# Protocol V. On-Scene Judgement Calls



## thatJeffguy (Oct 24, 2009)

I'll preface this by saying I have *no* training yet, what so ever.  Realizing that having no training and opening my mouth leaves a gigantic vacuum in which a foot can fit in, I'm going to jump in here and see what happens.

The BLS ambulance where I ride as an observer was called to the scene of a 47yo male vomiting blood and "feeling poorly".  Our driver knows the man is HIV+ and HEP+, unsure which specific HEP he's got.  We arrive, he's mobile, smells of alcohol and, despite his claims of vomiting blood, he's just basically retching and spitting up (brace yourself for the most unscientific term ever here) "snotty spit".  The EMT-B's get the man on the stretcher and load into the ambulance.  Hospital is about 7 minutes away.  Patient says he's going to hurl so I grab the e. basin for him, again, just some snotty spit, no traces of blood.  EMT-B takes history, pt states he's HIV+, has "severe" anxiety, past history of suicide attempts.  EMT-B asks if he's been drinking, patient answers yes, a "few drinks" in the past few hours.  Patient states that usually he sees his grand kids every day and they keep him "normal" but they're out of town today.  The EMT-B uses a finger pulse oximeter, guy shows at about 93% so he gets oxygen.  The EMT-B doesn't do anything else, no pulse, no blood pressure, nothing.  

We stage on-scene at the high school football game and I ask him why he didn't take any vitals and what the patient could have presented with that would have caused him to take vitals.  He said that he was using his judgment that the guy was just intoxicated, emotional and having a bit of an anxiety attack.  I'm not *in any way, shape, or form* trying to call out the EMT-B on this, he's been doing it for 13 years so I'm aware his experience dwarfs my "experience" (or complete lack there-of).  However, our protocol is that patients get their vitals taken.   

I'm more specifically concerned with the abstract issue here; protocol versus the on-ground judgment call of a trained professional.  How frequently is that an issue and how should a neophyte deal with such things?


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## JPINFV (Oct 24, 2009)

Screw protocol. How about just doing a proper assessment in the first place? I can think of only a handful of cases where I can justify not getting a full set of V/S, and those either fall into when the patient requests not to have a BP taken or load and go situations with extremely short transport times (like less than a minute transport times).


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## reaper (Oct 24, 2009)

Pt should have had vitals taken, no matter what his complaint is. That sounds like a lazy EMT!


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## VentMedic (Oct 24, 2009)

Has this EMT ever heard of universal precautions?

The only vacuum I hear is the state sucking up this guy's license.

Oxygen has been applied without anything other than a spot check with a pulse oximeter?    The patient was treated without any further  assessment.   It seems this EMT couldn't get past the HIV+ part to provide adequate care. 

He also doesn't understand enough disease processes to know what is associated with alcohol and hepatitis.   

FAIL!


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## Dwindlin (Oct 24, 2009)

JPINFV said:


> Screw protocol. How about just doing a proper assessment in the first place? I can think of only a handful of cases where I can justify not getting a full set of V/S, and those either fall into when the patient requests not to have a BP taken or load and go situations with extremely short transport times (like less than a minute transport times).



Only other situation I wouldn't get vitals on is uncooperative patients.


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## JPINFV (Oct 24, 2009)

^
Good point. Forgot to think about that one. I will add the caveat that, all things being equal, I'll try harder to get a BP on a patient who I believe is uncooperative/combative due to metabolic or neurological issues that psychatric issues.


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## daedalus (Oct 24, 2009)

I second the above. Vital signs, are, vital. They need to be taken on all patients if possible, and it sounds like it was possible in this case.

Uncooperative patients are another story.


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## VentMedic (Oct 24, 2009)

Since this patient gave his hx willingly, including his HIV status, he was probably cooperative and even cared enough about the EMTs to tell them about his diseases. It is too bad the EMT didn't care.


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## thatJeffguy (Oct 24, 2009)

Thanks for the great information and timely replies.  I'll admit, when I was told he was HIV+ I was nervous, the HEP scared me more though.  When I was younger I worked in Central Processing, the department of the hospital tasked with decontamination, inspection, packaging, sterilization and inventory management for the surgical tools for our ER.  I've dealt with some of the nastiest, cruddiest, bloodiest, feces-caked instruments available and I'm sure that in my year there, quite a few AIDS patients were operated upon.  I'd be ashamed if I allowed a patients HIV+ status to affect my patient care, frankly.


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## DV_EMT (Oct 24, 2009)

Vitals.... ALWAYS!

thats my two cents


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## zaboomafoozarg (Oct 24, 2009)

Jeff, I think am *kind* of in your shoes . I'm halfway through my EMT class with no actual experience yet

But let me warn you, by and large the response that I got when I made a post slightly similar to yours here is that, those of us with no field experience or training are complete idiots for even daring to question the field practices of a real EMT. I'm not saying this myself, just warning you that you will probably get responses like this.Some people on this forum completely toss any amount of book learning ("protocol" in your case) out the window. 

I think the EMT was wrong though.


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## HCEMS (Oct 24, 2009)

I would like to see the PCR form that your B wrote out after the run.  I would have to think that your Medical Director would be pretty upset if he the B didn't right down any vitals at all.  The B did not perform good pt care nor does the hospital have any trending to go by with the vitals.  I wouldn't be surprised if your B didn't write down false vitals on your PCR form unless you have a really relaxed Medical Director.

My advice to you is even if they have 13 yrs of experience doesn't mean anything if they have been doing improper pt assessments for 13 years.  The only you can do is learn from his mistakes and don't replicate bad pt care.  I'm glad you were paying attention though! Good luck!


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## reaper (Oct 24, 2009)

zaboomafoozarg said:


> Jeff, I think am *kind* of in your shoes . I'm halfway through my EMT class with no actual experience yet
> 
> But let me warn you, by and large the response that I got when I made a post slightly similar to yours here is that, those of us with no field experience or training are complete idiots for even daring to question the field practices of a real EMT. I'm not saying this myself, just warning you that you will probably get responses like this.Some people on this forum completely toss any amount of book learning ("protocol" in your case) out the window.
> 
> I think the EMT was wrong though.



I have not seen one person stand up for the EMT yet? It is one thing to question a treatment and it get defended. It is another to question the laziness of a provider. There is no excuses for that!


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## CollegeBoy (Oct 24, 2009)

reaper said:


> I have not seen one person stand up for the EMT yet? It is one thing to question a treatment and it get defended. It is another to question the laziness of a provider. There is no excuses for that!


Okay maybee someone does need to stand up for the EMT:
1...2...3 NOT IT!!


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## mycrofft (Oct 24, 2009)

*thatJeffguy, good post!*

3 issues I see.
SHOULD VITALS HAVE BEEN TAKEN? Yes.

UNIVERSAL PRECAUTIONS (which by the way is no longer P-C, but I thnink it's the best phrase): you learn it, you practice it, gets to be second nature, you may screw up once in a while (hello, _human_) but fear shold never be part of your reaction unless the pt is assaultive or otherwise _exceptionally_ risky.

On-Scene Judgment versus Protocols: this judgement thing is cited by some as a reason to skirt protocols, and by adminitrators as a means to cover theri butt for cruddy protocols by blaming the line person. The little decision tree your brain is clicking along subconsiously or consciously has a branch that says "Whoops, don't recall a protocol for THAT!". This can be due to forgetfulness, poor training, the inevitable gaps in protocols versus real life, and the appearanc of common stuff to be exotic stuff due to combinations of causes, or just funny stuff happening. The completeness of the mental database some of our forum-mates are harping about is proven right there: when the cookbook fails and you have to decide whether to act, and if so, then _perform_, you will need that database  so your judgement is not guessment.

