# Does anyone carry a thermometer on their bus?



## NYMedic828 (Feb 9, 2012)

This always struck me as ridiculous.

We carry $50,000 in equipment on the average ALS ambulance here in NYC and we don't carry a $50 thermometer...

I personally am terrible at differentiating between someone who has and doesn't have a fever based on touch alone unless the patient is nearly cooking in their own skin.

I don't see why giving us a thermometer, as a tool to aid in ruling out sepsis or infection would be so terrible. I mean the first thing we do when we walk into triage is take vitals and temperature...


The only way I can accurately take your temperature in the field, is by jamming a probe down your esophagus. (Which doesn't work half the time because it gets stuck in the back of the throat and just bunches up)


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## medic417 (Feb 9, 2012)

No when I am on a bus I do not have a thermometer.  Now when on the ambulance I have multiple available.


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## NYMedic828 (Feb 9, 2012)

medic417 said:


> No when I am on a bus I do not have a thermometer.  Now when on the ambulance I have multiple available.


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## DesertMedic66 (Feb 9, 2012)

No we do not carry them on the ambulance. Depending on the fire department, they may have one.


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## medic417 (Feb 9, 2012)

This is sad.  A proper assessment and treatment plan can not be made for a person with fever or hypothermia, etc.  Yes you can make treatment decisions if patient is on the extreme of either end of the temp but not before they get extreme.


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## patput (Feb 9, 2012)

We don't have one on our rigs, but I'm pretty sure everyone has one in their personal jump bags we bring with us on our shifts. I had never thought about it before, but it is rather silly that with all the equipment on board these ambulances we don't have thermometer.


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## SeanEddy (Feb 9, 2012)

Every ambulance service I have worked for stocked oral thermometers. However, I went to CVS and bought my own "temporal" thermometer. It's quick and easier to use on kids. 

I agree, a temp can be an important part of an assessment.


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## 46Young (Feb 9, 2012)

When I worked on NSLIJ's 46Y/53Y/54Y, we had CPAP, but no glucometer or thermometer, so don't feel too frustrated. 

I like the tympanic thermometers we have at my FD. Like 417 said, it assists us in forming our differentials.


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## 46Young (Feb 9, 2012)

patput said:


> We don't have one on our rigs, but I'm pretty sure everyone has one in their personal jump bags we bring with us on our shifts. I had never thought about it before, but it is rather silly that with all the equipment on board these ambulances we don't have thermometer.



Your employer makes you buy your own jump bag and also stock it on your own dime?


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## Aidey (Feb 9, 2012)

We only have hypothermic thermometers. The reasoning is that we don't need normal thermometers because they wont change out treatment plan. I did buy a cheap temporal artery thermometer, but it disappeared and I haven't replaced it.


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## ffemt8978 (Feb 9, 2012)

We've got them on ours.


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## patput (Feb 9, 2012)

46Young said:


> Your employer makes you buy your own jump bag and also stock it on your own dime?



We are an volunteer agency, they supply everything. Maybe jump bag was the wrong word there, I was talking about our personal bags that we bring with us. Most of us through a few useful things (flashlight, leathermen, etc) in our bags along with personal items.


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## bigbaldguy (Feb 9, 2012)

Wow! I just assumed a thermometer was required on all rigs. If someone has a fever we give tylenol especially with peds. We also use to obtain temp in DOA's. Every patient gets temp taken for us it's part of standard work up.


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## WolfmanHarris (Feb 9, 2012)

We had them for about a year, then the trucks went in for standardization and they got pulled for no reason I'm aware of. We managed to keep ours for awhile, but then it disappeared at scheduled maintenance. I miss the damned things.

Though no with a sepsis directive hitting the books in the future, I imagine it'll make a reappearance.


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## medic417 (Feb 9, 2012)

ffemt8978 said:


> We've got them on ours.



Buses carry thermometers there?  :wacko:


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## rwik123 (Feb 9, 2012)

Yup. Tympanic thermometer mounted on the wall.


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## DrParasite (Feb 9, 2012)

Aidey said:


> We only have hypothermic thermometers. The reasoning is that we don't need normal thermometers because they wont change out treatment plan.


pretty much what I was going to say.

out of 4 of our trucks, 1 has a non-invasive thermometer (the one that goes on a patient's forehead).

I don't think I have had a need to gauge an accurate them in almost 10 years (outside of normal vital signs, or drowning/hypothermia).


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## Tigger (Feb 9, 2012)

Ambulance does not, bag at sports medicine job does. Campus health and our doctors want to know what the patient's temp is when we consult with them, I want to know what it is too since it can affect my treatment at the non-ambulance job.


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## Handsome Robb (Feb 9, 2012)

We have one. With covers for the probe. Doesn't get used all that much but we do use it from time to time. Mostly for peds but I have used it on adults as well. Like someone else said, I suck at differentiating febrile vs. afebrile unless they are beating me over the head with the fact that they are cooking themselves internally.


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## Hellsbells (Feb 9, 2012)

I'm quite shocked that there are services out there that don't stock thermometers. The idea it doesn't effect Tx is hogwash, at least in my service, a difference in temp can determine whether we take a pt to a hospital, clinic, or even leave them at home.


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## Remeber343 (Feb 9, 2012)

I agree, it seems strange that a box wouldn't have one. We have our in the box and in all of our aid bags. They come in handy. Our typical vitals consist of bp, hr, temp, chem, 4 lead.


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## Nerd13 (Feb 9, 2012)

We have one on every rig. I have yet to see it read accurately. I don't use it (excluding maybe hypothermia). If you're warmer than me then you probably have a fever. Doesn't change my treatment either way except to raise my level of suspicion for certain problems. We don't carry acetaminophen so I can't really do anything to help your fever if you have one. If you're cold then I'm going to treat that in the obvious ways. 

We did have one crew buy their own temporal scanner. I haven't heard how that's working out for them yet.


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## jjesusfreak01 (Feb 9, 2012)

Wake keeps one in the jump bag, another in the cabinet, and they just installed a thermometer upgrade on the LP15s they use. Protocol requires it before administration of acetominophen for fever reduction.


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## bigdogems (Feb 9, 2012)

We have both oral and rectal (for hypothermia protocol) We are required to have one on every pt. But that is in part that we are going to be participating in some studies and need it as a standard


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## ffemt8978 (Feb 9, 2012)

medic417 said:


> Buses carry thermometers there?  :wacko:



Since you already clarified the whole bus vs ambulance thing, I didn't think it was necessary to clarify any further.

To make you happy, on our ambulances (AKA medical bus/taxi), we have oral, rectal, tympanic, and temporal thermometers.


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## EMT-Tony (Feb 9, 2012)

we carry both oral and tympanic in every truck ALS, BLS, and the medic rapid response unit, guess were spoiled :unsure:


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## truetiger (Feb 10, 2012)

We have a thermometer in each rig and also have protocols for pediatric fever.


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## rescue1 (Feb 10, 2012)

We have tympanic thermometers on our ambulances


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## HMartinho (Feb 10, 2012)

So far as I know, the vitals signs are:

-BP
-Pulse
-RR
-Temp
- Pain.

So yes, it's really important take the temperature in some cases, as part of our assessment.

We carry tympanic thermometers. 

Until now, the best that I know are the tympanic.


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## Sasha (Feb 10, 2012)

We have little peel and stick color changing strips you put on their forehead. 

Still not entirely sure how they work and they don't stick too well. I usually document temp as "cool" "warm" "wnl" "hot" "cold"


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## R99 (Feb 10, 2012)

Yes we carry them, you need to be able to take.a temperature on a patient especially as it can.be a subtle sign of being seriously unwell, and especially before you do things like alternates or leave them at home


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## Tigger (Feb 11, 2012)

EMT-Tony said:


> we carry both oral and tympanic in every truck ALS, BLS, and the medic rapid response unit, guess were spoiled :unsure:



No, you are properly equipped.


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## zmedic (Feb 11, 2012)

Can you please list to me that things that having a thermometer will change in the field? Especially since if people are really sick the best temp is a rectal, which certainly isn't standard of care in EMS. Let me pre-empt some of your possible examples.

1. Pediatric fever- In most places medics can't give tylenol or Motrin, so what does it matter if the kid has a fever in the bus? If the kid feels hot open their blanket and help cool them down. If they seize you treat it, but febrile seizures aren't life threatening and my understanding is controlling with medications doesn't do much to prevent febrile seizures. 

2. Sepsis. How will your treatment of a 75 year old nursing home patient with altered mental status change if they have a fever or not? Are you going to start antibiotics in the field? Are you going to draw blood cultures? Are you going to start fluids that you wouldn't be starting otherwise because they are tachycardic? 

