Flail chest w/ nemothorax

[VentMedic]

undoubtly, are you suggesting I don't know the course of the treatment after the pt reaches the hospital or how to care for different age groups? But look at the treatment of spinus or transverse process fractures and many other non subluxations. what weight is given to ischemic cord injury (by far the most common) rather than transection or penetration? There has to be a very serious injury for a spinal surgery to be attempted.


There is also the knowledge that those with c or t fractures also have fractures of the opposite which show up on imaging and are often missed during examination. The day there is a one size fits all trauma treatment, I am quiting.

We could also talk about osteomalacia and osteoporosis in the elderly too, but i am trying hard to work with what was given and not debate every possibility. c'mon.

and I agree with this fully, but there is a difference between realistic index of suspicion, especially when you consider the rareness of cord injuries in a modern automobile and mechanism by speed or damage shown not to be reliable.

Additionally without critical thinking, there can be no improvement of patient care.

You have seriously taken this at a personal level.

I am quoting things that every Med Student learns as they come to educate themselves at a trauma center.

Did you notice my comments:

The anatomically narrow thoracic spinal canal also leads to a high incidence of associated neurologic complications. The higher the rib fxs the more chance of also finding spinal injuries. The younger the child, the more chance of spinal injuries since it takes great force to break the flexible ribs of the very young.

Without critical thinking and assessing the patient for more than just the obvious or from a limited knowledge, you have a patient with a life changing event in a wheel chair, suprapubic catheter and a daily bowel program.

Blankets statements or intentionally blowing off other possibilities are signs of irresponsible teaching and guidance in a world where accidents don't always happen as perfectly as some would like. You also can not ignore other disease processes and age which are also taken into consideration in trauma activation in some areas. Doing a thorough assessment means considering different possibilities and not just selective things to make YOUR own point. Do what is best for the patient.

The situation given is a flail chest. Do some research or spend some time at a trauma center or spinal injury rehab center. Shortcuts are great for the very experienced and properly educated but should not be taught for all nor should assumptions always be made especially when the literature may state otherwise. The medical director of the EMT student you were questioning may have a stack of literature to base his/her protocols from.

 

[Melbourne MICA]

Treading carefully

Since the thread went past the original query about what can a BLS operator do for this pt, did anyone mention pain relief? I assume the pt was in pain so settle the pt down with some morph (if available and within laws and guidleines).

This will help in avoiding unnecessary movement and clearly ejection is a high risk mechanism for c-spine injury plus the points Venty made. I don't see any reason why this pt can't be fully packaged.

If one area of treatment like the board has potential to compromise another area, like the pts ventilations, we have tools to manage this problem such as assisted ventilation or high flow or high concentration O2.

Besides shouldn't we apply what we have to manage immediate problems rather than speculate what may or may not happen if we do or don't?

Apply the treatments with care on the basis of a thorough assessment, reassess thereafter and modify management as needed. If you have a board and collars use them. If not, basic packaging including the 3 sided dressing and chest wrap, limit movement, best position for ventilation and make sure someone had called 911 if you are off duty.

Regarding the breathing issue, for all you know even back boarded the pt may maintain their Spo2's. But you won't know until you try. If the pt deteriorates markedly with this approach and you ahev limited tools at your disposal to correct the problem then the ABC's must apply so ventilation must take priority.

For all the difficulties a chest injury presents we have quite a few options to manage that problem and concurrent problems as well, though not as many at BLS level of course.

Trauma jobs in particular always come with more than one clinical problem.

In a nutshell, act upon what you can manage with what you have, accept the limitations of the situation and above all be prepared for changes in the pts condition.

Thats what I reckon.

MM

 

[daedalus]

Well hello!! Look at the MOI, anyone with a significant MOI under NREMT protocols says that they must be in FULL c-spine care.

MOI- MVA with PT thrown from vehicle.