*Good* protocols are "the law", wisdom from may years of incidents and experience. Abandoning them invites problems.

PS: blood from mouth: check the mouth for the origin, be it sinuses ("post nasal drip"), teeth, oral tissues, or unapparent (which can be bad). Smell breath and you may smell bad breath like bad teeth, bad breath like infection, bad breath like blood. "Blood in snot" could be trace bloeeding in esophageal, not nasal or nasopahryngeal, mucus, sign of an incipient esphageal bleed and cause for frequent vitals and getting thee to an emergency room _toute suite_.
Maybe. (


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## JPINFV (Oct 24, 2009)

mycrofft said:


> *Good* protocols are "the law", wisdom from may years of incidents and experience. Abandoning them invites problems.



Good protocols also generally recognizes that, while they are the ideal treatment plan for a specific chief complaint, that not all patients will fit inside the nice little boxes created and that the paramedic should use judgment to know when to deviate from those protocols. 

Also, the treatment plans developed by good prehosptial providers should independently match the protocols anyways.


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## Shishkabob (Oct 24, 2009)

Which is why many MD's are changing "protocols" to "guidelines" and letting their medics make the decision at what will work best in the given situation.


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## firetender (Oct 24, 2009)

There is no substitute for good judgment but that also includes good sense: Like if you're going to administer a drug (O2 is a drug) it's a really good idea to have documented vital signs along the way. 

There are protocols you must do because they're designed to work, there are protocols you follow because they CYA, and there are protocols that you're "expected" to follow, but few do. Some services are choking with protocols and the medics figure out what they can get away with. The local culture kind of decides that, until someone makes a stink about it and gets "by the book".

All in all, there's no pat answer except ALWAYS weigh written protocols against the needs and safety of the patient in the moment. Sometimes, they really don't synchronize. Just be prepared to document.


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## bunkie (Oct 24, 2009)

Vitals are your window into the patient. They should have been done absolutely. If he's squeamish about HIV and HEP, he needs a new job.


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## Seaglass (Oct 24, 2009)

RuralEMT said:


> Okay maybee someone does need to stand up for the EMT:
> 1...2...3 NOT IT!!



Me neither. Vitals are vital...


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## JPINFV (Oct 24, 2009)

RuralEMT said:


> Okay maybee someone does need to stand up for the EMT:
> 1...2...3 NOT IT!!



Visitors and regulars, please not the [sarcasm] and [Godwin] tags used in this post. 

[sarcasm]

How dare you all judge those poor EMTs? You were not there. You don't know what they saw. Maybe they had superior vision than all of us and could tell a blood pressure and pulse just by looking at the patient! Similarly, we should all be glad that he prevented the spread of such horrible and immoral diseases such as AIDS by keeping all of his equipment clean. Would you want you're daughter's boyfriend's aunt's best friend's cousin treated using a blood pressure cuff and stethoscope that had been used in the past on someone with AIDS!?!?!  [Godwin] Maybe the Third Reich was right with how to manage the sorts of populations who gets AIDS![/godwin] [/sarcasm]


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## Sasha (Oct 24, 2009)

JPINFV said:


> Visitors and regulars, please not the [sarcasm] and [Godwin] tags used in this post.
> 
> [sarcasm]
> 
> How dare you all judge those poor EMTs? You were not there. You don't know what they saw. Maybe they had superior vision than all of us and could tell a blood pressure and pulse just by looking at the patient! Similarly, we should all be glad that he prevented the spread of such horrible and immoral diseases such as AIDS by keeping all of his equipment clean. Would you want you're daughter's boyfriend's aunt's best friend's cousin treated using a blood pressure cuff and stethoscope that had been used in the past on someone with AIDS!?!?!  [Godwin] Maybe the Third Reich was right with how to manage the sorts of populations who gets AIDS![/godwin] [/sarcasm]




Hey if the pulse ox could pick up a pulse in his finger that means he at least had a BP of 80, and by the sounds of the beeping on the pulse ox you could estimate the pulse.

Touch a patient??? Why ever would you touch a patient?


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## Shishkabob (Oct 25, 2009)

Patients, especially of the female variety, have cooties.


I don't want cooties.



I throw my IV caths at them hoping to get a flash.


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## JPINFV (Oct 25, 2009)

^
Darts?


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## mycrofft (Oct 25, 2009)

*Anyone ever put the pulse ox on the arm the machine is squeezing for BP?*

There ought to be a thread about bad protocols and bad protocol systems, but I've stirred enough exlremento today.


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## traumamama (Oct 25, 2009)

such yummy descriptions of waste products Makes me hungry!  I am having a bowl of Jolly Time popcorn; what is everyone else eating One thing that has always amazed me in my 30 years of EMS-how we can talk about all the details of a gross call while we are eating-of course everyone around us has left Sick!  We are all sick!!


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## JPINFV (Oct 25, 2009)

traumamama said:


> One thing that has always amazed me in my 30 years of EMS-how we can talk about all the details of a gross call while we are eating-of course everyone around us has left Sick!  We are all sick!!




That really has nothing on a medical school commons during gross anatomy.


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## traumamama (Oct 25, 2009)

OK. So tell me a story-I will go and find a midnight snack


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## JPINFV (Oct 25, 2009)

traumamama said:


> OK. So tell me a story-I will go and find a midnight snack



Discussing how the practical went, especially in terms of how the professors tagged the corpus spongiosum of the penis. 

Discussing the sounds and smells of cutting through parts of the skull using a reciprocating saw. 

Discussing one professor's list of "party tricks" such as the cremaster reflex and kegal exercises. 

Sexual history/genitourinary review of system components during our standardized patient (SP) encounters (one of my classmates asked his SP if he had any "vaginal discharge" by accident. Good laugh for everyone involved, including apparently the SP). 

Let's just say that there's been some conversations that would have been very awkward a few short months ago that now easily pass for everyday conversation.


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## Miss Xina (Oct 25, 2009)

Why was this patient's glucose level checked? He may have been anxious from hypoglycemia..

I don't know enough about Hepatitis to say anything but really, knowing the patient has these diseases would make me LESS scared because I know what he has!

I'm more scared of the patients who don't tell me anything.. you don't have a clue then!!

Also, did the EMT give him oxygen via NRB or nasal cannula? If NRB then he could have vomited up into the mask or could have needed suctioning...

Do you think there'd ever be a time when we could check the blood-alcohol level in patients? I had a patient who was a known alcoholic who was unresponsive to painful stimuli so the medics didn't give him oxygen because he was known to them and they just assumed he was drunk. 

When the Drs saw him and checked his alcohol level, it was way below what he normally is and they had to check for brain damage!!

I don't know what the results were, but the fact that the medics were lazy and didn't give him o2 and the patient was unconscious for different reasons leads me to think we should be provided with the tools to check alcohol levels.

If the EMTs were nervous about the patient's Hep and HIV status, they could have just taken proper, or extensive BSI precautions. I'm sure the patient may not have minded.

We need to be able to thoroughly check our patients to see if it IS just the alcohol. Assumption is not a diagnosis or reliable method of deciding what treamtents are needed!


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## thatJeffguy (Oct 25, 2009)

I appreciate all of the informative posts that have come forth here.  In every job develops the tendency to allow routine to set in and cut corners.  If you work as a Broom Management Technician at the diner, that's OK.  When your actions could cost a life, gobs of someone else's money or a licensure/career that you care about, it's not the time to cut corners.  My aspiration is to be the type of medical *professional* that never allows a lackadaisical attitude to take root.


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## firecoins (Oct 25, 2009)

how is this a protocol versus on scene judgement thread?