3. Enviromental- First of all you need special thermometers, ones that go above 104 and bellow 94. Secondly this again should be rectal. Thirdly how will this change management? Guy is running around in 100 degree weather. He had hot red skin, altered mental status. Does it change your management if his temp is 101 vs 104? Same goes for hypothermia. It might make some difference in the ER if the patient is 85F vs 93F, but in the ambulance you are going to turn up the heat, blankets, warm IVF. 

I'd argue most of the time in the US the temp is going to distract you from other things you should be doing. To our friends in other countries, I aruge that you have a different system and different training. In the US I think if someone calls an ambulance they should be encourage to go the hospital generally. How hard you push should depend on how clearly it is shanagans. But I don't think a temp should sway you one way or another in most cases. 70 year old calls you for shortness of breath. Yes, if their temp is 101 I'm more worried about a pneumnoia. But if a 70 year old has trouble breathing an no temperature, they still should be in the ER. Conversly if a 35 year old calls because they feel sick, and they have normal vital signs (heart rate, mental status, blood pressure), I don't think that them having a temp of 104 pushes me to have them come to the hospital more than if they don't have a fever. 

My issue is that more information is not always better. If someone wants to advocate for having any treatment or equipment on an ambulance I say great, tell me (ideally back by research) how it will improve safety, efficiency, or patient outcomes. Otherwise it is just increasing cost and distracting from other core tasks (repeat vital signs, finishing paperwork in a timely fashion, gathering additional history.)


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## epipusher (Feb 11, 2012)

Why would you need to carry a thermometer on a school bus?


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## Sasha (Feb 11, 2012)

epipusher said:


> Why would you need to carry a thermometer on a school bus?



So you can keep sick kids home. All must have a normal temp before boarding the bus. 

NO FEVER SHALL PASS.


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## Aidey (Feb 11, 2012)

With more places having "sepsis alerts" I think that is where pre hospital temps are going to be the most useful. One of our hospitals is in the process of testing an in house alert, and one of the criteria is a temp under 97.4 or above 103 (I think those are the numbers).


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## zmedic (Feb 11, 2012)

Aidey said:


> With more places having "sepsis alerts" I think that is where pre hospital temps are going to be the most useful. One of our hospitals is in the process of testing an in house alert, and one of the criteria is a temp under 97.4 or above 103 (I think those are the numbers).



Again I think those temps should rectal, which I'm not sure is so fesible in the field. Also I'd like to see some data that a prehospital temp is going to reduce time to antibiotic administration. I think in most cases there should be signs of sepsis like tachycardia or altered mental status that would clue one in to the possible diagnosis. Also I wonder if people will be falsely reassure by a prehospital temp. 

Now there may be a role for it in the field, but I want to see some good data before I'd recommend if for widespread usage.


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## Aidey (Feb 11, 2012)

Sorry for the brief post before, I was on my phone. At this point the hospital is working on identifying patients who have possible sepsis, and then they are auditing the results to determine if having a sepsis alert is beneficial. 

The hospital testing out the sepsis alert has a list of criteria the patient must meet. The pt has to have a suspected infection, and then at least 2 or more of 5* physiological criteria. 

They are: 
Temp greater than 100.4 or under 96.8
Heart rate above 90
Respirations above 20 or PaCo2 below 32mm/hg
Confusion/Delirium/AMS
high or low WBC count, either above 12,000 or below 4,000.

Right now, we can't measure temp or WBC count, leaving only 3 criteria, and they can all be easily affected by secondary causes throwing off the results. The patient may be on beta blockers or have a pacemaker that prevents their heart rate from rising. There are multiple respiratory diseases that could cause the PaCo2 to stay above 32 mm/hg. The patient may have underlying confusion/delirium/AMS. 

So in the event they institute a sepsis alert program with these criteria we really need to be assessing temperature. I understand that rectal is the best, but the initial temps in the ER aren't rectal. If they get an abnormal reading they double check it rectally. So I think that given these circumstances it may justify checking temps pre-hospital. 

*Well, 6 if you count respirations above 20 or PaCo2 as two separate criteria.


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## triemal04 (Feb 11, 2012)

zmedic said:


> Again I think those temps should rectal, which I'm not sure is so fesible in the field. Also I'd like to see some data that a prehospital temp is going to reduce time to antibiotic administration. I think in most cases there should be signs of sepsis like tachycardia or altered mental status that would clue one in to the possible diagnosis. Also I wonder if people will be falsely reassure by a prehospital temp.
> 
> Now there may be a role for it in the field, but I want to see some good data before I'd recommend if for widespread usage.


No no no, it really needs to be an esophageal temp...of course, that's easiest done when the patient is paralyzed and intubated so...tubes for everyone!  Don't you see, it's the perfect solution; every patient will get an accurate temperature checked, and the number of intubations will skyrocket so high that every paramedic will be getting dozens of intubations yearly.  It's a win win situation!

Or...I may have had to much to drink...:beerchug:

I think it's a worthwhile thing to be able to measure, moreso in patient's who ARE intubated (especially trauma and mandatory in patient's who are post arrest and getting therapeutic hypothermia), but, first off, an accurate way to check needs to be available, and many thermometers aren't.  

The core temp is what needs to be known, and that can be...hard to gauge in some patients.

Once that's done, it won't neccasarily change treatement, but it would hopefully clue providers in that what they are doing/not doing is making the situation potentially worse.

Far as sepsis treatement goes...a fever or hypothermia isn't crucial to the diagnosis.  While it may help some providers to determine what is going on, I'd hope that not having a specific body temp wouldn't dissuade someone from calling a patient septic when all other indicators pointed in that direction.


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## R99 (Feb 11, 2012)

zmedic said:


> Pediatric fever- In most places medics can't give tylenol or Motrin



Except here, Australia, UK, maybe Canada 

Alot of paracetamol is being given for low grade fever and treating it may not be in the best interest of the patient 



zmedic said:


> 2. Sepsis. How will your treatment of a 75 year old nursing home patient with altered mental status change if they have a fever or not? Are you going to start antibiotics in the field? Are you going to draw blood cultures?



Yes and yes

A septic patient can be hot or cold and may present subtly non specifically unwell so a temperature might swing your decision to leave them at home or not

Just because you can't do something doesnt mean the concept is a bad idea


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## Hellsbells (Feb 12, 2012)

_Originally Posted by zmedic  
Pediatric fever- In most places medics can't give tylenol or Motrin_

Yep we give tylenol to peds in Canada too



> Otherwise it is just increasing cost and distracting from other core tasks (repeat vital signs, finishing paperwork in a timely fashion, gathering additional history.)



Yes, of course the 5-10 seconds it takes to get a temp is a great distraction to pt care, and in no way could be considered part of a competent assesment or related to their history.


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## usalsfyre (Feb 12, 2012)

zmedic said:


> Again I think those temps should rectal, which I'm not sure is so fesible in the field. Also I'd like to see some data that a prehospital temp is going to reduce time to antibiotic administration. I think in most cases there should be signs of sepsis like tachycardia or altered mental status that would clue one in to the possible diagnosis. Also I wonder if people will be falsely reassure by a prehospital temp.
> 
> Now there may be a role for it in the field, but I want to see some good data before I'd recommend if for widespread usage.



I believe it's being looked at here.


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## zmedic (Feb 12, 2012)

Like I said in my post, I was talking about in the US. We don't leave people at home unless they refuse.  Giving tylenol to peds doesn't improve outcomes, so what's the rush to do it via EMS via in the hospital? And if the kid doesn't need to be transported, the parents should have tylenol or motrin at home. If they don't, well what does one dose really do? They would need to come in for a script and a parenting lesson. 

You can argue it doesn't add that much time to patient care, but in many US cities transport times are pretty short. If people have so much extra time then why isn't their paperwork done when they are dropping the patient off with me? The run forms show up about an hour later. 

The cost is a big thing. Especially if you are advocating putting an electronic thermometer on every ambulance in america. Which the medical device companies would love. I can think of all kinds of things that would be cool to have on the ambulance. I'm sure that I could come up with arguments about how they could maybe help, but I think we need to get to the point where evidence comes first, then widespread implementation. How about ultrasound on every ambulance? Peak flow meters for asthma? (Whole other discussions)


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## medic417 (Feb 12, 2012)

zmedic said:


> How about ultrasound on every ambulance? Peak flow meters for asthma? (Whole other discussions)



Done and done.  Yes every ambulance should have them.


