# Treatment for flail chest



## Epi-do

Just a quick question for everyone (I am also going to do my own research to see what I can find out on my own).

What is currently being taught to EMTs regarding the management of a flail chest?

I ask because we held a physical agility and practical testing today as part of the hiring process.  For the trauma scenario the patient had a flail chest and an open tib/fib fracture.  Of the nine canidates that we had, only three of them even acknowledged the fact that the patient had a flail chest.  Of those three only one used a bulky dressing against the flail segment.  A second put the bulky dressing on the opposite side of the chest as the flail segment, and the third person said they _could_ use a bulky dressing but that BTLS is teaching to no longer do that. (Could anyone out there verify if this is true?)

We were just surprised that the other six didn't even acknowledge the injury and were trying to figure out why that may be.  Thanks for any input you guys may have!


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## firecoins

Epi-do said:


> Just a quick question for everyone (I am also going to do my own research to see what I can find out on my own).
> 
> What is currently being taught to EMTs regarding the management of a flail chest?
> 
> I ask because we held a physical agility and practical testing today as part of the hiring process.  For the trauma scenario the patient had a flail chest and an open tib/fib fracture.  Of the nine canidates that we had, only three of them even acknowledged the fact that the patient had a flail chest.  Of those three only one used a bulky dressing against the flail segment.  A second put the bulky dressing on the opposite side of the chest as the flail segment, and the third person said they _could_ use a bulky dressing but that BTLS is teaching to no longer do that. (Could anyone out there verify if this is true?)
> 
> We were just surprised that the other six didn't even acknowledge the injury and were trying to figure out why that may be.  Thanks for any input you guys may have!




buly dressing on the side of the injury.  Why anyone would put a bulky dressing on the reverse side? I have no idea.  I am told this doesn't really work anyway.


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## MSDeltaFlt

This is from PHTLS 6th Ed.

"Management of flail chest is directed toward pain relief, ventilatory support, and monitoring for deterioration.  The respiratory rate may be the most important parameter to follow.  Pulse oximetry, if available, is also useful to detect hypoxia.  Oxygen should be administered and IV access obtained, except in cases of extremely short transport times.  Support of ventilation with bag-valve-mask (BVM) assistance or endotracheal intubation and positive-pressure ventilation may be necessary (particularly with prolonged transport times).  Efforts to stabilize the flail segment with sandbags or other means are contraindicated."

PHTLS, BTLS, ATLS; they're all sponsored by the American College of Surgeons.

The reason they don't want you to mechanically stabilize the flail segment is because of the pain.  Two or more fractured ribs in two or more places creating a floating segment is going to hurt like hell.  You're not likely to see it in the early phases due to spasms with the intercostal muscles causing a splint of the segment.  You might be able to on palpation if they let you.  Remember, it's going to hurt like hell.

If you see paradoxical movement, it's a late sign.  By then, the pt will be hypoxic and so compromised, you'll need to bag them.  THAT's the definitive treatment.


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## Epi-do

Thanks alot Mike!  I knew someone here would be able to help me out.  I did also find a couple good articles that stated the same as the PHTLS book you quoted.  I passed the information along to those involved in the hiring process (including our EMS chief, so hopefully there will be an upcoming training to update everyone to the latest information).  In our scenario, there was crepitus and diminished breath sounds on the right.  There was also supposed to be unequal rise and fall of the chest.

The reason for not mechanically stabilizing the chest makes total sense.  All in all, it was a good scenario if for no other reason than it made me do some research and learn something new when the day was over.

Again, thanks for you help!


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## TKO

Fascinating!  Anyone have any other information?  What about pain control prior to manual stabilization, ie: sandbag or bandaging?  Isn't the point to reduce movement of the affected chestwall valid?

Any other BTLS/PHTLS revisions that have come about in the last 3 or so years?


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## CPG

Flail Chest.

1. Have pt. take deep breath in, place bulky dressing in hole.
2.  Have pt breathe out while you are holding bulky dressing, and at end of exhalation (sp?) tape in place.


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## EMS179

CPG said:


> Flail Chest.
> 
> 1. Have pt. take deep breath in, place bulky dressing in hole.
> 2.  Have pt breathe out while you are holding bulky dressing, and at end of exhalation (sp?) tape in place.