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## Sasha (Oct 25, 2009)

> I don't know enough about Hepatitis to say anything but really, knowing the patient has these diseases would make me LESS scared because I know what he has!



Bingo! EVERY patient could have some icky floating in their blood, and should be treated as such. Many people are not forthcoming with this information because they are afraid they will be treated like this guy was, with disdain and would not get less than the EMT/Medic's best care. 

Bravo for him for caring enough about their safety to be forth coming about his PMHX. You don't treat them any differently than any other person, wear gloves!


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## Sasha (Oct 25, 2009)

> how is this a protocol versus on scene judgement thread?



Protocol is get vitals on every patient, poor on scene judgement is "This guy is just a drunk, we don't need no stinkin vitals"


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## medichopeful (Oct 25, 2009)

Vital signs should always be taken.  However, there are 2 exceptions to this rule that I can think of:

1) The patient (who is CAO) refuses to let you take vitals
2) When there is no time to do it, basically because you are performing life-saving procedures or because you have enough things to do first and you have a short transport time.

Also, I am a little concerned that you have EMT-Bs with 13 years of basic experience.  Why doesn't he continue his education?


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## medichopeful (Oct 25, 2009)

Sasha said:


> Bingo! EVERY patient could have some icky floating in their blood, and should be treated as such. Many people are not forthcoming with this information because they are afraid they will be treated like this guy was, with disdain and would not get less than the EMT/Medic's best care.
> 
> Bravo for him for caring enough about their safety to be forth coming about his PMHX. You don't treat them any differently than any other person, wear gloves!



For the OP (seeing as you don't have any training, not a bad thing), every patient DOES have an infectious disease until proven otherwise.

It's sad that Sasha is correct about people withholding information because of the level of care.

(Sasha: I'm not saying you're sad.  I think you know what I mean )


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## RescueYou (Oct 25, 2009)

Basic vitals should ALWAYS be taken at some point or another. You need at least one set of base vitals to at least compare to or give to the hospital. Now, I've been on calls where I've never taken the bp, but I've never taken a call when I didn't check pulse, respirations, LOC, and pupils. Pulse ox isn't even absolutely necessary, but it's good that it was taken. 
As daedalus said, uncooperative patients are a whole new story...
But truthfully, vitals are necessary. Universal precautions are there for a good reason!


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## medichopeful (Oct 25, 2009)

*Sorry for triple post*

I was reading through, and I just saw something about "questioning" an individual with more experience.  I just want to point out, that you should ALWAYS question somebody if you are not sure why they did something in the field.  No doubt in my mind that it is the right thing to do.

HOWEVER, make sure you do it at the right time.  Preferably, after the call is done.  And do it in a respectful way.  Make it a conversation, NOT an accusation.  You will get much more information that way.


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## Sasha (Oct 25, 2009)

medichopeful said:


> Vital signs should always be taken.  However, there are 2 exceptions to this rule that I can think of:
> 
> 1) The patient (who is CAO) refuses to let you take vitals
> 2) When there is no time to do it, basically because you are performing life-saving procedures or because you have enough things to do first and you have a short transport time.
> ...



I also, occasionlly don't do vitals on hospice transfers when there is an order in their chart for no vitals. Sometimes their skin tears so easy or is so sensitive that it would be considered almost cruel to do them. They're not necessarily a/o. But I doubt you'll ever run into that on 911.


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## RescueYou (Oct 25, 2009)

thatJeffguy said:


> I'm more specifically concerned with the abstract issue here; protocol versus the on-ground judgment call of a trained professional.  How frequently is that an issue and how should a neophyte deal with such things?




PS. The field is very different than classroom shiz most of the time. Protocol is often bent for the sake of the patient. You can't plan for every scenario. This is where the "6th sense" and personal ability to make clear judgments of the EMT are key....nonetheless, again, vitals should always be taken.


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## medichopeful (Oct 25, 2009)

Sasha said:


> I also, occasionlly don't do vitals on hospice transfers when there is an order in their chart for no vitals. Sometimes their skin tears so easy or is so sensitive that it would be considered almost cruel to do them. They're not necessarily a/o. But I doubt you'll ever run into that on 911.



Good point, but I was focusing on only 911 calls. <_<


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## Miss Xina (Oct 25, 2009)

Sasha said:


> Bingo! EVERY patient could have some icky floating in their blood, and should be treated as such. Many people are not forthcoming with this information because they are afraid they will be treated like this guy was, with disdain and would not get less than the EMT/Medic's best care.
> 
> Bravo for him for caring enough about their safety to be forth coming about his PMHX. You don't treat them any differently than any other person, wear gloves!



Oh man, I truly assume all patients are infected either internally or externally. Who knows if they washed their hands after their last sexual encouter or number two in the loo?

I am paranoid about this because I consider BSI to be more of a priority than Scene Safety, yet with Scene safety, you can withhold treatment by refusing to enter the scene until the police secure the area.

Scene safety- you can SEE the dangers already present or developing.
BSI- y'can't!


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## Miss Xina (Oct 25, 2009)

medichopeful said:


> Vital signs should always be taken.  However, there are 2 exceptions to this rule that I can think of:
> 
> 1) The patient (who is CAO) refuses to let you take vitals
> 2) When there is no time to do it, basically because you are performing life-saving procedures or because you have enough things to do first and you have a short transport time.
> ...



I was wondering that, but I didn't want to step on any toes, I just got my EMT-B license over the summer and I am already enrolling on the general ed classes for the paramedic associates.


figure get those out of the way before I embark on the paramedic side of it and it'll make my life easier 

I couldn't stay in the same level for too long, I'd feel like I was wasting time.


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## Miss Xina (Oct 25, 2009)

medichopeful said:


> I was reading through, and I just saw something about "questioning" an individual with more experience.  I just want to point out, that you should ALWAYS question somebody if you are not sure why they did something in the field.  No doubt in my mind that it is the right thing to do.
> 
> HOWEVER, make sure you do it at the right time.  Preferably, after the call is done.  And do it in a respectful way.  Make it a conversation, NOT an accusation.  You will get much more information that way.



LOL I am such a child in that way. I am always asking "Why?" or "How?"

I find that they don't mind because it's pure curiosity mixed with humility. I think they appreciate an interested rider


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## medichopeful (Oct 25, 2009)

Miss Xina said:


> I am paranoid about this because I consider BSI to be more of a priority than Scene Safety, yet with Scene safety, you can withhold treatment by refusing to enter the scene until the police secure the area.



Why would you consider BSI to be of more priority than scene safety?  If the scene isn't safe, you shouldn't be considering BSI.  If you need BSI, the scene needs to be safe.  

So basically, you can't use BSI unless the scene is safe.  So why is it a second priority?


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## Miss Xina (Oct 25, 2009)

medichopeful said:


> Why would you consider BSI to be of more priority than scene safety?  If the scene isn't safe, you shouldn't be considering BSI.  If you need BSI, the scene needs to be safe.
> 
> So basically, you can't use BSI unless the scene is safe.  So why is it a second priority?



My point is, BSI is MORE important to me because I cannot see, or definitely know what is present on a disease level but you CAN see what is making the scene dangerous.

I am in complete control of BSI. I'm never in complete control of Scene Safety. 

So, it may not be in the order of BSI first then Scene Safety, but I do consider it more important.


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## Sasha (Oct 25, 2009)

BSI is part of scene safety.


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## Miss Xina (Oct 25, 2009)

Sasha said:


> BSI is part of scene safety.





Sigh, I know. I fear people are missing the point.

I notice how some medics/EMTs don't change the sheets after each patient. That worries me. I  would also just wipe down everything that comes into contact with patient when time permits.