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## ffemt8978 (Feb 12, 2012)

zmedic said:


> You can argue it doesn't add that much time to patient care, but in many US cities transport times are pretty short. If people have so much extra time then why isn't their paperwork done when they are dropping the patient off with me? The run forms show up about an hour later.
> 
> The cost is a big thing. Especially if you are advocating putting an electronic thermometer on every ambulance in america. Which the medical device companies would love. I can think of all kinds of things that would be cool to have on the ambulance. I'm sure that I could come up with arguments about how they could maybe help, but I think we need to get to the point where evidence comes first, then widespread implementation. How about ultrasound on every ambulance? Peak flow meters for asthma? (Whole other discussions)


What about the rural services with hour long transport times?  While I agree that having a temp won't change my treatment plan, I still think the trend of patient's vital signs (including temp) is important information to give to the hospital.  We usually end up delivering a patient to the ER with at least six sets of VS taken during transport.


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## Aidey (Feb 12, 2012)

I still maintain that if sepsis alerts get implemented thermometers would be beneficial. I do agree there there is not an overwhelming amount of evidence to support their use now. 

If I get started on my peak flow rant we'll never get back on track. I've never understood why we don't use them.


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## Hellsbells (Feb 12, 2012)

> Like I said in my post, I was talking about in the US. We don't leave people at home unless they refuse. Giving tylenol to peds doesn't improve outcomes, so what's the rush to do it via EMS via in the hospital? And if the kid doesn't need to be transported, the parents should have tylenol or motrin at home. If they don't, well what does one dose really do? They would need to come in for a script and a parenting lesson.



I don't really understand why you are against having thermometers in ambulances, honestly, the cost would be quite negligable to have them in every ambulance in the US. If giving antipyretics doesn't result in improved outcomes, as you say, then why even give it to children in the emerg dept? My way of thinking, is that if you begin drug admin enroute, it decreases the workload on staff at the hospital. Furthermore, we can give a dose of tylenol at home, and direct the parents to buy OTC childrens tylenol, and prevent an unessesary trip to the ER. 



> You can argue it doesn't add that much time to patient care, but in many US cities transport times are pretty short. If people have so much extra time then why isn't their paperwork done when they are dropping the patient off with me? The run forms show up about an hour later.



I can, and will, because it doesn't. This is a procedure that takes literally seconds, this argument is bizarre to me quite frankly.


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## usalsfyre (Feb 12, 2012)

zmedic said:


> Like I said in my post, I was talking about in the US. We don't leave people at home unless they refuse.  Giving tylenol to peds doesn't improve outcomes, so what's the rush to do it via EMS via in the hospital? And if the kid doesn't need to be transported, the parents should have tylenol or motrin at home. If they don't, well what does one dose really do? They would need to come in for a script and a parenting lesson.
> 
> You can argue it doesn't add that much time to patient care, but in many US cities transport times are pretty short. If people have so much extra time then why isn't their paperwork done when they are dropping the patient off with me? The run forms show up about an hour later.
> 
> The cost is a big thing. Especially if you are advocating putting an electronic thermometer on every ambulance in america. Which the medical device companies would love. I can think of all kinds of things that would be cool to have on the ambulance. I'm sure that I could come up with arguments about how they could maybe help, but I think we need to get to the point where evidence comes first, then widespread implementation. How about ultrasound on every ambulance? Peak flow meters for asthma? (Whole other discussions)


I had a snarky response, typed up, but thought the better of it. Suffice to say this, unless you are intimately familiar with the specifics of how a chart shows up on your doorstep (including how if the software interface makes any sense and the technology factors involved in moving the chart there) then it's a bit inappropriate to tell EMS to have their charts finished at your convenience. It would be similar to me saying "quit doing anything else until you finish the chart I need to transfer this patient out".  

I've noticed a "just get the patient here so I can work my magic" theme in many of your post. Field implementation of certain things makes sense. If you don't trust your providers to appropriately manage patients, perhaps you should work on improving that aspect. I pointed you to ongoing research about sepsis protocols in the US. I'm told by physicians familiar, if not directly involved with, that research that that research they are seeing significant reductions in time to antibiotic administration and appropriate resuscitation. Granted these are surrogate measures and final data remains to be seen.


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## abckidsmom (Feb 12, 2012)

ffemt8978 said:


> What about the rural services with hour long transport times?  While I agree that having a temp won't change my treatment plan, I still think the trend of patient's vital signs (including temp) is important information to give to the hospital.  We usually end up delivering a patient to the ER with at least six sets of VS taken during transport.



Us too.  And when a febrile patient decides (wink wink nudge nudge) to take tylenol on the scene, our vitals show a break in the fever with antipyretic.  

Still working on getting a fever/sepsis protocol so I don't have to feel nervous at all.


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## medic417 (Feb 12, 2012)

Hellsbells said:


> I don't really understand why you are against having thermometers in ambulances, honestly, the cost would be quite negligable to have them in every ambulance in the US. If giving antipyretics doesn't result in improved outcomes, as you say, then why even give it to children in the emerg dept? My way of thinking, is that if you begin drug admin enroute, it decreases the workload on staff at the hospital. Furthermore, we can give a dose of tylenol at home, and direct the parents to buy OTC childrens tylenol, and prevent an unessesary trip to the ER.
> 
> 
> 
> I can, and will, because it doesn't. This is a procedure that takes literally seconds, this argument is bizarre to me quite frankly.



I am really questioning whether he is a doctor even.  If so seems has not been exposed to much besides his local area.


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## R99 (Feb 12, 2012)

medic417 said:


> I am really questioning whether he is a doctor even..



he's probably a house surgeon or something lol

and you can't leave people at home wtf so u transport everybody?


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## zmedic (Feb 12, 2012)

Wow. Getting personal. 

I'm not going to go into my personal experience, because why would you believe it anyway. I think you should ask yourself "would this guy be hanging out on an EMS forum if he wasn't interested in EMS." And if you don't think I'm an MD, look at my other posts and decide if I know what I'm talking about or not.  To address some of your points. 

1. Research. I trust it when it's done and shows good results. I don't really care about studies that are under way, or analysis done partway through a study. I'll read a study when it is completed and the data is in. Don't care what people are planning to prove. 

2. Again. I'm writing from the perspective of the US. What medics do in England/NZ/Australia has nothing to do with what I'm saying. In other countries where you can leave the patients at home is a different story. Or if you are starting antibiotics enroute. Doesn't apply to US medics with a different level of training and different protocols. 

3: Trending temps. We don't even do that in the ER. Are you really advocating checking temps multiple times during a transport?

4: Prehospital ultrasound is another rant. Just don't have the energy to deal with it. 

5. Directing parents to get over the counter tylenol. I work in an area where people come to the ER to get prescriptions for Motrin so medicaid will pay for it. And giving them tylenol so their fever breaks doesn't improve the outcome, so don't see how there should be any push to giving it earlier. I think giving people things from the ambulance they should be buying over the counter just encourages them to call 911 for crap. Furthermore, there is some evidence that you have a fever so that your immune system works better. Kids the advantage to giving tylenol is that they are less cranky, not life and death. 

6. I'm certainly not a "get them to the ER so I can work my magic person." I'm a "only do things in the field that will make the patient feel better or improve outcomes" person. There are plenty of things that seemed logical, but were removed from protocol because they didn't work. MAST pants anyone? 

7: Charting. Yes I understand other things come first. Like patient care. But EMS makes a big deal of "we're gathering all this data for the hospital." If that data doesn't get transmitted to the docs and nurses in a timely fashion, it's as if it was never really collected. Now you can argue "anything important is communicated verbally,"  but having the run form helps.  Sure, taking a temp doesn't take that much time. But you add 30 seconds here to a call, 30 seconds there, and it adds up. Like starting an IV in trauma. Every medic tells me that they aren't the ones who are delaying transport in trauma. That they can intubate in seconds without stopping compressions during CPR. Yet the data says it adds time.


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## zmedic (Feb 12, 2012)

> he's probably a house surgeon or something lol
> 
> and you can't leave people at home wtf so u transport everybody?



Murphy's law in the US. You tell someone they don't need to go to the hospital you get sued. The best you can do in the vast majority of places here is say "we are happy to take you to the hospital, which we recommend. Now if you want to stay at home and call your doctor that's fine just sign this refusal that says you can die if we leave you here." 

Does it makes sense? No. But if someone calls 911 and says they want to go to the hospital we take them. God help the medic that doesn't.


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## ffemt8978 (Feb 12, 2012)

zmedic said:


> Wow. Getting personal.



Agreed, and suffice to say it has not escaped my attention.