Dustin
NREMT-B Student

Reliance on protocols and cookbook procedure is the mark of an ineffective and inexperienced provider. You should know the whys and pathophysiology, and that will be your guide on selecting the appropriate treatment. On this forum, as in real life, we are in the company of people who have a vast amount of more education than you or I do as EMT-Bs. Vent and Vene here are debating certain pathologies that you may not even be aware of. Be aware that, here, just as in real life, you will be required to back up your statements are treatments. If a MD or RN or RRT asks why you initiated c-spine, or oxygen, or some other treatment, and you say because it is protocol, you will lose a lot of respect/

 

[LAS46]

Well at the same time if we do not follow simple protocols then we may end up in much more trouble for not... According to my receiving facility if this PT came in not in full c-spine care then we would get into a lot of trouble... yes your PT with a flail chest and a nemothorax will be uncomfortable... but that PT who has been ejected out of the vehicle may have a spine injury and we have to take simple precautions for that... I am sorry to say but Saving Lives is more important than comfort for your PT in a case like this...

DC

 

[Sasha]

Well at the same time if we do not follow simple protocols then we may end up in much more trouble for not... According to my receiving facility if this PT came in not in full c-spine care then we would get into a lot of trouble... yes your PT with a flail chest and a nemothorax will be uncomfortable... but that PT who has been ejected out of the vehicle may have a spine injury and we have to take simple precautions for that... I am sorry to say but Saving Lives is more important than comfort for your PT in a case like this...

DC

Do yourself a favor and google harmful effects of backboarding. its more than just discomfort. there is evidence suggesting backboarding is just as effective at preventing further injury than not backboaring. id post links but thats hard from a phone but i will post them later.

doctors and rrts and nurses tend to seemm to appreciate people capable of critical thinking over chefs.

 

[JPINFV]

Nemothorax?

Just keep swimming, just keep swimming.


PS. Directed at people who are continuing to use the term, and not at the OP who has atoned for his sins.

 

[VentMedic]

Do yourself a favor and google harmful effects of backboarding. its more than just discomfort. there is evidence suggesting backboarding is just as effective at preventing further injury than not backboaring. id post links but thats hard from a phone but i will post them later.

doctors and rrts and nurses tend to seemm to appreciate people capable of critical thinking over chefs.

While the evidence is there, the medical director must also be on board with developing a protocol, training and documentation to effectively meet the criteria.

Selective Spinal Immobilization
http://www.emsresponder.com/print/Emergency--Medical-Services/Selective-Spinal-Immobilization/1$2223


Danger at the Door (Bledsoe)

http://www.ems1.com/ems-products/patient-immobilization/articles/426350-danger-at-the-door/


Incomplete Spinal Cord Injury
http://www.ems1.com/ems-products/patient-immobilization/articles/456767-incomplete-spinal-cord-injury/

The NEXUS Study
http://www.fieldmedics.com/articles/the_nexus_study.htm

 

[triemal04]

Unfortunately, even with everything said, using/not using a backboard in the given situation is a moot point for almost all services; it will have to be done. All 3 (Nexus, Canadian and Harborview) agree that this type of pt does need cervical spinal immobilization until an x-ray/CT is done. And there are very few places that will allow their personell to place a collar on someone and not use a board or other immobilization device (KED) at the same time. (if anyone works for a place like that, speak up) What really needs to be addressed is whether or not full immobilization or only cervical immobilization needs to be taken.

 

[marineman]

Just to add another view for the links Vent posted (thanks by the way a couple new sites I hadn't seen before)

This is only the abstract, can't find a link to the full study without paying.
http://www3.interscience.wiley.com/journal/120143495/abstract?CRETRY=1&SRETRY=0

The guidelines of the Nexus study is what we use when clearing C-spine. No I couldn't clear it on this patient and would have to fully immobilize. Life over limb tells me to fix the breathing before c-spine and my doc would have no problem with that but if I'm able to intubate and ventilate while immobilized I'd have my *** in a sling if he wasn't long boarded.

 

[Melbourne MICA]

What really needs to be addressed is whether or not full immobilization or only cervical immobilization needs to be taken.