> This is from PHTLS 6th Ed.
> 
> "Management of flail chest is directed toward pain relief, ventilatory support, and monitoring for deterioration. The respiratory rate may be the most important parameter to follow. Pulse oximetry, if available, is also useful to detect hypoxia. Oxygen should be administered and IV access obtained, except in cases of extremely short transport times. Support of ventilation with bag-valve-mask (BVM) assistance or endotracheal intubation and positive-pressure ventilation may be necessary (particularly with prolonged transport times). Efforts to stabilize the flail segment with sandbags or other means are contraindicated."



Efforts to stabilize the flail segment with sandbags or other means are contraindicated


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## mdtaylor

Flail Chest:

Give BVM to patient. Tell him that forcing air into his lungs will move his chest out together with the flail section minimizing pain. Sucking air in will cause the flail section to move opposite his ribs causing extreme pain.

They will gladly bag themselves.


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## skyemt

it does beg the question...

why, in the EMT curriculum, are we taught to stabilize with a bulky dressing, only to learn afterwards that this is contraindicated?

you can easily see the confusion...

most who have taken PHTLS will not stabilize, and most who have not taken PHTLS will stabilize...

must be an easier way!


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## EMS179

well has anyone seen the most recent "B" curriculum? Does anyone have a book from the past year or so laying around?


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## Sapphyre

EMS179 said:


> well has anyone seen the most recent "B" curriculum? Does anyone have a book from the past year or so laying around?



In class now.  With respect to closed chest injuries, including flail chest, my book (EMT Complete) says:

"If the patient is responsive, identify the specific injury site by questioning the patient and by palpation.  *Attempt to splint the injury site by placing a large trauma dressing, folded towels, or a blanket firmly over the site.*  This will help splint the injury, thereby reducing the pain and allowing the patient to breathe more easily."

So, yes, it's still being taught in B classes to splint a flail chest.


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## seanm028

Sapphyre said:


> In class now.  With respect to closed chest injuries, including flail chest, my book (EMT Complete) says:
> 
> "If the patient is responsive, identify the specific injury site by questioning the patient and by palpation.  *Attempt to splint the injury site by placing a large trauma dressing, folded towels, or a blanket firmly over the site.*  This will help splint the injury, thereby reducing the pain and allowing the patient to breathe more easily."
> 
> So, yes, it's still being taught in B classes to splint a flail chest.



I was taught the same thing.  I was very surprised to see this thread, since I got certified in August last year, and we were taught to place a bulky dressing over the segment and tape it from uninjured side to uninjured side.


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## skyemt

seanm028 said:


> I was taught the same thing.  I was very surprised to see this thread, since I got certified in August last year, and we were taught to place a bulky dressing over the segment and tape it from uninjured side to uninjured side.



yes.. that is the whole point...

everyone is taught to splint the flail segment in EMT class...

it is only after class, if you are in a medic class perhaps, or taking the PHTLS class that you come across information saying that splinting the flail segment is contra-indicated.

the issue i have, is this... according to our county, if there something not exactly specified in the protocols, such as splinting flail chest, the issue reverts back to curriculum used by NYS, which would be to splint...

it is a similar issue with the long board, as i have already gone down this path with the state...  many services can use a full body vacuum splint in place of the LSB... i approached the county with this, as the protocol does not specify what device you can use... since the full body vacuum can become rigid, and has many benefits, i wanted to use them. as per the county, the NYS curriculum specifies the LSB, and no other devices, and that is all we are cleared to use.  they acknowledged that change is in the works, and that clarification is needed, but it is not there now.

i wonder what the take would be on a state level regarding splinting vs. not splinting the flail segment...

perhaps, i will put in a call tomorrow...


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## MSDeltaFlt

skyemt said:


> yes.. that is the whole point...
> 
> everyone is taught to splint the flail segment in EMT class...
> 
> it is only after class, if you are in a medic class perhaps, or taking the PHTLS class that you come across information saying that splinting the flail segment is contra-indicated.
> 
> the issue i have, is this... according to our county, if there something not exactly specified in the protocols, such as splinting flail chest, the issue reverts back to curriculum used by NYS, which would be to splint...
> 
> it is a similar issue with the long board, as i have already gone down this path with the state...  many services can use a full body vacuum splint in place of the LSB... i approached the county with this, as the protocol does not specify what device you can use... since the full body vacuum can become rigid, and has many benefits, i wanted to use them. as per the county, the NYS curriculum specifies the LSB, and no other devices, and that is all we are cleared to use.  they acknowledged that change is in the works, and that clarification is needed, but it is not there now.
> 
> i wonder what the take would be on a state level regarding splinting vs. not splinting the flail segment...
> 
> perhaps, i will put in a call tomorrow...



