation.

I agree with you, but would like to note that true "fire superiority" in the military sense of the word...is not feasible in civilian Tactical operations...to much collateral damage. Although I am reminded of this movie.....

Responded off list. Well I tried to anyway, Dust, your inbox is full I guess

I guess I should have been clearer. I was un-clearly referencing previous discussions that have surfaced over the years on almost every internet forum about arming medics (both in and outside the "tactical enviroment"). Most of those arguments have centered around "emotional" (as opposed to objective) discussions about carrying guns at all, doing no harm, and other philosophical/ethical stuff. I apologize for not being clearer

Ok first of all, any thoughts on weather medics should be armed or unnarmed is NOT an ethical consideration...to place BS ethics imposed by someone far removed in a suite who will never be in the thick is ...well ....BS...in my mind. It is however an operational and functional consideration. Currently our TAC MED medics are not armed, this may or may not change but they havent been for the past 10 years. They are fully armored, and they always advance just behind the SWAT/ERT guys at the "point of last safety". Practically put, as an entry team clears a room the Tac Med guys are just outside the room. They currently have one or two officers with them for security. There have been at least two cases where being this close was needed, including a patient with a shotgun wound to the abd of a hostage, I believe. The pro's of the armed discussion is mainly that the TAC MED guys dont have to have two officers tasked to provide security for them. Arming the medics would give them the ability to defend themselves. And the issue of arming medics should be best approached as a safety issue ( it sucks to be the only guy in a room with out a gun!) NOT A DESIRE TO HAVE THE MEDICS PLAY COP (unless they are a cop ) The cons are liability of training and non sworn status. Armed medics should be trained to the same standard as the rest of the team for liability, as well as respect, issues. The issue of wether the medics are also securing prisoners, clearing rooms, etc is a functional one determined by each team, but in my mind causes problems overloading a vital function of a medic. "role blurring", or the BS about "medics dont cary guns" is indeed ridiculous and doesnt (or shouldnt) come in to the issue. This is about providing safety equipment to medics operating in a specialized enviroment, not about the everyday medic on the street..unless your everyday medic works streets of Bagdad. The discusion should be objective, not emotional. BTW, there is medical care under fire (Tactical casualty care), but it is different from tradional medical care, and is mostly BLS airway and bleeding control. Plenty has been writtten about it, GOOGLE is your friend.

I have heard of this, but it has not been an issue where I work, because there just isnt much "man tracking" done in most of the US. As far as crime scenes, Ive been asked for my boot size before, but thats about it. Even In Idaho, dont think its that common, but my experience in the rescue community was on the tech (i.e. rope nazi) side and not on the Search side. Who knows though. Neat topic to bring up.

Because it takes 5 seconds to look and see if I am dealing with a severe brady, a tachy (SVT, VT)or something else and make the decision if I'm going to go out to the ambulance, or stop in the front living room and try to get a head of the game there. Also because by the time you yank this poor son of a bitch even into the living room, you now have blown 5 minutes in many cases ... 5 minutes where your partner can be setting up something for you, like meds, or pacing pads, or anything... Its just different styles, but I cringe when I hear people make up excuses why they didn't get vital information because they were doing something else... There are times when I would do a snatch and grab, as you mentioned, but haveing a basic idea what is (or more importantly ...isnt) going on in the first 2-3 minutes is helpful. And as for getting tangled up in the EKG, thats why the leads are detachable from the monitor.

Perhaps thats the real reason their medical director resigned. He got trying to change the unchangeable.

But Rural Metro wasnt a fire agency there (I dontthink) but an EMS one. Wonder what the motivation was?

Thats not the point. The point is that the medic talked the guy out of a transport when he didn't, and even if thats not the case, it sounds like his documentation was sub par of what ever he did do on scene, and to add sauce for the goose, this was a medic they should have know was sub par because of the testing /evaluation done previously that they ignored. Yes this could have happened in many systems, but in DCFEMS...I just am not even surprised anymore.

I think he sounds somewhat legit, jut not articulating himself well. Assuming his background is reasonably honest, I'll proceed. It sounds to me like your question isnt " what to do If I lost my love for EMS" Its " do you guys think I can tolerate the job enough to get a pay check again with out going postal" My answer is , based on what your telling me...dont even try. It sounds like the only jobs you have are the BLS IFT shuffle, and you already have a bad taste in your mouth for it. Therefore you will never put up with the job long enough to make it a career and get on with a good service with good benefits, and 911 work and on to paramedic school...and surprise, even then, even in all 911 services (what few are left)...you still have to put up with BS. In the off chance you do try to stick it out, chances are your unhappyness will sooner or later sabatoge your future in this business. SO make peace with the patient care part of the job, even the BS/non-emergency pt care, because thats what this job is all about... or move on to something else. Respectfully, find something else you can love, and do that. You will be happier, your patients will be better off, and your co-workers wont be miserable from working with you.

Now, keep in mind that up until October I was 1/2 time in the field and 1/2 in education....so my opportunity for field tunes was below average. I think I have had either 6 or 7 live tubes, 3 of wich I would classify as difficult (1 400 pounder respiratory --> cardiac arrest- got on 2nd attempt with a 4 miller, 1- severe facial trauma from auto-bike and unable to ventilate due to trauma- got on 1st with 3 mac and a bougie, 1 code--> simply very anterior---> C&L grade 3 view --> got on 2nd attempt with the bougie and a 4 mac) All had an ETT by the second attempt, most on the first. Still hoping to grab one or two more this year. This is the first year I can remember not having a nasal...but this is the firt full year we have had CPAP on the rigs too. We as a service squeak by with 6-12/year/medic .(All types of tube, RSI, Nasal, Oral, Etc) ..though I know of some black clouds that have had quite a bit more.... ..not great I know. Unfortunately ALL of the local ORs have shut their doors to everyone except Their own Air Medical..and them only grudgingly. This is unfortunately the reality. We don't have a true teaching hospital in this state, so its difficult to get true OR time.... Now to off set this, we do critical skills training twice a year with our docs (which includes difficult airway) and this year incorporated sim man difficult airway scenarios as well. All of our personnel go through this, EMT through medic, for teamwork purposes. We also do difficult airway stuff in the annual refresher course that includes pig trachs and sim man. So while not as good as getting in the OR... we have made every effort to compensate and do take it seriously.

The EMTs arriving on the ambulance with in 4 1/2 minutes SHOULD have had a defibrillator too, right?