This question has only one answer. Cx Collar by itself does not provide adequate immobilisation. This is well documented in the literature (sorry no citations) and reflected in protocols used by most if not all EMS services who apply spinal immobilisation according to time critical guidleines.

You either clear the spine on the basis of guidleine criteria or apply full immobilisation -it's all or none.

MM

 

[Melbourne MICA]

Extra

This question has only one answer. Cx Collar by itself does not provide adequate immobilisation. This is well documented in the literature (sorry no citations) and reflected in protocols used by most if not all EMS services who apply spinal immobilisation according to time critical guidleines.

You either clear the spine on the basis of guidleine criteria or apply full immobilisation -it's all or none.

MM

I typically always add the caveat that thinking operators wil always use best judgement in the interests of the pt and are not just slaves to the dictum of protocol. After all, EMS trully is the art of improvisation and flying by the seat of your pants.

Nonetheless, the all or nothng approach in spinal management by EMS is well founded by both research and practice in pre-hospital.

MM

MM

 

[CAOX3]

Flail chest with a pneumo? I think that would be considered distracting injury.

With the NEXUS criteria that buys you a board.

 

[Veneficus]

This question has only one answer. Cx Collar by itself does not provide adequate immobilisation. This is well documented in the literature (sorry no citations) and reflected in protocols used by most if not all EMS services who apply spinal immobilisation according to time critical guidleines.

You either clear the spine on the basis of guidleine criteria or apply full immobilisation -it's all or none.

MM

I think what the point being argued, yet again, is whether or not a long board, head blocks, and a collar actually do prevent damage. The most convincing one I htink is the dallas malaysia one, as it actually has a control group. (those boarded compared to those not boarded) I have seen only anecdotes detailing whether a board helps. I am not convinced it does. Though I have seen other methods that seem more likely to help if there is benefit.

You can argue what is done and where all day, but it doesn't make it right. The amount of spinal fx missed on xrays makes a strong arguement for only CTs, but there are also limitations to that. Why do facilities constantly still perform xrays looking for spinal fx? (i have a few theories, not least of which s lack of physical exam skill)

If you really want a brain teaser on spinal fx, compare how many patients are sent home after a few hours or days with a collar compared to those who have surgery or more invasive splinting. (like a halo)

 

[VentMedic]

You can argue what is done and where all day, but it doesn't make it right. The amount of spinal fx missed on xrays makes a strong arguement for only CTs, but there are also limitations to that. Why do facilities constantly still perform xrays looking for spinal fx? (i have a few theories, not least of which s lack of physical exam skill)

If you really want a brain teaser on spinal fx, compare how many patients are sent home after a few hours or days with a collar compared to those who have surgery or more invasive splinting. (like a halo)

And how many are in wheel chairs? If one person loses their quality of life because it was assumed there was no fracture because of the statistics in a piece of literature without reading the methodology or other literature with differing views, poor training/education or from what someone read on an anonymous forum, that is one too many. That is why future doctors are taught to do an assessment as well as reading the literature but they are also taught their own limitations and the exceptions. Just like some Paramedics who believe they know everything about a patient even though they have no lab data and just a field exam to back it up, doctors are taught to make use of the tools they have and not assume everything in all cases.

A backboard may not always be the best method of immobilizing a patient but log rolling the patient onto it so the patient can be moved without further damaging the spine is better than just having a patient struggle on their own to get to their feet or doing an extremity pull or lift. In MRI or CT Scan a slide board may have to be used anyway to position the patient without pulling on the shoulders and head. The patient probably will not stay on the board at a trauma center much longer than it takes to do an x-ray and/or CT or onto something they can maneuver the patient more easily and safely on.

Often both a CXR and CT Scan is done but for different reasons. Many times a central line, ETT and OG are placed. These are all done within the first 5 minutes of arrival. The sooner confirmation of correct positioning, the sooner those 3 devices can be used especially when it comes to stabilizing a flail chest and preventing further trauma to the lungs. Not everyone will get or should get a CT Scan. However, in the case of a flail chest, there are many reasons to do a CT Scan besides the spinal column.