Obviously, I am not gonna be able to do this after each call, but I think it's important to at least try.

The Pulse Ox thing (Sorry. I literally just woke up) wasn't working properly because it was too dirty. That was an eye opener for me. That  taught me that tools need to be cleaned so they can work properly.

It's a nice dream, and I know it's not always possible, but I would make an effort at the beginning, end and whenever else is possible to just give everything a once-over. Just to be on the safe side


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## JPINFV (Oct 25, 2009)

Miss Xina said:


> Oh man, I truly assume all patients are infected either internally or externally. Who knows if they washed their hands after their last sexual encouter or number two in the loo?



Who knows if the person who opened the door before you washed his/her hands as well? I always find it funny that EMS as a whole yells about BSI and universal precautions, yet it seems that almost no one really knows what universal precautions really is. This said, vomiting blood means you take precautions.


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## Miss Xina (Oct 25, 2009)

JPINFV said:


> Who knows if the person who opened the door before you washed his/her hands as well? I always find it funny that EMS as a whole yells about BSI and universal precautions, yet it seems that almost no one really knows what universal precautions really is. This said, vomiting blood means you take precautions.



LOL, I kinda clean my hands a few times in every day life.

Maybe I am OCD?? 

Talking of which, what possible reasons are there for vomiting blood? We didn't go over this in school.:unsure:


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## bunkie (Oct 25, 2009)

Miss Xina said:


> LOL, I kinda clean my hands a few times in every day life.
> 
> Maybe I am OCD??
> 
> *Talking of which, what possible reasons are there for vomiting blood? We didn't go over this in school*.:unsure:



Really? Where did you go to school? We had an entire day of lecture on this. I honestly think I'd look for a refresher with another program.


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## Onceamedic (Oct 25, 2009)

A couple of things that are occupational hazards..

1 - the frequent flyer.  You run on this person  20 times and its the same old bull crap.  The 21st time, they are having a CVA or MI or whatever.  

2 - minimization of symptoms.  This happens to the mid level provider - not the newbie that is still enthusiastic and not to the veteran that has been bit in the *** and learned the hard way.

The solution to both is a thorough and complete assessment.  If you do nothing else by the book - do the assessment well every time.  That's what it means to be a professional.  (and in case it's not obvious, a good assessment includes vitals.  No excuses ever for not getting a set.)


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## Miss Xina (Oct 25, 2009)

bunkie said:


> Really? Where did you go to school? We had an entire day of lecture on this. I honestly think I'd look for a refresher with another program.



Well, that taught me 

It was a summer class, so we probably skimmed over it. We're taught to, like treat symptoms, not worry about causes. 


Big lesson - we are not drs, we do not diagnose


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## medichopeful (Oct 25, 2009)

Miss Xina said:


> My point is, BSI is MORE important to me because I cannot see, or definitely know what is present on a disease level but you CAN see what is making the scene dangerous.
> 
> I am in complete control of BSI. I'm never in complete control of Scene Safety.
> 
> So, it may not be in the order of BSI first then Scene Safety, but I do consider it more important.



Okay.  I think I see what you mean.


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## Miss Xina (Oct 25, 2009)

medichopeful said:


> Okay.  I think I see what you mean.



BSI is things I can wear/do to avoid unnecessary diseases/infections, Scene Safety is things in the scene, like cars on the highway, guns/knives present.

LOL, maybe I am the only one that differentiates it that way :wacko:


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## bunkie (Oct 25, 2009)

Miss Xina said:


> Well, that taught me
> 
> It was a summer class, so we probably skimmed over it. We're taught to, like treat symptoms, not worry about causes.
> 
> ...



Call me *****y today but I'm taking the bolded as a smart *** hit back. I was actually headed to go grab my books out of the car and give you a straight out of the book listing.

I know we are not doctors, but that isnt an excuse for being ignorant about the potential cause of a symptom and frankly, IMO what is wrong with the limited education of the basic system. 

My program stresses that point as well, but we're also educated on WHAT, HOW and WHY, not just the thing we see. The more knowledge you have, the better off your patient is. If I dont have an idea of what is going on inside my PT to explain his symptoms I could miss something else entirely more important and then where are we? 

Oh yeah jack, he's pale and cool, unresponsive and his abdomen is rock hard. Dont know whats wrong with him, guess well just stuff him in this chair here and give him a ride in. We wont bother treating him or giving vital information to med control because we only took a summer class and we aren't doctors.  

Not being a doctor is not an excuse to be ignorant about the field you are in.


----------



## Miss Xina (Oct 25, 2009)

bunkie said:


> Call me *****y today but I'm taking the bolded as a smart *** hit back. I was actually headed to go grab my books out of the car and give you a straight out of the book listing.
> 
> I know we are not doctors, but that isnt an excuse for being ignorant about the potential cause of a symptom and frankly, IMO what is wrong with the limited education of the basic system.
> 
> ...




Ignorance is assuming you know it all already and refusing to learn more. You are actually telling me off for..what? Asking?

Maybe I shouldn't ask so many questions...

OK, I'll just stick to independent research and study like I usually do:sad:


----------



## bunkie (Oct 25, 2009)

Miss Xina said:


> Ignorance is assuming you know it all already and refusing to learn more. You are actually telling me off for..what? Asking?
> 
> Maybe I shouldn't ask so many questions...
> 
> OK, I'll just stick to independent research and study like I usually do:sad:



Did I say I knew it all? No and I dont pretend too. I'm "telling you off" for your "big lesson" comment. Not for asking. The only stupid question is the question left unasked. Personally for the sake of your PT's I'm glad you asked. And I'm glad that you want to learn and recgonize the areas that were lacking in your program. It's good to learn. But your comment rubbed me the wrong way on the wrong day. Now, I'd be happy to go get my book out of the car.. even if its cold and wet outside. ^_^


----------



## Miss Xina (Oct 25, 2009)

bunkie said:


> Did I say I knew it all? No and I dont pretend too. I'm "telling you off" for your "big lesson" comment. Not for asking. The only stupid question is the question left unasked. Personally for the sake of your PT's I'm glad you asked. And I'm glad that you want to learn and recgonize the areas that were lacking in your program. It's good to learn. But your comment rubbed me the wrong way on the wrong day. Now, I'd be happy to go get my book out of the car.. even if its cold and wet outside. ^_^



No, it's OK. I was merely saying the big lesson IN CLASS was that we do not diagnose. 

I'd rather leave you rubbed the wrong way and wait for a medic or someone with many years of experience to tell me.

Seeing as they know more than what I would have been taught at school, I figured they would just, you know.. list stuff.

I'm just glad that the guys I ride with are more open to discussing stuff.


----------



## bunkie (Oct 25, 2009)

Miss Xina said:


> No, it's OK. I was merely saying the big lesson IN CLASS was that we do not diagnose.
> 
> I'd rather leave you rubbed the wrong way and *wait for a medic or someone with many years of experience to tell me.*
> 
> ...



Wow, ok, whatever. I'm going to stop now before I get banned. I like this place a lot and plan on sticking my uneducated arse around for quite a while.


----------



## Miss Xina (Oct 25, 2009)

bunkie said:


> Wow, ok, whatever. I'm going to stop now before I get banned. I like this place a lot and plan on sticking my uneducated arse around for quite a while.



I wasn't saying anything bad about you, Jeez, you really are sensitive today. I was saying that I know people here who have been medics for 13 years for example.

They could just probably run off the textbook list and stuff they learned from experience.

I find I learn more from people that have been around the block a few times than I ever would from a book, or even a class!