Regardless of what PHTLS, BTLS, ATLS, or whatever cert you may have shows you even with emperical data, they will also tell you somewhere in the literature to follow your local protocols.  It's a little "save your butt" disclaimer that every book's legal department makes them print before they sell the cotton-pickin' thing.


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## daedalus

As an EMT, you should bandage the flail segment. This may be ancedoctal, but twice before I have seen it help with patient's pain myself. The current version of "Emergency Care" describes the use of a bulky bandage taped in place, 02, and careful monitoring for respiratory compromise.


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## medicdan

Does anyone use/stock or learn how to use the Asherman chest seal? Essentially its a big sticker with a one-way-valve on it. We used them a lot in Israel, and i know they are manufactured here, but I havent seen one.


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## Vizior

emt-student said:


> Does anyone use/stock or learn how to use the Asherman chest seal? Essentially its a big sticker with a one-way-valve on it. We used them a lot in Israel, and i know they are manufactured here, but I havent seen one.




I know of services in NY that have them, but have never seen them actively used.  However, unless the flail chest has caused an open pneumothorax, I don't believe that that device would be of any use in this situation.


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## daedalus

I apologise, it is a bulky dressing bandaged in place. Earlier I state a bulky "bandage" taped in place.


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## jedirye

I am also in medic school, and we have the current PHTLS book which states to not stabilize a flail segmant. However, I just signed up for ITLS at work, and after reading, it states: Be sure flails are well stabilized.

This is the Brady book (ITLS) 6th edition. I believe it is the newest. Sooo... I'm late for my class, catch ya later!

-rye


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## ResTech

I had a patient involved in an MVC with a pneumo and flail chest with paradoxical breathing upon initial assessment. We placed a trauma dressing over the flail segment and taped in place primarily just to provide protection to the flail segment. A bulky dressing helps reduce pain from inadvertent pressures or bumps to the flail segment during field care.


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## Topher38

Bulky dressing thats what I learned, Just got certified a few months ago.


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## Jeremy89

Topher38 said:


> Bulky dressing thats what I learned, Just got certified a few months ago.



Haha, I can't remember half of what I learned and that was just in January... but regarding the flail chest, that's what I recall- using a bulky dressing.


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## ERnurse17

r u talking about a open sucking chest wound.  cause i dont think that flail chests have to be open they can be closed.  maybe i misunderstood you.


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## ERnurse17

CPG said:


> Flail Chest.
> 
> 1. Have pt. take deep breath in, place bulky dressing in hole.
> 2.  Have pt breathe out while you are holding bulky dressing, and at end of exhalation (sp?) tape in place.



Are u talking about a sucking chest wound cause i dont think that flail chests have to be open.  Im sure they could be but the treatment you are talking about is for sucking chest wounds.  Maybe i misunderstood your post.


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## CFRBryan347768

Jeremy89 said:


> Haha, I can't remember half of what I learned and that was just in January... but regarding the flail chest, that's what I recall- using a bulky dressing.



That is very reassuring, thank god your more than 8+ states away LOL:blush:


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## Ridryder911

Okay, maybe before treating or attempting to treat, one should review what flail segments are and what it can produce. There is quite of bit of difference between a flail chest wall and a sucking chest wound. 

Truthfully, I rarely splint or even attempt to splint flail segments. Really, is a padded bulky dressing going to do any good. Might as well give them a pillow and tell them to hold against their chest wall, as someone mentioned earlier the key point is the potential injuries related to the flail segment and the paradoxical movement you will see. Of course a pnuemothorax, but pulmonary contusions and lacerated vessels, in which the detection is the key, and very little treatment is performed at a BLS level. 

Consistent review is essential, if one is not currently working or have a working knowledge. 

R/r 911


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## mikeylikesit

if they already have a pneumothorax though they are screwed unless you can alieviate tension. bulking it down will only apply more pressure and less relief in this situation. so before you place the dressing look for other signs.


