# Radial Artery Bleed



## Shabo

Guys,  I recently completed an ER clinical where we had a pt arrive by BLS truck with a 1-2 cm lac to the middle of the rt forearm. The elderly pt had apparently been bleeding for a while before help arrived. Pt was Alert upon BLS arrival and the bleeding was uncontrolled. They attempted to stop the bleed but couldn't and wrapped it in gauze and a cravat for transport. The pt completely decompensated before arrival to the ER and resuscitation was unsuccessful. I was hoping that you could help me with a few questions.

1. How long do you think it would take to bleed out from this wound? (meds unknown)
2. Is there a reason a tourniquet wouldn't be applied?
3. What would your response have been?

Thanks,
Shabo


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## Jon

Time to bleed out?

I've been told, anecdotaly, that if you slit your wrist the "right way" to kill yourself, you will only be able to slit one wrist (because you won't be able to make the slit wrist arm work to cut the other one) and that you will die very quickly.

In First Aid, for the last few years, torniquets have been "frowned on" because there is concern for ischemia of the appendage. My BLS protocols call for a torniquet only if the exsanguination is uncontrollable, where the descion is between a possible amputation of the arm or the patient dying. This is only after all other methods have failed.

As for why BLS didn't use a TQ... well, their protocols may not allow it, the EMT's may be under the impression that a TQ is evil (like leeches), and the EMT's may not have felt that the bleeding was really uncontrolled.

Might I have used a tourniquet? Perhaps... I wasn't there... I can't say what I would have done.


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## Ridryder911

In my thirty years, I have yet seen anyone die from "slit wrist".. and I have seen some real nasty ones that even caused amputations. Usually the vessels will constrict initially and there may be even little bleeding. 

Second, I do not understand allowing anyone to exsanguinate out. Direct pressure, pressure points should be able to control any extremity bleeding. I have even used a blood pressure cuff pumped just tight enough to cease the arterial flow on a patient that was on Coumadin. (This was per physician orders).. 

Many people "spazz" over bleeding, chances are they did not hold enough pressure or long enough. Many attempt to pull off bandages and place new ones, this is just like pulling off scabs.. allowing bleeding to occur. 

R/r 911


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## Guardian

Shabo said:


> Guys,  I recently completed an ER clinical where we had a pt arrive by BLS truck with a 1-2 cm lac to the middle of the rt forearm. The elderly pt had apparently been bleeding for a while before help arrived. Pt was Alert upon BLS arrival and the bleeding was uncontrolled. They attempted to stop the bleed but couldn't and wrapped it in gauze and a cravat for transport. The pt completely decompensated before arrival to the ER and resuscitation was unsuccessful. I was hoping that you could help me with a few questions.
> 
> 1. How long do you think it would take to bleed out from this wound? (meds unknown)
> 2. Is there a reason a tourniquet wouldn't be applied?
> 3. What would your response have been?
> 
> Thanks,
> Shabo




I tourniquet is a great thing if used by educated medical professionals (paramedics) and not boy scouts--lol.  Talk to trauma surgeons and they will tell you they use them routinely for hours in the operating room.  In 99.9% cases like the one you mentioned, a tourniquet would not be needed.  I would do what I've been trained to do.  Remember your 4 Ps.  Pinpoint, prompt, precise, pressure.  Don't just hap-hazardly wrap the wound with gobs of dressing.  Then elevate the extremity. I would be willing to bet money this would have worked.  If not however, use the BP cuff and partially constrict it.  Then as a last resort, cut off all blood flow with the big T of some sort.  This all should be done very quickly and calmly.  There are some cases where you may have to "clamp" an artery shut with a tool, but I'm not going there.

And let me end this with a public service announcement.  If you completely cut thought an artery, the body will restrict (suck up) that artery and stop the bleeding itself.  The key to killing yourself is to only partially cut an artery.  That way, you will bleed and bleed and the artery won't be able to constrict itself.  good luck!


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## Nycxice13

in NYC it is against protocol to use a tourniquet (as well as a BP cuff to constrict blood flow, which is acting as a tourniquet)


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## Guardian

Nycxice13 said:


> in NYC it is against protocol to use a tourniquet (as well as a BP cuff to constrict blood flow, which is acting as a tourniquet)



yea, nyc routinely goes against recognized national standards of care and common sense.  I feel for you.  There is good news though, protocols are just guidelines so screw em'.