----------



## Sasha (Oct 25, 2009)

How the heck can you treat something without a working diagnosis?


----------



## Miss Xina (Oct 25, 2009)

Sasha said:


> How the heck can you treat something without a working diagnosis?



*shrugs* 

beats me!!


----------



## Sasha (Oct 25, 2009)

Miss Xina said:


> *shrugs*
> 
> beats me!!



Then why advocate not diagnosing? I used to be ignorant as well and thought that you didn't diagnose.. but you HAVE to to treat something effectively. Symptoms are treated differently according to what you think is going on.

now that is not to say you go around telling someone their chest pain is GERD and they don't need to go to a doctor, but you always form a working diagnosis and go from there.


----------



## Miss Xina (Oct 25, 2009)

Sasha said:


> Then why advocate not diagnosing? I used to be ignorant as well and thought that you didn't diagnose.. but you HAVE to to treat something effectively. Symptoms are treated differently according to what you think is going on.
> 
> now that is not to say you go around telling someone their chest pain is GERD and they don't need to go to a doctor, but you always form a working diagnosis and go from there.



I'm not advocating not diagnosing. I was merely pointing out WHY in class we were not taught every cause for every symptom.

What erked me, was in role-playing, we had a patient who was having an asthma attack. I said that we needed to administer Epi. My teacher demanded to know why I think that, and cos I knew why, but couldn't quite put it into words, he said if I were a medic student then I would have not gotten marks for that call.

Seeing as we weren't taught that in class, I just happened to know it from experience, I thought he would have been impressed!

It was really early on in the course so I didn't really have the medical knowledge to explain it.

We had this huge debate in class why we don't diagnose yet they expect us to differentiate between an allergic reaction and an asthma attack.

We didn't get a good response.

Just because I am telling you what we were taught in class, does not mean I advocate anything!

We're taught to call medical direction for EVERYTHING.. except administer o2.

Another example, role playing. The patient is having a heart attack. I say this and my teacher says 'no, you don't say that, you're say "chest pains with radiating pain down the arm and shortness of breath"

Again, I asked why not.


----------



## Jon (Oct 25, 2009)

Miss Xina said:


> ... Big lesson - we are not drs, we do not diagnose



Incorrect. A long-held fallacy of EMS.

We may not call it a diagnosis - but guess what - we diagnose many of our patients.

To treat something, we NEED to at least have a differential diagnosis. We may call it something else to not interfere with the great medical hierarchy, but we diagnose.


----------



## Miss Xina (Oct 25, 2009)

Jon said:


> Incorrect. A long-held fallacy of EMS.
> 
> We may not call it a diagnosis - but guess what - we diagnose many of our patients.
> 
> To treat something, we NEED to at least have a differential diagnosis. We may call it something else to not interfere with the great medical hierarchy, but we diagnose.



Yeah, I know. I was merely pointing out WHY we weren't taught the causation of many symptoms. Which sucks.


----------



## zaboomafoozarg (Oct 25, 2009)

To those whom it may concern,

Lay off of Xina, folks.

Not sure how long it's been since many of you went through EMT school, but either it never happened to you or you forgot how *HARD* they pound into you that _you never diagnose a patient._

The fact is, the textbooks' main goal and theme by and large seems to be 1. cover your butt, 2. don't do anything wrong, and 3. work only according to protocols like a mindless pawn, THEN treat the patient after meeting goals 1, 2 and 3!

Sure, common sense tells us this is all wrong. You have to have at least an idea on the backburner of your mind as to what is going on with the patient so that you can begin to treat and provide ongoing care as well. (Not to mention watching for deterioration 

Now that doesn't mean you tell the head-ache patient, "Hey, you have an aneurysm in the brain" or anything like that. But rather you consider it a possibility and watch for signs of stroke, among other things, right? Right. 


There's a difference between being mindful of a POSSIBLE and/or PROBABLE diagnosis, and making your own definitive diagnosis which you're not qualified at all to do. Correct me if I'm wrong, Xina, but I believe you were talking about the latter, here?


To lash out at Xina and treat her like an imbecile because she echoed what most students have been taught is counter intuitive. Clearly what she said came off wrong and not entirely what she meant. So give some helpful advice instead of freaking out. 

That's all I'm going to say. If this rebuke applies to you, well... you know who you are.


----------



## JPINFV (Oct 25, 2009)

zaboomafoozarg said:


> Now that doesn't mean you tell the head-ache patient, "Hey, you have an aneurysm in the brain" or anything like that. But rather you consider it a possibility and watch for signs of stroke, among other things, right? Right.
> 
> 
> There's a difference between being mindful of a POSSIBLE and/or PROBABLE diagnosis, and making your own definitive diagnosis which you're not qualified at all to do. Correct me if I'm wrong, Xina, but I believe you were talking about the latter, here?



...which is pretty much what everyone is saying. No one is saying that a EMS providers make a definitive diagnosis. This is why the qualifying terms "differential" or "field" is being thrown around in front of "diagnosis."


----------



## zaboomafoozarg (Oct 25, 2009)

Not everyone.


----------



## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> Not everyone.



not one person told me any causes for bloody vomit LOL


But thanks for your support. I was kinda scared to come back!!!


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## JPINFV (Oct 25, 2009)

Miss Xina said:


> not one person told me any causes for bloody vomit LOL



There are ways to get the information you seek online.


----------



## firecoins (Oct 25, 2009)

Sasha said:


> Protocol is get vitals on every patient, poor on scene judgement is "This guy is just a drunk, we don't need no stinkin vitals"



vitals are apart of assessment. I guess they arpart of protocols but I usually refer to what I am suppossed to do once the assessment has been done.


----------



## Sasha (Oct 25, 2009)

firecoins said:


> vitals are apart of assessment. I guess they arpart of protocols but I usually refer to what I am suppossed to do once the assessment has been done.



But why do you do your assesment? Because protocols tell you too  Just nod and agree.


----------



## Onceamedic (Oct 25, 2009)

Miss Xina said:


> not one person told me any causes for bloody vomit LOL



Fair enough! Following is the differential diagnosis of hematemesis, or as you say, the causes for bloody vomit.

    *

      Trauma Causes
          o Benign mucosal tear/esophagus
          o Esophageal trauma

    *

      Electromagnetic, Physics, trauma, Radiation Causes
          o Esophageal burn
          o Esophageal radiation

    *

      Iatrogenic, Self Induced Disorders
          o Nasogastric suction

    *

      Surgical, Procedure Complication
          o Gastroscopy complication/effect
          o Ulcer, anastomotic/stomal/post surgery

    *

      Infectious Disorders (Specific Agent)
          o Leptospirosis/severe (Weils) type
          o Ebola virus disease
          o Yellow fever
          o Aspergillosis
          o Esophageal candidiasis
          o Intestinal anthrax
          o African hemorrhagic (Marburg) virus disease

    *

      Infected organ, Abscesses
          o Stomach abscess

    *

      Neoplastic Disorders
          o Leukemia, acute
          o Zollinger-Ellison syndrome/gastrinoma
          o Adenocarcinoma, gastric
          o Carcinoma, esophageal
          o Esophageal tumor
          o Gastric adenoma (polyp)
          o Stomach leiomyosarcoma
          o Stomach, carcinoma, scirrhous
          o Stomach lymphosarcoma
          o Stomach, leiomyoma
          o Gastrontestinal Stromal/Mesenchymal Tumor (GIST)

    *

      Allergic, Collagen, Auto-Immune Disorders
          o Duodenal Crohn's disease
          o Esophageal Crohn's disease
          o Milk protein allergy/diarrhea
          o Watermelon stomach/GAVE Scleroderma