Yes there are a large number of patients that get sent home without invasive procedures for spinal fxs. But, in the field, do you know that fracture is stable? How many even suspect there is a fracture because there may be NO deficits? Will it remain stable if you don't take some precautions? The statistics there may only lead one to be more cautious. These are the ones that may get documented by the ED and sent to your medical director saying you will be one lucky EMT(P) if the patient doesn't suffer permanent damage. So, you may still be darned if you do and darned if you don't. That is where you must have the support of your medical director, your guidelines or protocols and your documentation must be very thorough. Stating with one blanket sentence, no abnormalities or deficits noted will not hold up.

 

[Veneficus]

hope springs eternal

I still have hope that any EMS provider reading here can distinguish the difference between a discussion of benefit and potental complications from lack of resources in the field. If providers can't handle that they need to join my level, I am not lowering to them.

Additionally I have said it more than once, US practicioners have to be careful about reliance on imaging. I have had the honor of working at one of the finest trauma centers in the US for almost 4 years, clinical decision making is more important than mindlessly following protocols based on abstract studies and imaging.

And how many are in wheel chairs? If one person loses their quality of life because it was assumed there was no fracture because of the statistics in a piece of literature without reading the methodology or other literature with differing views, poor training/education or from what someone read on an anonymous forum, that is one too many..

You make it sound as if I just troll the web for studies and have no experience at all. There is a time for conservative measures, but this panic idea that every trauma patient is critically ill is foolish. Infact most of them are not. The amount of overtriage is currently unsustainable both economically and logistically. (particularly in the US) also, when I think of the list of exceptional trauma centers, no place in Florida even makes the list. Trauma surgeons who do not have other critical care aspects of practice are also a dyng breed.

That is why future doctors are taught to do an assessment as well as reading the literature but they are also taught their own limitations and the exceptions...

It should be no different for any providers. But the limitations cannot always be overcome, and unlike other providers, a doctor who signs the chart may not have the luxery of having all he/she wants. Furthermore, sometimes they even have to reach into the vast bank of knowledge and make something up because there is no protocol or "expert" consult.

Just like some Paramedics who believe they know everything about a patient even though they have no lab data and just a field exam to back it up, doctors are taught to make use of the tools they have and not assume everything in all cases.

I don't think it is ever good to assume, but i also don't think you need to perform every medical test available to man to make a dx either. It is a waste of all kinds of resources.

A backboard may not always be the best method of immobilizing a patient but log rolling the patient onto it so the patient can be moved without further damaging the spine is better than just having a patient struggle on their own to get to their feet or doing an extremity pull or lift. In MRI or CT Scan a slide board may have to be used anyway to position the patient without pulling on the shoulders and head. The patient probably will not stay on the board at a trauma center much longer than it takes to do an x-ray and/or CT or onto something they can maneuver the patient more easily and safely on.

the CT? A total body scan (now routinely utilized in trauma around the US) of head, neck, chest, abd, pelvis can take up to 45 minutes. Provided there is no wait for the scanner. Add some plain films and that could be an hour or more. Totally unacceptable. Thinking trauma care is the same even between two level I centers is inaccurate.

Often both a CXR and CT Scan is done but for different reasons. Many times a central line, ETT and OG are placed. These are all done within the first 5 minutes of arrival. The sooner confirmation of correct positioning, the sooner those 3 devices can be used especially when it comes to stabilizing a flail chest and preventing further trauma to the lungs.

The standard bed side xrays in trauma around the world is a chest, pelvis and cross table lateral of the spine. Some centers forgo these because they utilize the "pan and scan" CT. An xray to confirm tube placement is truthfully icing on the cake. There are other ways. The same with a central line, and if you are worried about thorax injuries, i don't see the logic in using a subclavian central line anyway. Measuring CVP and confirming line placement takes place after stabilization in the critically injured trauma patients. (sometimes postop)

Not everyone will get or should get a CT Scan. However, in the case of a flail chest, there are many reasons to do a CT Scan besides the spinal column.