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## Nycxice13

Guardian said:


> yea, nyc routinely goes against recognized national standards of care and common sense.  I feel for you.  There is good news though, protocols are just guidelines so screw em'.



Has nothing to do with going against common sense, has to do with the fact that in NYC you are never more than 5 minutes from a hospital. If you apply the right skills to control bleeding, you should make it to the hospital before it gets any worse.


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## Guardian

Nycxice13 said:


> Has nothing to do with going against common sense, has to do with the fact that in NYC you are never more than 5 minutes from a hospital. If you apply the right skills to control bleeding, you should make it to the hospital before it gets any worse.



what if someone is pinned in a car and has already lost enough blood to put them in compensated shock.  What if the extrication takes 40 mins for some reason.  what are you going to do then?  NYC is a great place, but their ems is stone age.


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## Nycxice13

Guardian said:


> what if someone is pinned in a car and has already lost enough blood to put them in compensated shock.  What if the extrication takes 40 mins for some reason.  what are you going to do then?  NYC is a great place, but their ems is stone age.



If they have that many problems, they ain't making it. Be realistic, not outlandish.


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## Guardian

Nycxice13 said:


> If they have that many problems, they ain't making it. Be realistic, not outlandish.



Lets say the only problem they had was an uncontrollable arterial bleed in the right leg and they were "trapped" with no other injuries.  Don't play this game with me.  And this is a completely reasonable scenario.


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## Nycxice13

If it is going to take 40 minutes to extricate him, hes not making it.


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## Guardian

Here's a little challenge to the great readers of this site.  You show me a protocol and I guarantee I can come up with a reason it can and should be disobeyed.


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## Guardian

Nycxice13 said:


> If it is going to take 40 minutes to extricate him, hes not making it.



 Can someone live 40 mins with a Tk on their leg?  Of course they can.  I'm not going to argue anymore.


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## Nycxice13

besides, if it is a 40 minute extrication, how the heck do you suppose I apply a tourniquet?


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## Guardian

reach in through the 1 ft of clearance you have though the windshield.  Now really, we got to stop this.  And by the way, I've had calls like this.  You better get this straight in your mind before it happens.  You're going to feel pretty bad when someone dies for no reason other than your inability to see protocols for what they are.  I know this probably goes against you marginal emt training, but now that you here, you should try and open you mind up to new ideas.  They can't say enough good things about tks since the war started in iraq.  It can take hours to do any major harm with tks.  Read and know that this world isn't black and white and protocols.


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## Recycled Words

Nycxice13 said:


> Has nothing to do with going against common sense, has to do with the fact that in NYC you are never more than 5 minutes from a hospital. If you apply the right skills to control bleeding, you should make it to the hospital before it gets any worse.



Exactly. New Jersey (or at least the part where I work) has the same protocol because within a 10 mile radius, we have 5 hospitals including a trauma center. The rule makes sense. For the same reason, we don't carry activated charcoal on our rigs and we don't get medics half the time we need them because the ride is too short for us to bother waiting for them once we're on scene.


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## Jon

Guardian said:


> Here's a little challenge to the great readers of this site.  You show me a protocol and I guarantee I can come up with a reason it can and should be disobeyed.


Guardian - I belive you... and I can probably think of some of the same reasons... I'll have to look through my protocols and find a "good" one for you


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## Jon

Nycxice13 said:


> If it is going to take 40 minutes to extricate him, hes not making it.


 
What, exactly, lets you say that? I've had vehicle extrcations where the second patient cannot be accessed until the first is packaged and removed, dramatically increasing the exrication time. Also, out here, the VFD often arrives after us, and if it is an exended extrication, it can take a few minutes for them to stage their tools and crib the vehicle... increasing your extrication time. I know that the NYPD ESU guys are great (FDNY's Rescue and Ladder guys are also great )... but even the best take time to do it RIGHT. A 40-minute extrication time is unusual, but not automatically fatal.