    *

      Congenital, Developmental Disorders
          o Arteriovenous malformations
          o Generalized essential telangiectasia
          o Intestinal telangiectasia

    *

      Hereditary, Familial, Genetic Disorders
          o Telangiectasia,hereditary hemorrhagic
          o Hereditary coagulopathies

    *

      Relational, Mental, Psychiatric Disorders
          o Bulimia and purging/eating disorder

    *

      Anatomic, Foreign Body, Structural Disorders
          o Gastrointestinal bleeding
          o Gastric ulcer
          o Penetrating duodenal ulcer
          o Peptic ulcer hemorrhage
          o Pulmonary hemorrhage/bleeding
          o Stomach, perforation
          o Upper GI bleeding
          o Channel pyloric ulcer
          o Epistaxis/nose bleed
          o Esophageal ulceration
          o Varices, esophageal
          o Fistula, Aorticoduodenal (Aorticoenteric)
          o Mallory Weiss syndrome(esophageal tear)
          o Gastric varices
          o Dieulafoy's Ulcer Lesion
          o Hemosuccus Pancreatitis

    *

      Arteriosclerotic, Vascular, Venous Disorders
          o Gastric infarct

    *

      Functional, Physiologic Variant Disorders
          o Malingering
          o Vomiting

    *

      Vegetative, Autonomic, Endocrine Disorders
          o Esophageal free reflux/GERD syndrome
          o Gastric retention, acute
          o Cushing/gastric stress ulcer
          o Portal hypertension
          o Hypergastrinemia

    *

      Reference to Organ System
          o Gastritis, acute
          o Duodenal ulcer
          o Disseminated intravascular coagulopathy
          o Gastritis
          o Gastritis, stress, erosive
          o Cirrhosis
          o Esophagitis
          o Peptic ulcer disease
          o Thrombocytopenia
          o Peptic esophagitis, chronic
          o Telangiectasia
          o Renal Failure Chronic
          o Barrett's esophagus syndrome

    *

      Eponymic, Esoteric Disorders
          o Blue rubber bleb nevus syndrome

    *

      Pathophysiologic
          o Bleeding diathesis

    *

      Heirarchical Major Groups
          o Gastric disorders
          o Esophagus disorders

    *

      Drugs
          o Aspirin (Acetylsalicylic acid) Administration/Toxicity
          o Non-steroidal anti-inflammatory drug
          o Corticosteroid Administration/Toxicity
          o Aspirin gastritis
          o Iron intoxication, acute
          o Salicylate intoxication/overdose
          o Drug induced Gastritis.
          o Warfarin (Coumadin) Administration/Toxicity
          o Chemotherapy, cancer (anti-neoplastic)
          o Heparin Administration/Toxicity

    *

      Poisoning (Specific Agent)
          o Baneberry (Actaea) intake/poisoning
          o Puff adder snakebite. (Bitis)
          o Alcohol gastritis
          o Cuckcoopint/Arum/Wake-Robin plant
          o Alkali corrosive/ingestion
          o Caustic agent ingestion
          o Corrosive agent ingestion
          o Corrosive esophagitis
          o Isopropyl alcohol ingestion/poisoning
          o Mercury salts/bichloride acute toxicity
          o Mushroom/Amanita Phalloides poisoning
          o Thallium poisoning
          o Alkali Ingestion/Poisoning

    *

      Organ Poisoning (Intoxication)
          o Corrosive gastritis
          o Gastritis, erosive/corrosive
          o Toxic gastritis/poison
          o Jejunal ulcer/stenosis from K tabs



PS..  when looking for causes of things, google "differential diagnosis" .  That is what will tell you the possible causes of the symptom you are interested in.


----------



## Chimpie (Oct 25, 2009)

> *EMTLife.com Community Guidelines: *The basic ground rules for discussions on our forum are simple: _be polite...._


Let's keep it civil.​


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## daedalus (Oct 25, 2009)

Well, an EMT cannot preform an effective differential diagnosis if they are only using what they learn in EMT class. They would need a much greater foundation in normal physiology and altered physiology than is taught to them intially, which really is an argument for continuing to learn all you can or curthering your medical education.


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## medichopeful (Oct 25, 2009)

JPINFV said:


> There are ways to get the information you seek online.



That's great.


----------



## mycrofft (Oct 25, 2009)

*Protocols versus on the scene calls...*

we are far afield.

Imagine yourself as an administrator trying to make sure a group of energetic partially (versus a doctor, or a paramedic) trained technicians are not over or maltreating the public. Required by law I might add. NOW think about how you would try to make this work.
This will teach you some of why there are protocols and why people who will not follow them need to go somewhere else. Like football and rugby; you want to plat rough, play rugby, because in football you will be benched then thrown out.

PS: The "if the shoe fits wear it" routine is an example of "shooting the choir"; since you can't find or face the culprit who raided the collection plate, you shoot the choir. EVERYONE takes rants to heart*, the the caveat "Only get excited about this if it applies to you" is a sloppy excuse for not emailing or naming folks you have a bone to pick with.



 *Unless they are like me and don't really care a lot of the time.


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## mycrofft (Oct 25, 2009)

*Kaisu!!*

Wow, ZEBRA FARM!!B)


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## zaboomafoozarg (Oct 25, 2009)

JPINFV said:
			
		

> There are ways to get the information you seek online.



And heaven forbid anyone ask here before exhausting all other avenues. This forum is ONLY to be used as a last resort for learning. Duh, Xina, just duh.   ^_^ 



			
				mycrofft said:
			
		

> EVERYONE takes rants to heart*, the the caveat "Only get excited about this if it applies to you" is a sloppy excuse for not emailing or naming folks you have a bone to pick with.
> 
> Unless they are like me and don't really care a lot of the time.




Not sure if you are talking to me Mycrofft, but I definitely fit into the footnote category: I just dun' care! Haha :blush: And if ya were speaking to me, then I will just say that it would be good for everyone to take my "rant" (though I would be very reluctant to call it that. More just like a friendly reminder) to heart even if the shoe doesn't fit, so everyone makes sure they _*!Stay *_Polite!


----------



## Onceamedic (Oct 25, 2009)

mycrofft said:


> Wow, ZEBRA FARM!!B)



Well.. she asked...


----------



## Miss Xina (Oct 25, 2009)

Kaisu said:


> PS..  when looking for causes of things, google "differential diagnosis" .  That is what will tell you the possible causes of the symptom you are interested in.



Thanks. And yep, we definitely didn't cover that.  Just, possible overdose, activated charcoal.

I asked my teacher why it was called "activated charcoal" and if there was such a thing as "deactivated charcoal"

He said he'd never thought about it and I had to find out for myself.

Now I know what to google. This is all that I wanted!!!

I just wonder if that would be the normal response to a NEWBIE asking questions.


----------



## Miss Xina (Oct 25, 2009)

daedalus said:


> Well, an EMT cannot preform an effective differential diagnosis if they are only using what they learn in EMT class. They would need a much greater foundation in normal physiology and altered physiology than is taught to them intially, which really is an argument for continuing to learn all you can or curthering your medical education.



And that is why I am just doing ride time. Not actually working yet. I am well aware that my class didn't prepare me to be on my todd with another basic.


----------



## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> And heaven forbid anyone ask here before exhausting all other avenues. This forum is ONLY to be used as a last resort for learning. Duh, Xina, just duh.   ^_^
> 
> 
> 
> ...