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## BandageBrigade (Feb 12, 2012)

*Please dont take offense*

But...
Zmedic you are not and cannot be writing from a perspective of every system in the US. You obviously have no idea how many systems are run. We carry both temporal and rectal thermometers in all of our ambulances. Temperature is a good aide/indicator for many therapies, such as active rewarming techniques (like using a bear hugger, which we carry). Ever hear of paramedic initiated refusals? Treat and release? We do them, as do many other services in the US, including several of the services that members of this forum are on. We draw labs (including cultures) on many of our  patients. My report is not done for or at your convenience. We have a policy of when they must be completed by. If there is any information you need about care I provided, you can ask when I give report. Otherwise all ERs have my work number.


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## zmedic (Feb 12, 2012)

I agree that I don't speak for everyone in the US. But I've worked in several states and give my perspective based on that.

From the research I've seen at conferences it seemed that when studied paramedic initiated refusal lead to about 10% of refusals that should have been transported to the ER, and my understanding is that not many places were still doing that. 

I understand that many places use thermometers on the ambulances. I'm asking if it's needed. I'm happy to be convinced that it is. Haven't been so far. The example that you gave of active rewarming. Are these patients that you had no idea were cold until they had a subnormal temp? Ie if they are awake they should be able to tell you they are cold. If they are altered and are found in just about any temp bellow 68 degrees they probably would benefit from some level of warming. Homeless patient outside in November? Needs warming. Again, I'm willing to be convinced. If data is out there that prehospital temperatures lead to early identification of sepsis and therefore earlier fluid administration and better outcomes I'd say let's do it. But I want to know if there are other effects. Are people going lights and siren to the hospital because they get a temp of 100.2 in an otherwise stable patient? Are there people who are being falsely reassured that the patient with a temp of 98.9 and a HR of 102 isn't septic? Does BLS need to be taking temps if they aren't going to be giving fluids to these sepsis patients? What is the false alarm rate of the sepsis notification policy? 

Speaking of costs, do we need a Bear hugger on every ambulance? I'm sure the company that makes those heaters and those disposible blankets think so. But it's a lot of money compared to turning up the heat in the ambulance and putting on 5 blankets.

To the forms. Yeah, I understand that it can't always be done by the time that you hit the door. But when I'm riding and I've done my assessment, done my treatment, done that second set of vitals, I'm writing so as much of the form is done as possible when I get there. At the big ERs like where I work now and where I've dropped off patients on the bus, the MD isn't sitting in the room listening to the report unless it's a critical patient or trauma. The RN gets the report. Sure I should be there for every patient that gets dropped off, but the truth is I tend to have 5-6 other patients I'm working on at the same time. 

And it's great you work in a small enough area that the ER has your number. But you want to know what it takes to get in touch with one of the FDNY units? Especially when the nurse doesn't write down their unit number? I'm just saying EMS collects a lot of info that nobody actually reads because it doesn't get matched up to the patient's chart until most of the diagnosis and treatment has already happened.


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## zmedic (Feb 12, 2012)

Speaking of costs, do we need a Bear hugger on every ambulance? I'm sure the company that makes those heaters and those disposible blankets think so. But it's a lot of money compared to turning up the heat in the ambulance and putting on 5 blankets. There are how many ambulances in the US? 
http://www.the-aaa.org/media/ambulance_facts.html
they say about 48,000. So something like a bear hugger is about $500 used for the OR style ones (I'm sure the portable ones are cheaper but lets say $100? That's some big bucks to put on every ambulance. I know thermometers are cheap compared to a lot of medical equipment. I'm seeing about $15 online. So $720,000 to put one on every ambulance. If it helps outcomes, great. But a few dollars here, a few dollars there really add up to healthcare costs. 

That was one of the big advantages to hospitals. They brought a lot of equipment that docs needed in one place and that saved money. So instead of every doctor needed a x-ray machine, and a lab etc there was a common one to use. Putting hospital type equipment out in the field goes in the other direction. If it helps by providing needed care earlier wonderful. But if not, don't do it. (I know I said I wouldn't go into ultrasound, but you want to figure out what it costs to put a $12000 ultrasound on every ALS ambulance in America?)


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## BandageBrigade (Feb 12, 2012)

There is very little you just posted that I can or want to refute. Regarding temps and active rewarming, we do step increments in active rewarming, so as not to rewarm to fast or to warm, therefore temps are obtained. Did I know these patients were cold and needed rearmed? Absolutly. Would blankets and the heater get the job done? Eventually, sure, but not as efficient as I'd like it to be. Any patient that is RSI'd gets temps recorded, preferably repeat ones. Would you be able to catch malignant hyperthermia with temps? You'd better, but it's nice to have. Can you tell your patient is having difficulty breathing without a pulse ox? Yes, but its still nice to have. Regarding the cost of a bear hugger, well we participate in lots of studies and trials for rural medicine and receive lots of grants through it.

Every treat and release or paramedic initiated refusal is reviewed by the medical director and our QA/QI supervisor does a follow up with each of these patients. 

We use Med-Media EmStat 5 for charting, unfortunitly the way it is setup it must be logged in and connect to our system to close out the report. It is very unfortunate that you cannot easily contact field staff, especially for patient care questions. We are provided a work cell phone specifically for this (down side is you have no reason not to answer when work calls you in).


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## BandageBrigade (Feb 12, 2012)

Also - I can't believe that your nurses don't write down a unit number or name.  The nurse always takes my name, and I hers, as well as the doctors name who is taking the patient. It is considered standard practise here.


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## systemet (Feb 13, 2012)

zmedic said:


> Giving tylenol to peds doesn't improve outcomes, so what's the rush to do it via EMS via in the hospital?



* Seems like a nice thing for the child.  Reduces their discomfort and suffering.  

* May prevent recurrence of a febrile seizure in a child with previous seizures.

* May prevent a child without a history of febrile seizures having their first?

Please correct me if any of these points are incorrect.  There's a lot I don't know, especially about peds, and I'm happy to be educated.  Wouldn't an antipyretic also be of benefit if there's a more serious underlying pathology, like meningococcemia?  Just wondering?



> You can argue it doesn't add that much time to patient care, but in many US cities transport times are pretty short. If people have so much extra time then why isn't their paperwork done when they are dropping the patient off with me? The run forms show up about an hour later.



Why does it matter if it add time to patient care if the patient isn't critical and time-dependent?  And why should paperwork be prioritised over patient care?



> How about ultrasound on every ambulance?



Here I think we need to show that it's useful.  That it allows us to identify a subgroup of patients who might otherwise wait in a triage area but that need emergent surgery.

It seems like it's useful in the ED, in more skilled hands.  I think we need to evaluate whether paramedics can use US effectively, and whether it improves outcomes.  I think people are currently doing this.

You mentioned in another post that you have strong opinions about this.  I'd like to hear them, it could be an interesting conversation.



> Peak flow meters for asthma? (Whole other discussions)



This would be great, although now pretty much everyone who looks half sick gets dexamethasone or prednisone.  It might help us avoid doing this unnecessarily.


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## systemet (Feb 13, 2012)

medic417 said:


> I am really questioning whether he is a doctor even.  If so seems has not been exposed to much besides his local area.



Let's not scare off an emergency physician who wants to spend his time contributing to an EMS forum.  We need more physicians actively engaged in EMS.


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## zmedic (Feb 13, 2012)

I'm starting another thread for ultrasound. As to febrile seizure, reducing fever doesn't  reduce the rate of febrile seizure.


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## systemet (Feb 13, 2012)

zmedic said:


> I'm starting another thread for ultrasound. As to febrile seizure, reducing fever doesn't  reduce the rate of febrile seizure.



Odd.  Perhaps my understanding is overly simplistic, but I thought the risk of seizure was associated with the rate that the temperature increased?  I would have expected the incidence of seizure to decrease with antipyretics.

Do you have a link to a decent review handy?


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## Smash (Feb 13, 2012)

systemet said:


> Odd.  Perhaps my understanding is overly simplistic, but I thought the risk of seizure was associated with the rate that the temperature increased?  I would have expected the incidence of seizure to decrease with antipyretics.
> 
> Do you have a link to a decent review handy?




I don't have the references on my iPhone but I recall reading something similar a while back. No-one really knows why febrile seizures happen. At some point during a febrile illness the hypothalamus decides enough is enough and propagates a wave of uncoordinated activity: a seizure. 

However this doesn't seem to be related to absolute temperature or change in temperature. Seizures seem to be as likely as whether the fever is waxing or waning.  There is a hypothesis that the seizures is related to circulating inflammatory mediators rather than temperature (which is of course related to said temperature) but it doesn't seem anyone really knows. 

We don't give anti-pyretics routinely anymore as it doesn't seem to help. We will give Tylenol if the patient is uncomfortable with myalgia for example, but not as a means of reducing temperature in itself, as it doesn't reduce the likelihood of seizures anyway. 