Guardian said:


> reach in through the 1 ft of clearance you have though the windshield. Now really, we got to stop this. And by the way, I've had calls like this. You better get this straight in your mind before it happens. You're going to feel pretty bad when someone dies for no reason other than your inability to see protocols for what they are. I know this probably goes against you marginal emt training, but now that you here, you should try and open you mind up to new ideas. They can't say enough good things about tks since the war started in iraq. It can take hours to do any major harm with tks. Read and know that this world isn't black and white and protocols.


 
Right.... however, some folks will use the arguement that the MAST-Pants were "the next great thing" duing the Vietnam era.... and look what happened to them.

I agree that tourniquets have a place for use by trained professionals, and even boy scouts, when ALL OTHER METHODS fail... BSA still teaches Tourniquets, as a last-ditch measure after direct pressure, elevation, and pressure points fail to stop the bleeding. 




Recycled Words said:


> Exactly. New Jersey (or at least the part where I work) has the same protocol because within a 10 mile radius, we have 5 hospitals including a trauma center. The rule makes sense. For the same reason, we don't carry activated charcoal on our rigs and we don't get medics half the time we need them because the ride is too short for us to bother waiting for them once we're on scene.


 
The idea that "you're 5 minutes from the hospital" works just fine... until the fecal matter hits the ventilation device... then you are up a creek without a paddle, and open to lawsuits.... Can you see youself on the stand: "Why did my client die? Becuause Joe EMT decided that they didn't NEED to carry actvated charcoal because they were close to a hospital.... but during the blizzard, after my patient ingested 400 tylenol and the ambulance broke down in the middle of the Blizzard... They failed to have the appropriate medication on hand, and my client died... The family needs 50 Million dollars for pain and suffering."

I realize it isn't your choice, really, as to how your service stocks their rigs... but as Guardian already pointed out... a prolonged vehicle extrication can make your time in contact with the patient invcrease dramatically.


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## Recycled Words

Jon said:


> The idea that "you're 5 minutes from the hospital" works just fine... until the fecal matter hits the ventilation device... then you are up a creek without a paddle, and open to lawsuits.... Can you see youself on the stand: "Why did my client die? Becuause Joe EMT decided that they didn't NEED to carry actvated charcoal because they were close to a hospital.... but during the blizzard, after my patient ingested 400 tylenol and the ambulance broke down in the middle of the Blizzard... They failed to have the appropriate medication on hand, and my client died... The family needs 50 Million dollars for pain and suffering."
> 
> I realize it isn't your choice, really, as to how your service stocks their rigs... but as Guardian already pointed out... a prolonged vehicle extrication can make your time in contact with the patient invcrease dramatically.



True, however it's not the service, it's the state that _prohibits_ us from doing so because it makes more sense to administer the medication 5 minutes later in a controlled environment.


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## DT4EMS

I would like to point out something.

Darn near every advance we made (trauma related) has been due to combat.

I was able to see a study that was conducted in the field in Iraq. It is called Damage Control Rescue.

Very, very interesting. One of the results of the study were tourniquets we placed EARLY. I thought it was pretty wild at first but the results were outstanding.

Another thing.......... look at the recent EMT books. Look how the new EMT-B is taught to contrl bleeding. It may surprise you.............. It did me and the past two EMT-B refresher courses I have taught. Let me know what you think of it.


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## Jon

Recycled Words said:


> True, however it's not the service, it's the state that _prohibits_ us from doing so because it makes more sense to administer the medication 5 minutes later in a controlled environment.


NJ doesn't let you carry Charcoal?

At the part-time job, all our rigs are dual-certed (PA and NJ) and all must carry 50g of Activated Charcoal, for the PA cert. I've never had the opportunity to use it in Jersey (or PA, and it isn't on my to-do list ).


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## Jon

DT4EMS said:


> I would like to point out something.
> 
> Darn near every advance we made (trauma related) has been due to combat.
> 
> I was able to see a study that was conducted in the field in Iraq. It is called Damage Control Rescue.
> 
> Very, very interesting. One of the results of the study were tourniquets we placed EARLY. I thought it was pretty wild at first but the results were outstanding.
> 
> Another thing.......... look at the recent EMT books. Look how the new EMT-B is taught to contrl bleeding. It may surprise you.............. It did me and the past two EMT-B refresher courses I have taught. Let me know what you think of it.