I didn't know I had the power to cause such a fuss!  ^_^


----------



## zaboomafoozarg (Oct 25, 2009)

P.S., I would like to make a formal, polite apology to everyone who read my previous post on page 8. I realize now that telling anyone to lay off of anything is a heinous crime worthy of great chastisement, which I appropriately received in due course, and I would like to completely blot out that remark and quite possibly the very post itself not only from this forum but from the history of humanity itself. If you were one of the unfortunate souls who had to read that grossly indecent comment of mine, I humbly ask your forgiveness of my abominable transgression and would also plead for your gracious mercy.

Yours truly,

Thoroughly Convicted.


----------



## JPINFV (Oct 25, 2009)

Miss Xina said:


> I just wonder if that would be the normal response to a NEWBIE asking questions.



There's a certain bit of research that you should be able to do on your own. For example, I wouldn't ask on here "which muscle is split by the gastric muscle (stylohyoid muscle)" on here because I could very easily look it up online and through my other resources. This would be different than, say, asking for reviews of companies and schools or running through scenarios or calls. You can Google "causes of blood in vomit" while you can't Google "How would you run a call with blood in vomit."


----------



## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> P.S., I would like to make a formal, polite apology to everyone who read my previous post on page 8. I realize now that telling anyone to lay off of anything is a heinous crime worthy of great chastisement and I would like to completely blot out that remark and that comment not only from this forum but from the history of humanity itself. If you were one of the unfortunate souls who had to read that grossly indecent comment of mine, I humbly ask your forgiveness of my abominable iniquity and would also plead for your gracious mercy.
> 
> Yours truly,
> 
> Thoroughly Convicted.



LOL.  I wonder if you'll get a lashing like me. 

One question and you'd think it was the spanish inquisition! 

I forgive you


----------



## Miss Xina (Oct 25, 2009)

JPINFV said:


> There's a certain bit of research that you should be able to do on your own. For example, I wouldn't ask on here "which muscle is split by the gastric muscle (stylohyoid muscle)" on here because I could very easily look it up online and through my other resources. This would be different than, say, asking for reviews of companies and schools or running through scenarios or calls. You can Google "causes of blood in vomit" while you can't Google "How would you run a call with blood in vomit."



Well, now I know not to ask   Maybe I was hoping for a real answer from reliable resources who could somewhat give me a little insight. 

I have learned my lesson *nods solemnly*


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## JPINFV (Oct 25, 2009)

Miss Xina said:


> LOL.  I wonder if you'll get a lashing like me.
> 
> One question and you'd think it was the spanish inquisition!
> 
> I forgive you




...bring me, the *the rack*


----------



## Miss Xina (Oct 25, 2009)

JPINFV said:


> ...bring me, the *the rack*



:beerchug::beerchug::lol:


----------



## zaboomafoozarg (Oct 25, 2009)

Xina, your forgiving kindness precedes you! Thank you, thank you, thank you. 




If it were me, I would have naturally assumed that Xina or whoever asked wanted some insight into the thread as well. 

I mean, if the guy is DRUNK and has bloody vomit, that would prolly narrow the "differential diagnosis" thing down from that huge extensive list that Kaisu posted.



And I dunno about other people, but I would have taken the given information and then attempted to expound of the scenario, if I knew enough about the topic in the first place-- instead of just saying, "Google it, newb."


----------



## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> Xina, your forgiving kindness precedes you! Thank you, thank you, thank you.
> 
> 
> 
> ...



That reminds me of one of many of Dr Cox's rants LOL "newb"

Well, at least I got some information. I can google each and every one of those and have a good study-fest in the comfort of my own home ^_^


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## JPINFV (Oct 25, 2009)

zaboomafoozarg said:


> And I dunno about other people, but I would have taken the given information and then attempted to expound of the scenario, if I knew enough about the topic in the first place-- instead of just saying, "Google it, newb."



To be fair, I Googled it for you.


----------



## Miss Xina (Oct 25, 2009)

JPINFV said:


> To be fair, I Googled it for you.



I THOUGHT SO!! 

and here I was thinking you had made that list off the top of your head! :wacko:


----------



## Sasha (Oct 25, 2009)

Miss Xina said:


> Well, now I know not to ask   Maybe I was hoping for a real answer from reliable resources who could somewhat give me a little insight.
> 
> I have learned my lesson *nods solemnly*



You got real answers from a reliable source... You got taught how to google. The whole bring a man to fish, and teach a man to fish mumbo jumbo. JP taught you how to google/fish. I would depend on reputable pages from a google search than people online due to the sources to back it up.

Also Kaisu gave you a list... so why are you upset?


----------



## Miss Xina (Oct 25, 2009)

Sasha said:


> You got real answers from a reliable source... You got taught how to google. The whole bring a man to fish, and teach a man to fish mumbo jumbo. JP taught you how to google/fish. I would depend on reputable pages from a google search than people online due to the sources to back it up.
> 
> Also Kaisu gave you a list... so why are you upset?



I'm not, Jeez. Did you see a frowny smiley there? You obviously don't get british humour.


----------



## zaboomafoozarg (Oct 25, 2009)

Not that I would be able to see the tears streaming down and flowing all around or anything even if they existed, but I don't think anyone was upset.









oh crap, who am I trying to fool...... *sobs quietly in the corner*


----------



## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> Not that I would be able to see the tears streaming down and flowing all around or anything even if they existed, but I don't think anyone was upset.
> 
> 
> 
> ...




Man, you're lame. I only had one single, lonesome tear roll down my cheek. and I really had to squeeze that one out ! LOL


----------



## zaboomafoozarg (Oct 25, 2009)

Xina, obviously you have not taken the course in which you learn.... *dun dun dun*


Internet Forum Cheapshot Tactic #1: Call other people upset as much as possible, regardless if they are or not, in order to establish superiority and dominion. And to further the greater good, of course.  ^_^ 


It should be in your handbook though.



Sorry BTW, I just weep easy. I'm a sympathetic crier, but I also do a darn fine job of _initiating_ the flood too.


----------



## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> Xina, obviously you have not taken the course in which you learn.... *dun dun dun*
> 
> 
> Internet Forum Cheapshot Tactic #1: Call other people upset as much as possible, regardless if they are or not, in order to establish superiority and dominion. And to further the greater good, of course.  ^_^



OOOH! NOW I get it!

Thanks! In plain English that would probably be called 'bullying" lol

Although, I do fear that I have only been on this site, for what... 3 days? and I have already caused such a stir.

Typical though, women always tend to feel competitive. I wonder if I'll get kicked off of this site because I'm like, totally new and no one would miss me if I vanished mysteriously into the dark void that is known as "real life"


----------



## JPINFV (Oct 25, 2009)

Sasha said:


> You got real answers from a reliable source... You got taught how to google. The whole bring a man to fish, and teach a man to fish mumbo jumbo. JP taught you how to google/fish. I would depend on reputable pages from a google search than people online due to the sources to back it up.
> 
> Also Kaisu gave you a list... so why are you upset?




To be fair, though, I'd consider Kaisu pretty reliable. :beerchug:


----------



## Onceamedic (Oct 25, 2009)

The point I was trying to make by posting that huge list is that no one can answer a question like "what causes vomiting blood?" out of context.  It can be any number of things, as I demonstrated.
The symptom is just a tiny piece of the patient puzzle.  I am sure that as an EMT, one of the things you will learn, or have already learned, is the assessment algorithm.  In the field, we don't write down SAMPLE and ask those questions in that order, but it is vital to get the elements of the assessment and know them cold.  It is only in the context of a million things - many of which you pick up in the first 30 seconds of patient contact, that enable you to answer the question for that specific patient in the circumstances you find them in.  