If the director of trauma believes the studies of xrays being inadequete they will get a CT. That is a large percentage. Yes you can see many things on CT, like shadows on the aortic arch. (which in a trauma patient is likely not a clot. Infact it is normal artifact usually, and more than one intensivist has been reprimanded for starting anticoags based on that finding I have been at M&M meetings personaly where it was brought up.)

Yes there are a large number of patients that get sent home without invasive procedures for spinal fxs. But, in the field, do you know that fracture is stable? How many even suspect there is a fracture because there may be NO deficits?

With the way EMS uses spineboards today I can't imagine a provider not suspecting an injury, even when it would qualify as impossible. "The if even one patient..." arguement while noble, is unrealistic, we'd have to run every test on every patient.

In the field I would say it would start with some real education and not dire warnings to inspire panic that every patient is on death's door and the end of the world at hand.

Will it remain stable if you don't take some precautions? The statistics there may only lead one to be more cautious. These are the ones that may get documented by the ED and sent to your medical director saying you will be one lucky EMT(P) if the patient doesn't suffer permanent damage. So, you may still be darned if you do and darned if you don't. That is where you must have the support of your medical director,

I never suggested not having to take precautions, but i do call into question the effectiveness of the standard method. There is absolutly nothing I have seen showing a LSB makes any difference. If you demand controlled double blind macro studies for new treatments the same standard needs to apply to all treatments.

Getting the medical directors support and furthering medicine requires discussion and argument that starts somewhere. If it can be done over a bar napkin, it can be done on a forum. If providers cannot see the difference between calling a treatment into question and changing treatment without going through the proper channels, it is probably just a matter of time before they make a terrible mistake, what they read here probably will only speed up the inevitable.

your guidelines or protocols and your documentation must be very thorough. Stating with one blanket sentence, no abnormalities or deficits noted will not hold up.

I worked in a system where literal interpretation of protocols was the culture of everyone except the medical director. It is not practical or reasonable, there will always be some vagueness and need for deviation. Otherwise every possible situation would have to be defined.

Poor documentation rests on the provider.

 

[VentMedic]

I

the CT? A total body scan (now routinely utilized in trauma around the US) of head, neck, chest, abd, pelvis can take up to 45 minutes. Provided there is no wait for the scanner. Add some plain films and that could be an hour or more. Totally unacceptable. Thinking trauma care is the same even between two level I centers is inaccurate.

You need to update yourself on imaging technology or find a more modern and up to date trauma center to work in. Not every hospital in the U.S. is as backwards as you may think by the one you have experience with. I haven't spent that long in CT with a patient in about 15 years.

It takes 2 minutes to scan a head and neck. Many scanners now have the ability to do the whole body without turning the patient around. Have you seen the ED models in Europe where the scanner sled is the ED stretchers? Major trauma centers will usually have their own scanner which eliminates the waiting. They may also prioritize the patient for the scanner based on a good report from the Paramedics.

The standard bed side xrays in trauma around the world is a chest, pelvis and cross table lateral of the spine. Some centers forgo these because they utilize the "pan and scan" CT. An xray to confirm tube placement is truthfully icing on the cake. There are other ways. The same with a central line, and if you are worried about thorax injuries, i don't see the logic in using a subclavian central line anyway. Measuring CVP and confirming line placement takes place after stabilization in the critically injured trauma patients. (sometimes postop)

Have you only worked in one trauma center?

We do not need surgeons to place our lines. For the technology and meds we may utilize, we prefer to safely confirm placement. As they say haste makes waste. Have you ever seen what happens if an HFOV placed on a patient where the ETT is too close to the carina? How about meds placed in grossly misplaced lines? First rule of medicine: Do no "additional" harm.

The same with a central line, and if you are worried about thorax injuries, i don't see the logic in using a subclavian central line anyway.