Right on, Kip.

I know that Luno has made comments regarding combat medicine, and that the FIRST step in controlling severe bleeding, under fire, is a tourniquet.


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## Luno

*Guardian*

Here's my take on protocols.  In EMS, you accepted the certification, you agreed to operate by protocols, nothing more, nothing less.  If you feel you can't, then here's your opportunity, do not practice in an area where you feel you have to break protocol.  Are there things about protocols that are wrong?  Absolutely.  Are you in a position to disregard them as "guidelines" when you feel that they're inconvenient?  Absolutely not.  If you don't like the way you have to do something, then don't do it.


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## KEVD18

i have a few things to add to this:

"if the extrication requires 4omin, how can i get to the pt to apply the tq"

easy. its going to take me 40min to get to pt out becaue i have to be concerned wiht his cspine and other possible fx's. you can bend, twist, manipulate yourself in ways we couldnt even jokingly consider with an mva pt. also, what was said about extrication times was accurate. if the car landed say on the roof, i have to crib it, pop the glass, decide on an entry strategy, stage my tools and cut. below is a pic of one of the worst cars ive extricated from. granted it was a tx and i had time to play with but we still worked it like a real call.





this one took 37min before we could put hands on the pt and IIRC another 15 before extricated to the rig.the first thing i did was put my most limber medic in and let him go to work.

on the topic of activated charcoal:
mass recently took activated out of the standing orders for all levels and made it a med control option. i work in boston so i completely understand the "im only 5min from the H" mentality. its all bs anyway because, reading the dosing from my activated charcoal, its says to admin 1gm/kg. i weigh 225lbs, which is 102kg. meaning i would need 102gm of ac. i carry 15. sound a bit pointless?


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## Ridryder911

Wow!... 

First, protocols should be used as "guidelines" ...."not as thee and thou shall"; it is a shame that a state has mandated protocols, this should be up to the local medical director and their discretion. 

Yes, I understand NY protocols and yes they need to be reviewed and redone.. there should be an outcry from medics in the field. I understand they are not able to perform FSBS as well using  a glucometer. 

Kip, is right we learn most of trauma care from war time events. I have read initial findings, and agree that we will probably see an increase use of tourniquets for major extremity wounds. Let us remember though; blast injuries versus crushing injuries are different in type of injuries and treatment. In current war events majority of severe wounds are from implosion and explosive type blasting devices, not what we commonly see in the private sector. 

In the majority of my long career, there are very few MVC's that I have ever seen where I could not reach to a patient. Removing is another story. For as treatment, common sense has to come into play..many believe you should do no care, if you are within a close proximity. I can understand on non-emergent, where outcome will not be seen, but to allow exsanguinating hemmorraging is gross negligence care. 

I do ask if those that administer Activated Charcoal, if it contains Sorbital ? Why, activated charcoal without is useless... unless you can excrete it rapidly. 

R/r 911


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## Recycled Words

I don't know if the rule about activated charcoal applies to all of NJ, but I know that in Bergen County we can't use it. They only just said recently that we could _carry_ epi-pens, until then we could just use one prescribed to a patient. Supposedly something is in the works to let us use glucometers and I've _heard_ something about letting us use ET tubes but I don't know how accurate that is.


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## Guardian

I'm very disappointed in some of the replies I'm seeing.  I would expect some newer emts to question me on the "protocols are guidelines" thing but would have never imagined some of the "veterans" doing the same.  This is basic stuff.  I'm imploring you to talk to your medical director about this issue.  My protocols actually say that they are only to be used as guidelines and our med director has backed this up many, many times.

My scenario is completely reasonable and you could run into it tomorrow.  And when the person dies because you did nothing, you can expect to see me in court.  I will do my best to ruin you.  And that's coming from a guy who loves ems and ems people.

We're professionals who should be thinking about saving lives first and foremost.  I don't deviate from protocol much.  I take it very seriously and call medical control when I do.  I'm not saying disregard you protocols.  I've got mine memorized three ways to Sunday and still carry a copy with me at all times when on duty.  What I am saying is there will be situations where you have to deviate from your protocols.  Not because you want to be cool and different, but because someone will die if you don't.  There's a big difference between those two.