There is more to the answers given you by the experienced members of this forum than meets the eye.  You have to get really good at figuring things out - especially when it's just you and the patient and there is no one else there to ask.

and don't forget, the patient doesn't read the book 

PS..   aw gosh JPINFV - **blush***


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## Sasha (Oct 25, 2009)

Miss Xina said:


> OOOH! NOW I get it!
> 
> Thanks! In plain English that would probably be called 'bullying" lol
> 
> ...



Hmm... I'm not bullying, your continued sarcasm just seemed to say "upset" to me because the answer wasn't spelled out for you and you were actually challenged.

You've got to remember when posting on an internet forum it is open for all sorts of interpertation and you will get all sorts of opinions, some of which you care to hear and some of which may not agree with your own.


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## Miss Xina (Oct 25, 2009)

Kaisu said:


> The point I was trying to make by posting that huge list is that no one can answer a question like "what causes vomiting blood?" out of context.  It can be any number of things, as I demonstrated.
> The symptom is just a tiny piece of the patient puzzle.  I am sure that as an EMT, one of the things you will learn, or have already learned, is the assessment algorithm.  In the field, we don't write down SAMPLE and ask those questions in that order, but it is vital to get the elements of the assessment and know them cold.  It is only in the context of a million things - many of which you pick up in the first 30 seconds of patient contact, that enable you to answer the question for that specific patient in the circumstances you find them in.
> 
> There is more to the answers given you by the experienced members of this forum than meets the eye.  You have to get really good at figuring things out - especially when it's just you and the patient and there is no one else there to ask.
> ...



Well, they could at least TRY!


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## zaboomafoozarg (Oct 25, 2009)

I get the sense that I'm right on the verge too. Usually happens on the internet. I'm actually quite a pleasant fellow in real life, but the internet just has so many people that need telling, and I Cant. Help. Myself. Aaaaagh! 

So if I disappear quietly (which is counter-characteristic, of course) then you should obviously fear the worse.


 Until then, though, I'm having a good time here. I like this forum. GROUP E-HUG, anyone!?


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## Miss Xina (Oct 25, 2009)

Sasha said:


> Hmm... I'm not bullying, your continued sarcasm just seemed to say "upset" to me because the answer wasn't spelled out for you and you were actually challenged.
> 
> You've got to remember when posting on an internet forum it is open for all sorts of interpertation and you will get all sorts of opinions, some of which you care to hear and some of which may not agree with your own.



I figured my obvious attempt to use as many smilies as possible to illustrate that I was actually joking would have sufficed.


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## Sasha (Oct 25, 2009)

JPINFV said:


> To be fair, though, I'd consider Kaisu pretty reliable. :beerchug:



Me too, but she didn't explain each and every thing on the list. How am I to know why they cause hematemesis? (Provide me a let me google that for you link to each one of those, I dare you! )


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## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> I get the sense that I'm right on the verge too. Usually happens on the internet. I'm actually quite a pleasant fellow in real life, but the internet just has so many people that need telling, and I Cant. Help. Myself. Aaaaagh!
> 
> So if I disappear quietly (which is counter-characteristic, of course) then you should obviously fear the worse.
> 
> ...



I'm up for a bit of E-bonding!

<<<<<HUGS>>>>>

I also find this to be rather entertaining. Worrying, really isn't it?


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## zaboomafoozarg (Oct 25, 2009)

I think sarcasm is more of a technique used to try to alleviate the major _*serious biznezz*_ some of ya'll got goin' on here.


Sarcasm is like the O2 of the internet. Not always a bad thing, and generally applicable everywhere, at least a little bit. 





			
				Miss Xina said:
			
		

> I figured my obvious attempt to use as many smilies as possible to illustrate that I was actually joking would have sufficed.



No. Clearly it is a defense mechanism that indicates your tentative, ultimately failing attempt at holding back mass tears.


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## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> I think sarcasm is more of a technique used to try to alleviate the major _*serious bidness*_ some of ya'll got goin' on here.
> 
> 
> Sarcasm is like the O2 of the internet. Not always a bad thing, and generally applicable everywhere.



I find it makes life generally more tolerable.

But that's just me. Maybe I am like, totally completely upset and I've used sarcasm so much growing up that I never know when I am just being sarcy and when I'm really upset.

I think she's opened up pandora's box...NOOO!!!:unsure:


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## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> I think sarcasm is more of a technique used to try to alleviate the major _*serious bidness*_ some of ya'll got goin' on here.
> 
> 
> Sarcasm is like the O2 of the internet. Not always a bad thing, and generally applicable everywhere.
> ...



Wouldn't it be funny if I had dry eyes and had to use eye drops to create such tears? LOL that tickles me!


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## Onceamedic (Oct 25, 2009)

Oh dear - I have to disagree with you here.  Sarcasm is almost invariable an expression of repressed anger and/or hostility.  I kid you not - psych 101


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## Miss Xina (Oct 25, 2009)

Kaisu said:


> Oh dear - I have to disagree with you here.  Sarcasm is almost invariable an expression of repressed anger and/or hostility.  I kid you not - psych 101



wow, so you must really have sexual fantasies about your mother and your sister has penis envy?

Couldn't it just be that I am british and we use dry, sarcastic humour for EVERYTHING??


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## zaboomafoozarg (Oct 25, 2009)

I called it. I knew you were just blinking it all back, trying to swallow it all down.


This is why forums are dangerous places. It's a dog eat dog world, this new era of internet anonymity.


And as we can see, some people can't handle it! 



Namely... me. :wacko:



_Exit Stage, weeping uncontrollably._


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## zaboomafoozarg (Oct 25, 2009)

So, Xina, the question that comes to mind is....




Could it be that I am british, and I just never knew?  h34r:


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## JPINFV (Oct 25, 2009)

zaboomafoozarg said:


> but the internet just has so many people that need telling, and I Cant. Help. Myself. Aaaaagh!



Do you follow the proper treatment algorithm when people "need telling?"


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## JPINFV (Oct 25, 2009)

Kaisu said:


> Oh dear - I have to disagree with you here.  Sarcasm is almost invariable an expression of repressed anger and/or hostility.  I kid you not - psych 101



I'm a big ball of repressed anger and hostility then...


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## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> I called it. I knew you were just blinking it all back, trying to swallow it all down.
> 
> 
> This is why forums are dangerous places. It's a dog eat dog world, this new era of internet anonymity.
> ...



NOO!!! Don't leave me alone here.. it's a dark, lonely place.. and you're my only beacon of light!


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## Sasha (Oct 25, 2009)

JPINFV said:


> I'm a big ball of repressed anger and hostility then...



I keep telling you...


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## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> So, Xina, the question that comes to mind is....
> 
> 
> 
> ...



Maybe! 

Although, I doubt you're cool enough to be British.

Yes, sarcasm. Maybe I really am hostile to YOU.. EEK! I probably hate everyone I've ever met!


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## Miss Xina (Oct 25, 2009)

JPINFV said:


> I'm a big ball of repressed anger and hostility then...



You probably caught it from all the british comedies you seem to enjoy


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## zaboomafoozarg (Oct 25, 2009)

Guys, it seems as if we are becoming almost too light hearted again.



Which says to me, it's setting us all up for another emotional crash and burn.

Someone better stir the pot again.... effectively letting the gas out the 4th side of the occlusive dressing on this bloody sucking chest wound of a thread.


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## Miss Xina (Oct 25, 2009)

zaboomafoozarg said:


> Guys, it seems as if we are becoming almost too light hearted again.
> 
> 
> 
> ...



what's a blood sucking chest wound? LOL

I'M JOKING!!!!!


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## zaboomafoozarg (Oct 25, 2009)

%@&!%* google it, you ^$#*% %*(@ ^$*% %!@$ %@#!  



!!!!



Oops, I take it back. :blush: <3


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