I'll try to find some references tomorrow.  Also, this does not mean that I would argue against thermometers in the ambulance.  We use them routinely in a number of different settings.


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## systemet (Feb 13, 2012)

Smash said:


> I'll try to find some references tomorrow.  Also, this does not mean that I would argue against thermometers in the ambulance.  We use them routinely in a number of different settings.



If you have them, it'd be appreciated, but I can also look this up myself, so don't worry if you're busy.  We used to give tylenol pretty routinely to sick kids, but I've been out of the field for a bit, so things may have changed in my old area as well.


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## systemet (Feb 13, 2012)

Looks like I found an ok reference here:

I'm feeling a little silly, but I'm learning!

========================================================



Arch Pediatr Adolesc Med. 2009 Sep;163(9):799-804.
Antipyretic agents for preventing recurrences of febrile seizures: randomized controlled trial.
Strengell T, Uhari M, Tarkka R, Uusimaa J, Alen R, Lautala P, Rantala H.
Source

Department of Pediatrics, University of Oulu, Oulu, Finland.
Abstract
OBJECTIVE:

To evaluate the efficacy of different antipyretic agents and their highest recommended doses for preventing febrile seizures.
DESIGN:

Randomized, placebo-controlled, double-blind trial.
SETTING:

Five hospitals, each working as the only pediatric hospital in its region.
PARTICIPANTS:

A total of 231 children who experienced their first febrile seizure between January 1, 1997, and December 31, 2003. The children were observed for 2 years.
INTERVENTIONS:

All febrile episodes during follow-up were treated first with either rectal diclofenac or placebo. After 8 hours, treatment was continued with oral ibuprofen, acetaminophen, or placebo.
MAIN OUTCOME MEASURE:

Recurrence of febrile seizures.
RESULTS:

The children experienced 851 febrile episodes, and 89 of these included a febrile seizure. Febrile seizure recurrences occurred in 54 of the 231 children (23.4%). There were no significant differences between the groups in the main measure of effect, and the effect estimates were similar, as the rate was 23.4% (46 of 197) in those receiving antipyretic agents and 23.5% (8 of 34) in those receiving placebo (difference, 0.2; 95% confidence interval, -12.8 to 17.6; P = .99). Fever was significantly higher during the episodes with seizure than in those without seizure (39.7 degrees C vs 38.9 degrees C; difference, 0.7 degrees C; 95% confidence interval, -0.9 degrees C to -0.6 degrees C; P < .001), and this phenomenon was independent of the medication given.
CONCLUSIONS:

Antipyretic agents are ineffective for the prevention of recurrences of febrile seizures and for the lowering of body temperature in patients with a febrile episode that leads to a recurrent febrile seizure.
Comment in


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## bushinspector (Feb 13, 2012)

SeanEddy said:


> Every ambulance service I have worked for stocked oral thermometers. However, I went to CVS and bought my own "temporal" thermometer. It's quick and easier to use on kids.
> 
> I agree, a temp can be an important part of an assessment.



In Oklahoma each truck must have one. It is one piece of equipment that is required by the state


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## triemal04 (Feb 13, 2012)

medic417 said:


> I am really questioning whether he is a doctor even.  If so seems has not been exposed to much besides his local area.


Well since personal insults are accepted again...

I'd say I have doubts that you are even an EMT let alone a paramedic...but there really isn't any doubt about that.


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## ffemt8978 (Feb 13, 2012)

triemal04 said:


> Well since personal insults are accepted again...
> 
> I'd say I have doubts that you are even an EMT let alone a paramedic...but there really isn't any doubt about that.



No they're not and knock it off!


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## kymedic25 (Feb 13, 2012)

Temporal and esophageal probe thermometers here.


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## medic417 (Feb 14, 2012)

triemal04 said:


> Well since personal insults are accepted again...
> 
> I'd say I have doubts that you are even an EMT let alone a paramedic...but there really isn't any doubt about that.



Hi how have you been?  Hope you are having a great day.


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## MedicBrew (Feb 14, 2012)

kymedic25 said:


> Temporal and esophageal probe thermometers here.



Esophageal probe, WOW!! 

Are you currently using it for induced hypothermia, uncooperative patients...?


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## the_negro_puppy (Feb 14, 2012)

What about comfort?

When I have a fever I like to take anti-pyretics


Get a temp, then give tylenol if indicated/ patients wants it

Anyone who says "you dont need thermometers" on Ambulances needs to have their head checked. It is another valuable tool of assessment.


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## kymedic25 (Feb 14, 2012)

MedicBrew said:


> Esophageal probe, WOW!!
> 
> Are you currently using it for induced hypothermia, uncooperative patients...?



Induced hypothermia and intubated patients.


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## Hellsbells (Feb 15, 2012)

Personally, before this topic, I'd have thought there was little cause for controversy over the use of Thermometers in ambulances. To me they are almost akin to other vital signs. I'll agree with Zmedic to the point that they don't typically change our Tx profoundly. However, a temp also helps to form an overall clinical picture of our pt. 

I think it is a huge leap to call for the nessesity of evidence or studies to back up the usefulness of obtaining temps prehospitally. Sure, we could provide studies it is benefical in a sepsis protocol, but then what? Only take temps for pts with suspected sepsis because there is no evidence its effective in the Tx of other conditions? 

Would there be cost to providing all ambulances with thermometers? Sure there would, but Zmedic, you intentionally miscalculate the cost by counting every ambulance in the country. Perhaps people who work for services in the US already equiped can speak to this, but my guess is that procuring thermometers for their respective services has not been an undue financial hardship. Furthermore, I doubt that even the service area you work in would be pushed to the brink of insolvancy were they to do the same.


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## Veneficus (Feb 15, 2012)

If I could? I would like to ignore all of the subsequent nonsense and just talk about the matter at hand.



zmedic said:


> Can you please list to me that things that having a thermometer will change in the field? Especially since if people are really sick the best temp is a rectal, which certainly isn't standard of care in EMS. Let me pre-empt some of your possible examples.



Before we get to all of this, if we are arguing about what a particular piece of equipment changes in the field, we should also do the same for the ED.

I would like to point out, that if we took everything off of an ambulance that didn't have research backing its efficacy, the only thing on there would probably be an AED.

As for research, I have pointed out many times, most of the current techniques in EMS and even more than a handful in the ER are based off of 20+ year old expert opinion. Much of it from emergency physicians whos conclusions are highly suspect.

Let us take the analysis of research one further. One or two studies does not and should not change practice guidlines. Especially here people like to demand the citing of sources and cite one or two studies. 

How many credible medical practices have 1 or 2 citations? 

Because the emphasis of evidence based practice is relatively new in the world of medicine, clinical research on many things, especially in the emergency setting are extremely sparce.

It also doesn't take into account individual experience or intuition, which is just as important to treating patients as quantitative measurement of area under the curve. Especially when the research is mathmatically manipulated to form a bell curve to make a clinical guidline based off of it more palatable.

Do you have a plan to collect usable data on patients who require immediate intervention in the current ethical standards?

While defending the true faith of scientific medicne, please remember that it is generally accepted not to treat patients soley on epidemiology, but by the presentation of the one you actually in front of you.

If 95% of your patients fall under a guidline from validated research, what is the plan for the other 5%? Treat them the same to force them into the guidline and when it doesn't work call it an acceptable loss?

No offense dude, but it doesn't take a doctor to run an algorythm, an NP or PA will work just fine. Why pay more to get the same?



zmedic said:


> I'd argue most of the time in the US the temp is going to distract you from other things you should be doing.



Like what?

What does EMS do that is so complicated or critical that taking a temperature would interfere with it?

A temperature is a vital sign. Is it ok for EMS to have an incomplete set of vital signs when every other provider in every other environment records such?

Why not eliminate BP too? 

Let me just preempt this?

There are plenty of physical findings of hypovolemia and inadequete perfusion.

For medication administration, the numbers are rather arbitrary and vary from agency to agency. Even medical specialty to specialty.

If a patient is tachycardic with clinical manifestations of poor perfusion, is it going to change EMS treatment because you assign a number to it?

On the reverse, if you have a 80 year old lady who is not tachycardic with no physical findings of distress is the fact her bp is 80/60 going to prompt treatment? 

Of course not.



zmedic said:


> In the US I think if someone calls an ambulance they should be encourage to go the hospital generally.



Why so you can bill them?

People who call an ambulance don't always need a hospital. I stipulate they probably need healthcare. Most certainly don't need an ED (and the associated cost) and would likely be better served at a much reduced rate by a GP or urgent care. 



zmedic said:


> But I don't think a temp should sway you one way or another in most cases..