I'm really nervous about ems education and this issue highlights why.  I hope there are some prominent ems people reading this and/or thinking about how we are teaching our new providers.  I hate that every thread ends up with one of us preaching the importance of education, but I feel I have no choice.


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## Nycxice13

In NYC protocols are to be followed, and not used as guidelines. 

Sure, testify against me in court, I have the state on my side.


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## Ridryder911

Guardian said:


> I'm really nervous about ems education and this issue highlights why.  I hope there are some prominent ems people reading this and/or thinking about how we are teaching our new providers.  I hate that every thread ends up with one of us preaching the importance of education, but I feel I have no choice.




Another one feels my frustration. 
	

	
	
		
		

		
		
	


	




Unfortunately, it appears very few EMT's are taught about anything on EMS systems and their profession. We push through the basics of what protocols are, basic system development, and the use of common sense. Rather, we have now manufactured robots with assurance of saying mnemonics of BSI, scene safe (even on the granny fall), 02 NRBM, puls ox, and DCAP..  PQRST...EIOU. Only for them not to truly understand the "whole picture".  Unfortunately, EMS instructors are not taught to teach critical thinking skills.

Rules and protocols are *guidelines* that can be amended and changed. Does your EMT's and medics get involved with protocol development ? Do you and others EMT's/medics have a good working relationship with your medical director and discuss patient care ? 

I was reading an article in an _ Emergency Nursing Journal_ titled *If You're Not Outraged, You're Not Paying Attention*. Which I thought was a ironic title that could be used in EMS. 

I used to believe the number one problem in EMS was lack of education, but after reading EMS forums and working with even the best at heart I have found apathy to be the biggest of our concern. Many fail to look past the basic texts as being the "bible" in EMS. What many do not realize EMT books takes about seven years to be published and most material is our of date by publication. This is one of the difficulties in education. One has to keep abreast of continuous growth and expenditure.  

It is your job.. (paid or not), the system is made of you!. Not, participating in changes, or reforms is the worst one can do for the profession and in the long run for their patients. 

R/r 911


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## fm_emt

I blame all of the bloodsucking lawyers!


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## Jon

Ridryder911 said:


> Wow!...
> First, protocols should be used as "guidelines" ...."not as thee and thou shall"; it is a shame that a state has mandated protocols, this should be up to the local medical director and their discretion.
> 
> Yes, I understand NY protocols and yes they need to be reviewed and redone.. there should be an outcry from medics in the field. I understand they are not able to perform FSBS as well using a glucometer.
> <Snip>
> I do ask if those that administer Activated Charcoal, if it contains Sorbital ? Why, activated charcoal without is useless... unless you can excrete it rapidly.
> R/r 911


Rid,
I agree that protocols should allow some flexability. I disagree over local medical director control... that requires a medical director willing and able to write agressive protocols. PA has already gone to statewide protocols for BLS, and the ALS ones are written and being rolled out right now.

One of the issues with PA's protocols is that some places had such outdated protocols that they didn't even need a digital glucometer. The new protocols standardize care, and mean that a medic doesn't have to remember different protocols when he goes between jobs. It also means that you don't have 2 drastically different standards of care just miles apart... except at the borders of the state.

Rid - I'm all for protocol flexability...both the ALS and BLS protocols contain some optional protocols/meds with Medical Director approval. Also, they have parts of algorythyms (like Bicarb for codes) that are allowed if OK'd by OLMD.

What is an FSBS? Finger stick blood sugar?

As for Sorbitol... I've been told we aren't allowed to use it in PA, becuase it is a non-approved med. Gotta love Pensyltucky.




Guardian said:


> <snip>We're professionals who should be thinking about saving lives first and foremost. I don't deviate from protocol much. I take it very seriously and call medical control when I do. I'm not saying disregard you protocols. I've got mine memorized three ways to Sunday and still carry a copy with me at all times when on duty. What I am saying is there will be situations where you have to deviate from your protocols. Not because you want to be cool and different, but because someone will die if you don't. There's a big difference between those two.<snip>


Great point. One example I can think of is Bicarb for crush syndrome... it needs to be done, but it is an infrequent event, so you probably don't have a protocol for it... BUT... your OLMD should be able to approve this for you... even if he does have to look it up for a minute or two.