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## REMSI Medic 10

Epi-do said:


> Just a quick question for everyone (I am also going to do my own research to see what I can find out on my own).
> 
> What is currently being taught to EMTs regarding the management of a flail chest?
> 
> I ask because we held a physical agility and practical testing today as part of the hiring process.  For the trauma scenario the patient had a flail chest and an open tib/fib fracture.  Of the nine canidates that we had, only three of them even acknowledged the fact that the patient had a flail chest.  Of those three only one used a bulky dressing against the flail segment.  A second put the bulky dressing on the opposite side of the chest as the flail segment, and the third person said they _could_ use a bulky dressing but that BTLS is teaching to no longer do that. (Could anyone out there verify if this is true?)
> 
> We were just surprised that the other six didn't even acknowledge the injury and were trying to figure out why that may be.  Thanks for any input you guys may have!



we were taught to use bulky dressings to hold down a flailed segement.


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## REMSI Medic 10

mikeylikesit said:


> if they already have a pneumothorax though they are screwed unless you can alieviate tension. bulking it down will only apply more pressure and less relief in this situation. so before you place the dressing look for other signs.



but there isn't anything a EMT-B can do for a pneumothorax(or any kind of thorax) in the field without a ALS provider there to help.

 Well, other than 15L non-rebreather and some diesel therapy and wait for ALS to get there.


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## mikeylikesit

REMSI Medic 10 said:


> but there isn't anything a EMT-B can do for a pneumothorax(or any kind of thorax) in the field without a ALS provider there to help.
> 
> Well, other than 15L non-rebreather and some diesel therapy and wait for ALS to get there.



yeah, but you could...not make it worse, do what your trained to do though, cause unless you can make that distinction, it wouldn't be a bad thing to bulk it down to help provide comfprt to your patient.


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## philfry

Our protocol here is if the patient is conscious, splint obvious flail segments with bulky dressing.  If unconscious move straight to intubation and airway protocols.  However, I have yet to see anyone splint any segments...


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## DBieniek

Were some of you guys not required to become a PHTLS (or equivalent) provider prior to obtaining your EMT-B liscense?


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## Epi-do

Here, PHTLS, or any other trauma cert is not required to be an EMT in IN.


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## DBieniek

Oops, I phrased that wrong. It's our company that requires PHTLS, BTLS, etc before being hired. It has nothing to do with getting your card.


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## alex71

i jsut finished my class a few days ago and we were taught the whole time direct pressure and bulky dressings  07/09/08


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## traumateam1

> Does anyone use/stock or learn how to use the Asherman chest seal? Essentially its a big sticker with a one-way-valve on it. We used them a lot in Israel, and i know they are manufactured here, but I havent seen one.


OH! OH! I have one!! But... haven't used it yet... :sad:


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## traumateam1

Getting back to the treatment of a flail chest. Here in BC you are suppose to tape a bulky dressing onto the injured side. That's what it says in the text book. Oh and the obvious watch for resp. destress and then failure.


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## NC-EMT08

I just finished Basic class the beginning of this month with the AAOS book, "Emergency Care and Transport.."  We were taught to stabilize flail segments with a bulky dressing during the rapid trauma assesment after checking for JVD, tracheal deviation, etc.


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## mycrofft

*Res Tech, I'm with you plus some other potshots.*

Welcome to the interface between real world and protocols. Use your local protocol, but Res Tech seems to me to have the best handle. Figure out how to get local protocols to reflect the real world if they don't already.

If I hear the words "pulse ox" again today I'm gonna squeal. (Sorry, been a long day at work). Flail chest is established clinically, and part of the  pretty early presentation is lessening oxygenation. Put on the O2 however you need to and within protocols, but spend not your time on little flashie thingees until the pt is supported. If the O2 sats continue to drop, what are you going to do differently, besides drive faster and maybe attempt to address a hemo/pneuomthorax which also is evident clinically? 

I think the true questions about flail chest revolve around delay and transport: how can you get Vickie Victim or Pete Patient out of the woods after extrication? Any input from the active duty military members? Any ER docs or techs or nurses? Wilderness med folk?


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## gradygirl

In both my Basic and Intermediate classes, we were told to split the fracture site with bulky dressings. After doing some research in medical journals, I have found a common conclusion: while splinting is not necessarily harmful, it is harmful to splint with something heavy or restrictive, such as a sandbag or belt. Sandbags, and the like, are too heavy to allow for adequate chest rise, potentially leading to hypoventilation, etc. Other types of splints do in fact do give some comfort to the patient.