Subclavian?

We do IJs which allows us more flexibility for various monitoring devices especially if a TBI is also suspected.

when I think of the list of exceptional trauma centers, no place in Florida even makes the list.

If you don't like the U.S. system you don't have to work here. As you keep saying you are a dual citizen. Why waste your time in this country if you believe our medical practices are so inferior? Florida has some pretty good trauma centers associated with teaching hospitals that do some outstanding work. Some of our research even makes it to Europe. I also thought Europe's ED model of having a CT scanner at practically even bedside was fairly ridiculous also but they seem to have some logic behind that setup.

The human body is complex and it is difficult to get one recipe to fit everyone. Thus, some doctors do error on the side of caution and not just go by some statistical data that says only 1% possibility of something if there might be a possibility that that one patient will be part of that one percent. And as I already stated, not all of our patients get the total body workup.

With the way EMS uses spineboards today I can't imagine a provider not suspecting an injury, even when it would qualify as impossible. "The if even one patient..." arguement while noble, is unrealistic, we'd have to run every test on every patient.

In the field I would say it would start with some real education and not dire warnings to inspire panic that every patient is on death's door and the end of the world at hand.

I am not going to criticize an EMT(P) who puts a patient on a back board because of what they have seen at the scene even if the patient's initial assessment appears negative. Our doctors will usually listen to the EMS providers if they express concern about the way they found the patient.

However, the OP was about a flail chest and I think I have justified why I would back board that patient. Ribs can bend to almost 30 degrees and if there is still enough force to break those, I can NOT ignor other possibilities for injuries. That may be backwards in your ideal world but even those of us in Florida can manage to save lives occasionally in our trauma centers and do have EMS providers that can give good care in the field.

 

[Amack]

How can this be treated on a BLS level?

With a fishing pole...to get "Nemo" out of the thorax

 

[Veneficus]

You need to update yourself on imaging technology or find a more modern and up to date trauma center to work in. Not every hospital in the U.S. is as backwards as you may think by the one you have experience with. I haven't spent that long in CT with a patient in about 15 years. .

I doubt a manufacturers test site is operating with old equipment, especially considering we were testing the latest advances before it was available on the market.

It takes 2 minutes to scan a head and neck..

yea, a head, but what about the neck, chest, add, and pelvis? those magically get done in no time?

Many scanners now have the ability to do the whole body without turning the patient around...

I have never seen one where you had to turn the patient around.

Have you seen the ED models in Europe where the scanner sled is the ED stretchers?...

once or twice.

Major trauma centers will usually have their own scanner which eliminates the waiting. They may also prioritize the patient for the scanner based on a good report from the Paramedics. .

and in busy hospitals you can have a wait for the dedicated trauma scanner.

Have you only worked in one trauma center? .

worked at length in one, seen many across the world as the guest of others.

We do not need surgeons to place our lines. For the technology and meds we may utilize, we prefer to safely confirm placement. As they say haste makes waste. Have you ever seen what happens if an HFOV placed on a patient where the ETT is too close to the carina? How about meds placed in grossly misplaced lines? First rule of medicine: Do no "additional" harm..

I guess I conceed that nobody does anything advanced or correct except you guys.

according to your statements nobody sees patients except you anyway.

Subclavian?

We do IJs which allows us more flexibility for various monitoring devices especially if a TBI is also suspected.

perhaps other places do not make the line location based on findings, but i doubt it.

If you don't like the U.S. system you don't have to work here. As you keep saying you are a dual citizen. Why waste your time in this country if you believe our medical practices are so inferior? Florida has some pretty good trauma centers associated with teaching hospitals that do some outstanding work. Some of our research even makes it to Europe. I also thought Europe's ED model of having a CT scanner at practically even bedside was fairly ridiculous also but they seem to have some logic behind that setup. .

It is not abot liking or disliking the system, it is about recognizing no system is perfect and using the best from each. If the practice was perfect it would be economically sustainable, which it clearly isn't. I think you put a little too much faith in what you see in florida.