Ridryder911 said:


> Another one feels my frustration.
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> 
> Unfortunately, it appears very few EMT's are taught about anything on EMS systems and their profession. We push through the basics of what protocols are, basic system development, and the use of common sense. Rather, we have now manufactured robots with assurance of saying mnemonics of BSI, scene safe (even on the granny fall), 02 NRBM, puls ox, and DCAP.. PQRST...EIOU. Only for them not to truly understand the "whole picture". Unfortunately, EMS instructors are not taught to teach critical thinking skills.
> 
> Rules and protocols are *guidelines* that can be amended and changed. Does your EMT's and medics get involved with protocol development ? Do you and others EMT's/medics have a good working relationship with your medical director and discuss patient care ?
> 
> I was reading an article in an _Emergency Nursing Journal_ titled *If You're Not Outraged, You're Not Paying Attention*. Which I thought was a ironic title that could be used in EMS.
> 
> I used to believe the number one problem in EMS was lack of education, but after reading EMS forums and working with even the best at heart I have found apathy to be the biggest of our concern. Many fail to look past the basic texts as being the "bible" in EMS. What many do not realize EMT books takes about seven years to be published and most material is our of date by publication. This is one of the difficulties in education. One has to keep abreast of continuous growth and expenditure.
> 
> It is your job.. (paid or not), the system is made of you!. Not, participating in changes, or reforms is the worst one can do for the profession and in the long run for their patients.
> 
> R/r 911


Amen!


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## Luno

Okay, RidRider, I agree with you, it shouldn't be that way, EMS should be taught concepts, not canned solutions, but is that legally defendable?  I'm aghast at the condition of EMTs as they come out of school, they're full of formulas and canned protocols, but do they understand why they do what they do? No.  The problem here isn't what's right or wrong, it's what can the lawyers take?  The issues here aren't what's best for the patient anymore, they're how can I cover my own behind when the 45yo POS drug addict gets a POS lawyer and tries to get rich.  I absolutely agree that you need to be involved with the development of protocols to the best of your ability, but I would not recommend straying outside of them because they don't fit your wishes today.  That being said, Guardian, I'm not adverse to calling in for a doc so that I can do what I need to do, that may fall outside of my protocols, but be aware that it is not SOP, but rather an exception.  This whole thing kind of reminds me of when I teach a two day class, the first of ARC FA/CPR/AED, and the second of basic 10 min med/tactical.  The first day is very dry, we go over very basic things, and do I think that it's the best way to do some things, well, not exactly, but the people want the certification, they will do it the ARC way.  The second day, I try to relay concepts, then show potential solutions, this way they can understand that an arterial bleed is bad, first, then secondly they can start their plan to stop the bleeding.  They can understand air entering the chest other than through the airway is bad, then they can start their plan.  While I feel that this is the best way to teach this area of prehospital medicine, I also feel that it is the least defendable way.  Sometimes the lawyers have made it easier for us to just let someone die than to go outside the lines and save them.  Is it right?  Absolutely not.  I agree with you though Rid, "if you're not outraged, you're not paying attention..."  But I'm not sure where the line is to be drawn.


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## Ridryder911

This is part of the problem we are teaching canned lectures and canned responses. This is being validated in poor care and skills, when the patients does not fit into the "protocol" or are in the gray area. This is why it is so essential EMS instructors know how to enforce and teach critical thinking skills. As well, students should be evaluated for such and should be a part of their grade. 

Lawyers can only get blood if poor medicine was performed. Having a thorough medical knowledge in assessment and diagnostic skills, is a way to prevent such events. As more and more people use EMS, more increasing liability. Many feel detailed protocols will prevent such event, in reality actually increases such. As many hospitals have found out, it is much better to to be vague and left up to discretion, than not to have someone to follow protocol to each letter. 

Personally, I refuse to work for an EMS with protocols greater than 100 pages, that does not allow me to have autonomy in care. If they want a robot .. so be it, they don't need me. 