So, it looks like everyone is right. Yes, splinting is ok. No, splinting with overly restrictive devices in not ok. To put a blanket statement that "all splinting is ok" or "all splinting is harmful" is not painting the entire picture..

However, always follow protocols, because as we know, you gotta CYA.


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## PeskyHotDog

I am currently in an EMT class and we were taught to use a bully dressing on the side of the injury.


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## STXmedic

Yup. Treatment hasn't changed much since 5 years ago, when this thread was last replied to...


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## RedAirplane

PeskyHotDog said:


> I am currently in an EMT class and we were taught to use a *bully* dressing on the side of the injury.



Was that dressing being mean to all the others in the jump bag?


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## DesertMedic66

Ishan said:


> Was that dressing being mean to all the others in the jump bag?


It wasn't being mean. It's just misunderstood


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## chaz90

Wow. There are some terrifying replies from earlier in this thread. 

Tension pneumo, flail chest...Eh, what's the difference anyway? I know they both involve the chest-ish area so clearly they should be treated identically


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## Jim37F

Yikes...I had no idea there were people saying don't splint a flail chest....my EMT class basically taught us flail chest=paradoxical movement, paradoxical movement = flail chest and that in our trauma assessment scenarios if we found paradoxical movement we splint it with a big, bulky trauma dressing taped onto the chest over the injury. 

What really got me were some of the replys on the first page mentioning "oh the people who took PHTLS already knew not to do this...." Kinda surprised me since I just did PHTLS a few weeks ago. Granted PHTLS teaching priorities have probably changed in the last ten years or so when those replays were wrote lol but my class spent pretty much no time on specific treatments and a lot of time on assessments but I definitely DON'T remember them saying don't treat a flail chest with a big, bulky trauma dressing taped in place over the injury....

So I just double checked my EMT textbook, my PHTLS textbook and even my Paramedic textbook I have (I do plan on going soon-ish! Lol) and they all pretty much say treat with position of comfort, supplemental oxygen, be prepared to BVM, and diesel bolus to the trauma center...the EMT text says "the patient may find it easier and less painful to breathe if the flail segment is immobilized. You can tape a bulky pad against that segment of the chest for this purpose, although taping too tightly will also prevent adequate ventilation". The paramedic text however disagrees by simply saying "Field stabilization of the flail segment is not recommended" and then goes on to talk about being prepared to ventilated. PHTLS text does agree by saying "efforts to stabilize the flail segment with sandbags or other means that may further comprise chest wall motion and, thus, ventilation are contraindicated".

Funny how the EMT curriculum is basically teaching the exact opposite as what the Paramedic and PHTLS textbooks are saying (even the EMT textbook itself seems to shy away from automatically taping the bulky dressing on, yet that's what they drilled into our heads in lecture :/


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## Flying

Huh, Wikipedia covers flail chest better than the EMT textbook.


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## Frozennoodle

Definitely not splinting the flail chest anymore.


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## BigBadWolf

Just finished class and we were told to lay the patient on the injured side.


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## Amelia

We were taught occlusive dressing taped on one side (or leave a corner open) to let excess air out, control bleeding as much as you can and book it to the hospital. Ps can probably do a lit more though.


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## redundantbassist

Amelia said:


> We were taught occlusive dressing taped on one side (or leave a corner open) to let excess air out, control bleeding as much as you can and book it to the hospital. Ps can probably do a lit more though.


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## Amelia

For the record, that is what Brady EMT 12th edition says. And I will learn the protocol and do whatever they say. Because if I get the job they will pay me so I have to keep them as happy as a cat with a can opener.


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## redundantbassist

Amelia said:


> For the record, that is what  says. And I will learn the protocol and do whatever they say. Because if I get the job they will pay me so I have to keep them as happy as a cat with a can opener.


I'm honestly not sure if you're joking or not


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## DesertMedic66

Amelia said:


> We were taught occlusive dressing taped on one side (or leave a corner open) to let excess air out, control bleeding as much as you can and book it to the hospital. Ps can probably do a lit more though.


Flail chest is not a suckling chest wound.


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## Clare

Sucking chest wound - put a defibrillation pad over it 

Flail chest - do nothing specific, support ventilation, it tensioning do a thoracostomy.


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## redundantbassist

DesertMedic66 said:


> Flail chest is not a suckling chest wound.