Dr., honestly, how often does a single quantitative finding of anything sway your treatment one way or the other? 1%? 5%?

It is the totality of findings that create a clinical picture, not one. That doesn't change no matter what country you are from, what area of healthcare you practice in, or what level.  



zmedic said:


> But if a 70 year old has trouble breathing an no temperature, they still should be in the ER..



I am going to have to disagree and say they should be admitted to an inpatient service in the hospital. Pneumonia in the geriatric population is not going to resolve with the treatment done in the ED. I would even bet in your institution, there is an age criteria for discharging pneumonia patients from the ED. 



zmedic said:


> Conversly if a 35 year old calls because they feel sick, and they have normal vital signs (heart rate, mental status, blood pressure), I don't think that them having a temp of 104 pushes me to have them come to the hospital more than if they don't have a fever.



??? You cannot be serious. If your neighbor asked you to look at their kid (out of hospital) and the kid had normal vitals and a temp of 99, you would suggest going to a hospital instead of an appointment with a pediatrician or an urgent care?

Really?

If that is the case, you are providing no better medical advice than the algorythms from nurse on call. I would be embarassed to say I was no more helpful than such. I would certainly lose considerable credibility among my superiors and peers. 



zmedic said:


> My issue is that more information is not always better. If someone wants to advocate for having any treatment or equipment on an ambulance I say great, tell me (ideally back by research) how it will improve safety, efficiency, or patient outcomes. Otherwise it is just increasing cost and distracting from other core tasks (repeat vital signs, finishing paperwork in a timely fashion, gathering additional history.)



Funny that, I said the same thing everytime I saw patients get a plethora of tests in the ED which take up far more time, resources, and cost in order to protect the doctor and hospital from legal action. 

Ask yourself, does that really benefit the patient?

Before you answer that though, recall the burdon of proof and cost effectiveness required to institute routine health screenings for various diseases. 

I am not trying to be a jerk (though I may be succeeding) but you cannot possibly demand more of paramedics and at the same time try to tell them what they are already doing doesn't make a difference anyway. 

You cannot tell them not to do something that is standard for every other healthcare provider level in the world and not reduce them to more than a glorified taxi. (Even med techs learn to take temperatures)

Please spare me how the ED is going to save all the poor unfortunate souls of the world until they can admit patients to their service or can treat outpatient healthcare issues at the same cost and effectiveness as a PCP.


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## triemal04 (Feb 15, 2012)

zmedic said:


> My issue is that more information is not always better. If someone wants to advocate for having any treatment or equipment on an ambulance I say great, tell me (ideally back by research) how it will improve safety, efficiency, or patient outcomes. Otherwise it is just increasing cost and distracting from other core tasks (repeat vital signs, finishing paperwork in a timely fashion, gathering additional history.)





Veneficus said:


> Funny that, I said the same thing everytime I saw patients get a plethora of tests in the ED which take up far more time, resources, and cost in order to protect the doctor and hospital from legal action.
> 
> Ask yourself, does that really benefit the patient?


:rofl::rofl::rofl:
I can't help but find it funny.  Not only do you both almost seem to be argueing the same thing, but one of you, or both, also have complained (appropriately) about the lack of education that US paramedics have for the amount of things that we can do.  

Wouldn't it be better to focus on actually learning how to APPROPRIATELY apply the standard therapies that are being done before something else is added?  I'm all for having a way to check a temp, but when to many people can't even figure out what they should do with the information that is currently being gathered...should something else really be added?  

Or should the focus be on figuring out how to use what we have AND THEN adding more?

Being able to determine a core temperature (which most thermometers that I've seen commonly used won't gauge) is good to be able to do and can be an important piece of info.  In certain cases (ROSC hypothermia, trauma patient's, anyone getting tylenol, and maybe sepsis patients) it should be mandatory.  If someone wanted to check it on every patient because it is a "standard" vital sign that's fine; it doesn't take long to check and shouldn't distract anyone.

But...to play devil's advocate...

The arguement that it is a "standard" vital sign is fine but what is it changing?  Hell, even in hospital, in most patients it is NOT being checked except at admission and maybe many hours later.  Ignoring the specific instances I mentioned above, how often will knowing the exact temperature change your treatement?  Will it really change things beyond subjectively realizing that your patient feels hot/cold/normal/warm/cool to the touch and has vitals signs consistent with someone with an elevated/decreased temperature?  Hell, even in a septic patient, if you can't determine that that is the problem in the vast majority of cases WITHOUT knowing their exact temperature, then not having a thermometer is the least of your problems.

It goes right back to what I said above; perhaps before another tool is added the focus should be learning to use what we have.

Veneficus, haven't you mentioned in the past that in the part of Europe you're in many doctors focus more on their hands on exam and history and less on using multiple diagnostic tests?  Perhaps this would be a time to implement that strategy here.


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## Veneficus (Feb 15, 2012)

triemal04 said:


> Veneficus, haven't you mentioned in the past that in the part of Europe you're in many doctors focus more on their hands on exam and history and less on using multiple diagnostic tests?  Perhaps this would be a time to implement that strategy here.



As I said in the post above, temperature is part of the total exam.

To address your concern, it doesn't always have to be exact. (not to omit cases when it does or when it may be useful)

You cannot tell if somebody has a fever simply by placing your hands on them. It is influenced by too many things. Like if you are wearing gloves or your skin temperature relative.

Examples how it comes into play. 

Generally fever is a physiologic defense. Just because somebody has a fever, doesn't mean it should be treated. To do so would inhibit the normal physiologic defense to infection.

However, at some point, a fever can become pathologic, near this point, treating it is the lesser of two evils. Particularly if it is causing the pt considerable distress. 

Because of the reliance of technology and lack of clinical accumen of many modern providers, specific numbers, charts, etc. have been developed to guide treatment. (it seems to me many providers on both sides of the pond rely too heavily on these to make decisions) 

So somebody decided based on some research somewhere, that a fever should be treated if the quantitative measurement is equal or >40C.

Realistically, if your thermometer is a little off, is 1 or 2 degrees either way going to matter? No.

From another perspective, while a temperature does not always present in immunogenic pathology (like sepsis) when temperature is elevated prior to other more specific testing, it provides a clue as to the pathology of complaint. (so you don't always get a clue, it doesn't mean when you do it is less useful)

It is known in pathophysiology that a bacterial infection often causes a higher temperature that lasts longer. Could that perhaps be a clinical finding that is integrated into a clinical picture?  (I certainly think so)

Now if you are one relying on those hard and fast numbers to help you with a diagnosis, well, what can I say? I'm sorry.

What really sets me off about this post isn't really the complaint about lack of paramedic education or intervention. It isn't the apparent tone of the response. (which is why I am not interested in all the who is a doctor who is a medic BS) 

It is first the double standard. 

You can't say "show me the evidence" and complain about effectiveness/cost in one area of medicine and not apply that same standard to your own.

Personally, I think a practicioner in order to be a credit to their specialty should demand a higher level of evidence from their peers than from others, but I would be ok with equal. 

Also, as I keep pointing out. Just because you have a handful of studies (or less) you can't call that evidence. There are too many limitations.

You cannot only accept studies from people within your specialty. There is an inherent bias in that. 

As well, there are limitations to scientific medicine. Not because I want there to be, because the observational methods are not perfect.

Second, like I said, you can't demand more from paramedics (or EMS) and then deny them the simplest of tools (which forces them below standard) because you claim it doesn't change what is done. I could pick out examples of diagnostics that do not change treatments in every discipline of medicne. But they are done because they support or refutes other findings.

I agree. Paramedic and EMS education in the states sucks. It is well below the standards of the rest of the modern world and needs changed.

No arguments there.

But, I can say without doubt, physical exam and history are the most important skills any provider can master. 

Paramedics all over the world, including the US, are uniquely positioned to make great use of these skills as well as perfect them. (by virtue of the limited diagnostics they have) 

That ability does alter treatment. It determines who gets a 12 lead based on suspicion. It determines who gets an IV, and at what rate. It determines medication administration decisions. What protocol to follow. What transport destination. The list goes on.

Yes, paramedics have to learn to use the tools they have before it is reasonable to give them more. But the ability to take a full set of vital signs and integrate those findings into their differential Dx, is something they need to be able to use today, if they can't they are unacceptably deficent.

I am not saying temperature will always be a useful indicator, but as experience does play a role in provider decision making, I have an anecdote.

I was a relatively yound paramedic and it was drilled into me that temperature is a vital sign. That it should be taken as part of such. More so that capilary blood sugar and spo2. 