The reason for local medical direction is essential is for more autonomy and needs of the local community. For example such as use of Bicarb in rhabo (communities that have a higher response of crushing injuries) and maybe one that has a psych level (for use of tricyclic O.D.'s). There are areas that need to be able to RSI and place chest tube, then there is places that local community is never more than a few miles away from a level I. 

Any progressive EMS has to have a progressive medical control. The state should recruit EMS physicians that want to participate in EMS direction. Unfortunately, majority of EMS medical control have never been through a medical director course sponsored by NAEMSP. 

Like we have said multiple times before, we have an array of messes in EMS. Starting with apathy, that no one wants to change it, until it affects them locally. 

R/r 911


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## Nycxice13

Ridryder911 said:


> W..
> 
> Yes, I understand NY protocols and yes they need to be reviewed and redone.. there should be an outcry from medics in the field.
> 
> R/r 911



They were redone as of august of 06. The BIG change, removing capillary refill from patient assessment.


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## Ridryder911

Okay, maybe I'm missing something. It appears the large and supposed to be aggressive EMS are on some slippery slopes downward. 

I was reading where LA uses the "idiot box" to make interpretations for 12 leads, NYC unable to perform simple tests such as glucose interpretation and I now wonder why removal of checking for capillary refill ? Did someone screw up ? And, would that make any difference if it was delayed or brisk in any treatment regime ? How hard is that ? 

I find it sad, that many large areas are attempting to have "blanket" protocols and promoting cook book medics. Why they are not requiring fully educated and highly skilled medics, that are able to perform a thorough assessment having the education and knowledge to make a diagnoses upon their own abilities, without a protocol to guide them on what to do. 

Some attempt to use the excuse..."It's a large service, or even we are rural".. You don't  understand! Yes, I do.. medicine is medicine, no matter if it is in Wyoming or Hawaii! An AMI is still a heart attack no matter what the population is, a second degree burn is still such in a city 3 million or a town of 500. The medic should possess an education and knowledge of knowing how to execute and perform an accurate and thorough history and physical examination. As well, the same medic should know the general treatment regime on how to treat each of those injuries without having memorized a protocol !  Emergency medicine does not diversify that much. 

I would find it disgusting to witness a medic (or proclaimed as such) to be able to obtain an ECG, but unable to interpret it (Why do it ?). The same as unable to control bleeding from a limb or extremity. If one cannot perform the tasks that _they are supposed to be able to perform_ i.e. performing emergency medical care.. then that system needs to *really think hard about itself, and quit assuming they are actually performing adequate care!* 

How, discouraging it would be to see a medic treat a RLQ abdominal pain on a female only as a potential appendix, without having ruled out ovarian cyst, ectopic pregnancy, PID, etc.. by means of history, and assessment skills. But, what happens if they do not have such protocols for nothing but a general abdominal pain or only a specific protocol, can you not treat the other illnesses or recognize them ? 

Shame on EMT's and medics for allowing EMS to becoming a first aid service instead of providing emergency *medical* services. I was confused of why patients had higher outcomes when transported by p.o.v. and the decreased numbers of accuracy field diagnoses versus actual diagnoses. As well as the deterioration of advanced life support skills such as intubation. 

Wow!.. How things have changed since I first started. We were hungry for knowledge, and to bring the profession up to the same level as a recognized health care professional. We refused to allow others to lower patient care standards, or accept sub-par training and education and half arse protocols. Many fought hard to get EMS recognized, only to now see that it has fallen backwards. 

I guess what is worse, is the many that don't care.. as long as they still can play with their lights and sirens, or get that paycheck... I encourage those really do care about patient care to get involved with your state and local EMS associations. Surely, there are those that want to progress EMS upwards. 

R/r 911


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## Nycxice13

NYC is thinking about the fact that everyone and everywhere are close to hospitals, so certain things in their opinion aren't as necessary as they would be with a more rural system. But what REMAC seems to be forgetting is the importance of quick action and accurate assessment.

I don't really understand why they removed capillary refill, I know I still do it. I think it is a somewhat important part of assessing perfusion.


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## Guardian

Nycxice13 said:


> They were redone as of august of 06. The BIG change, removing capillary refill from patient assessment.