The human body is complex and it is difficult to get one recipe to fit everyone. Thus, some doctors do error on the side of caution and not just go by some statistical data that says only 1% possibility of something if there might be a possibility that that one patient will be part of that one percent. And as I already stated, not all of our patients get the total body workup..

epidemiology is one of those tools, if not all patients get a total body workup why would you expect an EMS provider to always do every treatment they can? Are they that inferior?



I am not going to criticize an EMT(P) who puts a patient on a back board because of what they have seen at the scene even if the patient's initial assessment appears negative. Our doctors will usually listen to the EMS providers if they express concern about the way they found the patient.

However, the OP was about a flail chest and I think I have justified why I would back board that patient. Ribs can bend to almost 30 degrees and if there is still enough force to break those, I can NOT ignor other possibilities for injuries.

There is a difference between an occult injury and an imaginary one.

That may be backwards in your ideal world but even those of us in Florida can manage to save lives occasionally in our trauma centers.

clearly, it is nobody else who can

and do have EMS providers that can give good care in the field.

Not the way you describe the inadequecies of EMS.

I must say, you seem to know all about every aspect of medicine professor, how foolish it was of me to think medical school could teach me something about medicine that can't be covered in an RRT or paramedic course. I sure did waste a lot of money and effort.

I really hope one day to match the knowledge and ability of an ancillary provider whos education will never let them take full responsibility for a patient.

Maybe the rest of the world will figure out whatever magic the perfect Florida system has. How dare I suggest it is not the only perfect way.

Sorry professor, you will never be a "doctor" guess you'll have to reconcile that sooner or later.

 

[Amack]

Cynical aren't we?

lol

 

[VentMedic]

I must say, you seem to know all about every aspect of medicine professor, how foolish it was of me to think medical school could teach me something about medicine that can't be covered in an RRT or paramedic course. I sure did waste a lot of money and effort.

Thank you for acknowledging my title. I have worked hard to get to that level. However, it doesn't mean I still can not be proud of my RRT and Paramedic credentials.

I have been in EMS long enough to know the deficiencies that exist in it. If you haven't noticed I am not the only one on this forum that notices it. Those that want to just stick their head in the sand and acknowledge their EMS system is perfect may be part of the problem.

We have providers of many levels and different ages or experiences on this forum. I try to make statements of caution and post links for them to do more reading on their own. One shouldn't make their title of future doctor sound as a voice of authority and this is how it should be done.

Maybe the rest of the world will figure out whatever magic the perfect Florida system has. How dare I suggest it is not the only perfect way.

I never said any one system was perfect. I was replying to your rather obvious insult to Florida.
Here is the quote by you again.

when I think of the list of exceptional trauma centers, no place in Florida even makes the list.

Do you know anything about the Ryder Trauma Center? Orlando Regional? Tampa General?
How about other states?
San Francisco General? R. Adams Cowley Shock Trauma Center?

You have a very opinionated view of how things are done in a trauma center based on the one you have worked at. Also, just seeing a trauma center is not always the same as actually working in one. Some things do change as different patients come in and different attendings are managing the rotations. The next day may be very different. That is the beauty of medicine. There are many ways to accomplish similar goals.

You have made alot of blanket statements. Yet even in the hospitals there will be protocols that may need to be followed even as a doctor. Don't expect an EMT(P) to challenge or disobey the written protocols of their medical directors just because you say so or try to call them incompetent for doing what is required of them. Some systems do have elaborate guidelines and not just recipes. However, there too they should not be bullied into going against their own judgement because you believe something is backwards by your own standards. You are not a doctor but you have made your opinions sound like you already are because you are a "med student" who does not have the full or any responsibility of a patient. That makes the licensed providers responsible for that patient and you when you are at that bedside.

You still have a long way to go in med school once you do get accepted. You may not even achieve your goals at all for whatever reasons. I can guarantee your low opinions of other healthcare providers in EMS, nursing and the allied health professions will not be to your benefit.