So I was on an FTO period as a new employee. We went to a call of "difficulty breathing." Found an elderly lady tripoding, definately difficulty breathing. She had dependant edema, a history so long it read like a pathology review but CHF was in there and she did have her own bottle of furosimide. Gave her some oxygen, EKG, 12 lead, albuterol, heard the crappy lung sounds, FTO prompted me that furosimide would be indicated in this lady. 

But I thought, furosimide is contraindicated in pneumonia. (for paramedics of that period in history) CHF patients are prone to pneumonia. So I took a temperature. Which was elevated. I elected not to give the furosimide because of the temperature. In my mind it stood to reason, she takes furosimide, doesn't have this level of difficulty breathing every day, what makes today different?

Because the FTO was hell bent on finding the official Dx (because I am sure he was looking for something negative to say about my not following the protocol like a cookbook, he was one of those guys) the official admitting dx was pneumonia.    

It was the only time in my career as a medic temperature changed anything. But it did. While I would like to say it was an amazing finding that helped the pt. The truth is, it probably helped me more because I didn't get dinged for not following the cookbook and I had an iron clad reason. 

Is it possible she would have had pneumonia and not have an elevated temperature? Of course it is. Would I have given her the furosimide if she didn't have an elevated temperature? I speculate I most certainly would have, of not by my choosing than by order of the FTO.

Maybe giving her the med would have changed nothing in her condition, I am not saying withholding the treatment altered anything for her.

But the finding did alter my treatment decision.

Admittedly, I cannot recall taking a temperature ever again made a difference to me as a paramedic.

It is likely now that furosimide is largely being removed from prehospital medicine, such a situation will never happen again. 

But really, what does a thermometer cost to operate? 

A few dollars over it's life to sometimes provide information that can sometimes be intergrated into a physical exam?

Really if you want to impress me with picking a fight on what shouldn't be on an ambulance, start with cardiac arrest medications or long spine boards.

or the damn MAST. (PASG) whatever you want to call it.

The study showing they are effective at bleeding control in a ruptured AAA with a systolic BP below 50mmhg really didn't impress me.


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## triemal04 (Feb 15, 2012)

I'm not looking for a fight about anything.  I think the ability to check a temp should be one that paramedic's have.  Like I said above, if certain things are done, or situations encountered it should be mandatory.  And even if it's not, I've got no problem if someone wants it checked on everyone.

I also don't work with a bunch of effing morons.  Many do.  In looking at EMS as a whole, adding something, however small it may be without knowing what to do with it, or how to integrate it into everything else that is found is asinine.

It's why things are so :censored::censored::censored::censored:ed up right now.  "Wow...we can do this in the field and it'll make our job so much easier!  But we won't teach anybody about it, after all it's so simple we don't need to!  And even better, we can stop teaching them about something else because of this new thing!"

Sound familiar?

No, you can't always tell if someone is febrile by touching them (and if someone checks that with their glove on it illustrates my point about needing to know how to work with what we have before adding more); but  more often than not you can.  And if you add in the patient's history, physical, surrounding, etc etc (all those things that we are *SUPPOSED* to know how to interpret) you should be able to figure it out the vast majority of times.  Admittedly, not always though.  Hence why I do like the ability to check.

Taking sepsis for example.  As you said, a fever may or may not be there.  Knowing if there is one will definetly *help* with determining, but it should not be the *deciding* factor; if you don't know the exact temp but still do a thourough exam and take a good history...you should have a good idea about what is going on.  I know.  I'm repeating myself.

Look at the patient you mentioned for instance.  Looking back on it, can you honestly say that, based on what you asked and saw then, and what you would have seen/asked knowing what you do now, was knowing a specific temperature the only thing that pointed towards pneumonia?  Or was there more?

From my own experience, excluding the types of patient's I've mentioned previously, I can't honestly say that my treatement or assessment of a patient was every changed by knowing their exact temperature.  Even in patient's that I've given tylenol to, it was clear that they were febrile before I had a number value.  For patien'ts like the one you talked about, there have been things in their history and exam that made me lean towards pneumonia instead of CHF.  And I'm a :censored::censored::censored::censored:ing average paramedic; if I can figure this out then anyone should be able to.  

Obviously, I may be forgetting specific cases, and none of that means that it won't be something that changes what I do in the future.

I don't know where I'm going with this beyond depressing myself.  Should a paramedic have the ability to check a temp?  I agree they should.  Should they *need* to check one to make an appropriate diagnosis in most cases?  No.  Should it be used as a crutch to make up for a poor assessment?  No.  Do they need to know how to integrate that information into the rest of their exam?  Yes.

Right now, as a country, we aren't there.


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## Veneficus (Feb 15, 2012)

*sorry*



triemal04 said:


> I'm not looking for a fight about anything.  I think the ability to check a temp should be one that paramedic's have.  Like I said above, if certain things are done, or situations encountered it should be mandatory.  And even if it's not, I've got no problem if someone wants it checked on everyone.
> 
> I also don't work with a bunch of effing morons.  Many do.  In looking at EMS as a whole, adding something, however small it may be without knowing what to do with it, or how to integrate it into everything else that is found is asinine.
> 
> ...



I meant collective "you," not you personally.

To answer your question honestly, aside from the history and suspicion of new onset, temperature was all I had to defeat the cookbook. So I went with it.

If it makes you feel better, I use serial temperatures on my daughter when she gets sick to decide if I will give her something or not.

I know when she is sick without the temp. But I guess you could say it guides my decision. But I give it a +/-1


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## Tigger (Feb 15, 2012)

Temperature is a vital sign, is it not? It might not be for EMS, but it is in the rest of healthcare. Even working on a straight BLS truck I'd like a thermometer so I can give the temp as part of my report.

Bigger hospitals that have ambulance triage probably have "communal" thermometers, but when you roll into a small (or big I suppose) ER where the patient goes straight to the room it seems like passing along the fact that the patient has a fever might be good. 

I'm also tired of taking clear UTI patients into ERs and having someone asking for his temp and being forced to sheepishly respond "a little warm."


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## rmabrey (Feb 16, 2012)

We have them. Do we use them? No. It's a pain to get them out of the drug box, if you even have one, temperature doesn't change treatment. The ER will check anyway. 

Sent from my Desire HD using Tapatalk


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## Hellsbells (Feb 16, 2012)

> It's why things are so ed up right now. "Wow...we can do this in the field and it'll make our job so much easier! But we won't teach anybody about it, after all it's so simple we don't need to! And even better, we can stop teaching them about something else because of this new thing!"
> 
> For patien'ts like the one you talked about, there have been things in their history and exam that made me lean towards pneumonia instead of CHF. And I'm a ing average paramedic; if I can figure this out then anyone should be able to.



So, to be clear, you argue that Thermometers should not be placed on the ambulance because practitoners can not or will not be trained to use them?  Yet, on the other hand any middling paramedic can tell the difference between CHF and pneumonia without the aforementioned tool?




> We have them. Do we use them? No. It's a pain to get them out of the drug box, if you even have one, temperature doesn't change treatment. The ER will check anyway.



Thank you great sage, for finally settling this argument.


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## triemal04 (Feb 16, 2012)

Hellsbells said:


> So, to be clear, you argue that Thermometers should not be placed on the ambulance because practitoners can not or will not be trained to use them?  Yet, on the other hand any middling paramedic can tell the difference between CHF and pneumonia without the aforementioned tool?


No, I don't think a thermometer should be placed on an ambulance until every provider is capable of using the tools that are allready available to them.  That includes the ability to take a good history, perform a good physical exam, take in the entire situation and then process that information.

I think a large part of why things are so screwy down here is illustrated by this whole arguement, and I said it in my last post.  Instead of teaching people how to think they're being given a tool that acts as a crutch, and can be, and often will be, misused.

Yes, even something as simple as a thermometer.  If the basic knowledge and abilities aren't there, it can screw things up.  I can talk about the patient's that I've seen brought into the ER who were treated completely innapropriately by the ambulance crew because they found a fever and decided that was the real issue.  It does happen.  

Why not learn to work with what is there first, and then add more tools as they become needed?

As an aside, I thought I was clear about this; in the vast majority of cases, if a thorough history/physical is done and someone with half a brain thinks about it, knowing a specific numeric value for someone's temperature should not be what makes or breaks their diagnosis.  Now, I'm not going to pretend that is the case nationally right now; I know there is a ways to go before we get there as a whole.  But why not look at it like that?  Everybody always talks about adding to the paramedic scope and abilities, but seems to forget that many right now can't even do the basics appropriately.

It's how we got in this situation in the first place.