Learn something new everyday lol


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## DesertMedic66

redundantbassist said:


> Learn something new everyday lol


Aparrently my phone has heard of a suckling chest wound before. However I have not haha.


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## redundantbassist

DesertMedic66 said:


> Apparently my phone has heard of a suckling chest wound before. However I have not haha.


Joking aside, it is scary to think that there are multiple people, whom i am assuming treat patients on a regular basis, that can't even tell the difference between a flail chest and an open pneumothorax.


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## Flying

redundantbassist said:


> Joking aside, it is scary to think that there are multiple people, whom i am assuming treat patients on a regular basis, that can't even tell the difference between a flail chest and an open pneumothorax.


To be fair, they probably don't encounter those conditions on a regular basis.


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## Handsome Robb

Flying said:


> To be fair, they probably don't encounter those conditions on a regular basis.



That's not a good excuse at all.


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## redundantbassist

Flying said:


> To be fair, they probably don't encounter those conditions on a regular basis.


This is very basic knowledge that every EMT is taught and should know.


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## Flying

I look back. What am I even saying....


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## DesertMedic66

I'm hoping they may have just gotten the terms confused. Hopefully if they see it on a call they will realize the correct treatment.


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## Amelia

OMG I must have been drinking stupid juice last night. Bulky dressings and give them a pillow to hug for stability and for comfort. Sorry guys, after a birthday party in the morning and funeral in the afternoon-my brain was done. I dint know why I was thinking pneumothorax. My fault- probably need to go review chest and abdominal trauma.....

< not the sharpest tool in the shed


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## Amelia

redundantbassist said:


> Joking aside, it is scary to think that there are multiple people, whom i am assuming treat patients on a regular basis, that can't even tell the difference between a flail chest and an open pneumothorax.


1. Seeing it is different from reading it on a message board
2. I have never seen one
3. Way to encourage new EMTs (big thumbs up)


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## Amelia

And wow... Thanks for dragging me through the mud, guys. Just finding my roots in the industry and get stomped on. One terminology switch up and your drug to the stake. I am going to end it here because what I want to say would upset Chimpy, but thank you for being complete ***holes.


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## NomadicMedic

If that gets you upset, you need thicker skin.


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## Tigger

Amelia said:


> And wow... Thanks for dragging me through the mud, guys. Just finding my roots in the industry and get stomped on. One terminology switch up and your drug to the stake. I am going to end it here because what I want to say would upset Chimpy, but thank you for being complete ***holes.


This is hardly getting stomped on. I bet you'll remember the difference going forward.


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## CALEMT

Amelia said:


> And wow... Thanks for dragging me through the mud, guys. Just finding my roots in the industry and get stomped on. One terminology switch up and your drug to the stake. I am going to end it here because what I want to say would upset Chimpy, but thank you for being complete ***holes.



You think this is bad just wait until you do that in front of a medic at a ambulance company or fire dept., pretty sure it will be worse...


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## Amelia

I honestly think you guys think I am more upset than I really am. Unfortunately message boards dont show tone, but yes, I was annoyed, but i really do have a "sheesh" attitude. I made a mistake. I owned my mistake. Case closed. No need for undergarments to get into the mix here. Lets shake hands and move on. Lesson learned!


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## redundantbassist

Amelia said:


> I honestly think you guys think I am more upset than I really am. Unfortunately message boards dont show tone, but yes, I was annoyed, but i really do have a "sheesh" attitude. I made a mistake. I owned my mistake. Case closed. No need for undergarments to get into the mix here. Lets shake hands and move on. Lesson learned!


Don't sweat it. I guess I was being a little too harsh when I was replying to your comments. I had just finished dealing with an employee at work (who is known for not following directions) prior to coming on here and replying to you, so subconsciously I was venting to you. I realize now how minor your mistake was, yet I continued to ream you out, and make myself look like a jackass in the process.

I'm sorry, Amelia.


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## COmedic17

..pee on it.


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## Amelia

redundantbassist said:


> Don't sweat it. I guess I was being a little too harsh when I was replying to your comments. I had just finished dealing with an employee at work (who is known for not following directions) prior to coming on here and replying to you, so subconsciously I was venting to you. I realize now how minor your mistake was, yet I continued to ream you out, and make myself look like a jackass in the process.
> 
> I'm sorry, Amelia.


No worries. I had a rough day too. I was just a little confised because I have only been an EMT for 6 weeks. I really like everyone here and like being here. 

Cheers!


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