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## triemal04 (Feb 16, 2012)

Veneficus said:


> I meant collective "you," not you personally.
> 
> To answer your question honestly, aside from the history and suspicion of new onset, temperature was all I had to defeat the cookbook. So I went with it.
> 
> ...


Be more specific if you can, I'm honestly curious about this.  Looking back, do you think that, *knowing what you do now*, if you were to examine that same patient using the same physical resources you had then but your current knowledge, that you wouldn't be able to find/illicit something in either the history or exam that would point towards pneumonia?

The last line is part of what I've been trying to say.  You should allready have an idea of what is going on without checking.  It can help with figuring out what the problem is, but shouldn't be the only thing.


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## Veneficus (Feb 16, 2012)

triemal04 said:


> Be more specific if you can, I'm honestly curious about this.  Looking back, do you think that, *knowing what you do now*, if you were to examine that same patient using the same physical resources you had then but your current knowledge, that you wouldn't be able to find/illicit something in either the history or exam that would point towards pneumonia?



KNowing what I know now, I am fairly certain I could have elicited a historical response and my ability to listen to and differentiate lung sounds is much better now than as a paramedic. I could also use percussion as a useful tool.

As a new paramedic I did not have such insights. I admit, I needed the crutch.

Having said that however, as I mentioned in my n=1 anecdote, without the quantatative number, I would have been hard pressed to convince the FTO otherwise, even with the knowledge I have today.

If having paramedics take a temperature stops somebody from following through a line item cookbook, then as far as I am concerned they are worth exponentially more than they cost. 



triemal04 said:


> The last line is part of what I've been trying to say.  You should allready have an idea of what is going on without checking.  It can help with figuring out what the problem is, but shouldn't be the only thing.



I had an idea what might be going on then. But I had no way to convince somebody else. 

Would a doctor take into account such suspicion. I think so. BUt we have to be realistic about something that has gone on in EMS for ages. 

The new people coming out of school have better/more up to date education than many of the older people. (the same is true in medicine) 

However, the pseudocommand structure in most of EMS in the US does not permit the same discussion before forming treatment modalities that a junior doctor speaking to a senior doctor does.

As much as I would like to see it, I don't think it is really realistic in the US to put somebody with my education on an ambulance though. 

In order to match that, you are talking about more than a decade of experience and education combined with 6 years of graduate medical and concentrated pathophysiology education. 

You can't get paramedics to a minimum of an associates degree.

How could you possibly compare the proficency of a new medic (me or otherwise) to a rather extensively educated and experienced provider? (forget things like talent and intellect, stick with the measurable things)

I have spent more hours researching "small" topics like aneurysm and AKI for my pathophysiology requirements(4/6 months respectively, 6-8 hours 6 days a week, averaged out to 1680 hours for those 2 topics) than most paramedics have total hours in class in their whole education.

It also gives me considerably more insight than my peers who only study medicine. 

Sorry to say, but paramedics are going to need some crutches until at least a 4 year degree is mandatory and probably even then.


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## Hellsbells (Feb 18, 2012)

> The last line is part of what I've been trying to say. You should allready have an idea of what is going on without checking. It can help with figuring out what the problem is, but shouldn't be the only thing.



Personally, I don't think a thermometer is a magic wand, to be waved over a patient, resulting in an ironclad Dx, as you say its just one part of a larger picture. Why do you think basics or Paramedics can't be taught how to use this tool. In my experience, when new equipment is put on the unit, we get an appropriate inservice on how it works. 

I'll admit, I don't work in the US, but personally I can't see the addition of a thermometer on the unit being such a timebomb, it results in misery, blown assessments and lazy Hx by all who touch it. 

triemal04, I'll ask you, what would it take to convince you a practitioner was properly trained to use this tool?


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## triemal04 (Feb 21, 2012)

Hellsbells said:


> Personally, I don't think a thermometer is a magic wand, to be waved over a patient, resulting in an ironclad Dx, as you say its just one part of a larger picture. Why do you think basics or Paramedics can't be taught how to use this tool. In my experience, when new equipment is put on the unit, we get an appropriate inservice on how it works.
> 
> I'll admit, I don't work in the US, but personally I can't see the addition of a thermometer on the unit being such a timebomb, it results in misery, blown assessments and lazy Hx by all who touch it.
> 
> triemal04, I'll ask you, what would it take to convince you a practitioner was properly trained to use this tool?


I do think that paramedics, EMT's, or even a random person off the street could be taught how to use a thermometer and appropriately interpret what they find in connection with everything else they have seen/heard/found/touched/etc/etc.  I think that paramedics should be taught how to do that.

That is the problem though.

I've come across probably stronger than neccasary on this, but this is a nice microcosm of where EMS in the US is at.  To answer your question, once someone can take an appropriate oral history, perform a thourough physical exam, understand how a patien'ts surroundings fit in, interpret a medication list, understand some basic medical concepts and understand some basic pathophysiology and know about diseases (you get the point I'm sure so I'll stop), fit all that information together and come up with a pretty good idea of what is going on without more than a few simple tools (or not so simple in some cases), then there wouldn't be any reason not to have that, or many other things available to them.

But until they can understand all that, adding a new piece of information may do nothing more than confuse someone.

If you want to skip all that, basically until someone can come up with as accurate a diagnosis as possible without something, and be able to interpet a new finding without getting confused, nothing else should be added.

It's not that this is a "timebomb," though I flat out gaurentee that it would cause many people to treat/not treat patient's innapapropriately.  It's only been what I've seen, though I'm sure you'd find many similar stories if you polled ER personell, but I can give you several examples.  Like I said earlier, it's just another example of how things got so screwy down here.


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## triemal04 (Feb 21, 2012)

Veneficus said:


> KNowing what I know now, I am fairly certain I could have elicited a historical response and my ability to listen to and differentiate lung sounds is much better now than as a paramedic. I could also use percussion as a useful tool.
> 
> As a new paramedic I did not have such insights. I admit, I needed the crutch.
> 
> ...


Sure.  And I'm not suggesting that paramedic's need to be educated to the MD level; just that if more time was spent on assessment skills and overall knowledge that it would be a better idea and have better overall results than filling the knowledge gap with equipment.



Veneficus said:


> I had an idea what might be going on then. But I had no way to convince somebody else.
> 
> Would a doctor take into account such suspicion. I think so. BUt we have to be realistic about something that has gone on in EMS for ages.
> 
> ...


That can definetly be a problem.  There's always people out there who can literally have the solution staring them in the fact and not see it.

I still stand by the point that, unless you truly understand how to function *without* something to the best of your ability, and then get properly taught how to use, and intergrate a new tool into you assessment, you should not be using it.  And if that tool is used as a crutch to make up for that lack of education, that is the time when you are more likely to find people misusing it.

In your example, you found a fever, though potentially you also could have determined it was pneumonia another way.  In my examples, people have found a mildly elevated temp and decided that the acute bronchospasm from the patient's longstanding COPD was pneumonia and didn't need treatement.  Or the near-classic cardiac chest pain in patient's with and without distubring histories was pain from pneumonia because they found a fever.  

Without knowing how to use it, and having the background to use it, it can go both ways.



Veneficus said:


> As much as I would like to see it, I don't think it is really realistic in the US to put somebody with my education on an ambulance though.
> 
> In order to match that, you are talking about more than a decade of experience and education combined with 6 years of graduate medical and concentrated pathophysiology education.
> 
> ...


Again, that wasn't what I was suggesting.  Simply that until people can work with what they allready commonly use (in the US) and perform some basic things, there is no point in adding more.  If you did would it help in some cases?  Sure, but it would also cause problems in some cases.  



Veneficus said:


> I have spent more hours researching "small" topics like aneurysm and AKI for my pathophysiology requirements(4/6 months respectively, 6-8 hours 6 days a week, averaged out to 1680 hours for those 2 topics) than most paramedics have total hours in class in their whole education.
> 
> It also gives me considerably more insight than my peers who only study medicine.
> 
> Sorry to say, but paramedics are going to need some crutches until at least a 4 year degree is mandatory and probably even then.


That is unfortunately the type of thinking that has gotten the EMS system here so screwed up.  Not pointing fingers, but it really is.  Instead of trying to fix things, bandaids are just thrown on the problem which only makes things worse.  In some cases the bandaids may work, but on a national level, looking at everyone concerned, they really don't.


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## EMS123 (Feb 22, 2012)

Have an ear thermomete in each rig... used mostly for peds even though not in NYS BLS Protocols.


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## MasterIntubator (Feb 22, 2012)

Original question:  Yes. 3 of them.  Oral/Ax, Rectal, temporal thermometers.  And use them regularly.


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