A big change? Do you need a protocol to tell you when and when not to check for cap refill?  This would be hilarious if in weren't so sad.  Are you upset they don’t allow you to think for yourself?  Are you mad because they think you’re an idiot?  I don’t think you’re an idiot, but they obviously do.

This isn’t a competition between my EMS system and yours.  This isn’t a competition between “my” city and NYC.  I’m proud of where I live and work but I don’t associate myself with a particular city.  When my hometown city does something stupid, I don’t defend them.  If fact, I’m their harshest critic.  This brings me to my question.  Do you agree with your EMS protocol system?  Don’t base your answer on trying to defend NYC.  Base your answer on pt care and your own thoughts regarding how an ems system should be run.

This whole protocol issue was so hard for me to swallow, I actually contacted http://www.nycremsco.org/contact.asp and if I find out anything, I’ll post it on here. 



Rid, there are still plenty of people like me around who are willing to fight tooth and nail to see ems progress.  My names not guardian for nothing.  I’m also starting to think apathy is the major problem.  No matter how much initial ems education we put people through; there will always be a problem if apathy exists.  This is because ems is one of the most dynamic professions in existence.  I wouldn’t be surprised if 20 years from now, half of what we do now will be contraindicated for pt care.  We should probably start a new thread on this topic, but how can we combat apathy?

Here are some ideas.  I don’t want to get rid of all basics, god knows we need them.  But, I am seeing a growing trend of more and more career basics.  What’s a career basic you ask?  To me, it’s someone who is happy to spend their life in basic mediocreville.  If you don’t feel comfortable moving straight to paramedic, I’m cool with that.  What I’m not sure about are the ones that remain at the basic level.  They wear the badge, call themselves “medics” or “emts” and ride around in ambulances with flashing lights and are perfectly content knowing as little about pt care as possible.  That’s apathy folks.  If these people were forced to move on to paramedic, it might help to weed out the apathetic ones who are putting people’s lives at risk.

It’s just a thought.  I would love to hear other suggestions.


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## Nycxice13

Guardian said:


> A big change? Do you need a protocol to tell you when and when not to check for cap refill?  This would be hilarious if in weren't so sad.  Are you upset they don’t allow you to think for yourself?  Are you mad because they think you’re an idiot?  I don’t think you’re an idiot, but they obviously do.
> 
> This isn’t a competition between my EMS system and yours.  This isn’t a competition between “my” city and NYC.  I’m proud of where I live and work but I don’t associate myself with a particular city.  When my hometown city does something stupid, I don’t defend them.  If fact, I’m their harshest critic.  This brings me to my question.  Do you agree with your EMS protocol system?  Don’t base your answer on trying to defend NYC.  Base your answer on pt care and your own thoughts regarding how an ems system should be run.
> 
> This whole protocol issue was so hard for me to swallow, I actually contacted http://www.nycremsco.org/contact.asp and if I find out anything, I’ll post it on here.
> 
> 
> 
> Rid, there are still plenty of people like me around who are willing to fight tooth and nail to see ems progress.  My names not guardian for nothing.  I’m also starting to think apathy is the major problem.  No matter how much initial ems education we put people through; there will always be a problem if apathy exists.  This is because ems is one of the most dynamic professions in existence.  I wouldn’t be surprised if 20 years from now, half of what we do now will be contraindicated for pt care.  We should probably start a new thread on this topic, but how can we combat apathy?
> 
> It’s just a thought.  I would love to hear other suggestions.



Uhhm, how bout you read the post above yours.

And stop with the personal insults, its sooo fifth grade.



> Here are some ideas.  I don’t want to get rid of all basics, god knows we need them.  But, I am seeing a growing trend of more and more career basics.  What’s a career basic you ask?  To me, it’s someone who is happy to spend their life in basic mediocreville.  If you don’t feel comfortable moving straight to paramedic, I’m cool with that.  What I’m not sure about are the ones that remain at the basic level.  They wear the badge, call themselves “medics” or “emts” and ride around in ambulances with flashing lights and are perfectly content knowing as little about pt care as possible.  That’s apathy folks.  If these people were forced to move on to paramedic, it might help to weed out the apathetic ones who are putting people’s lives at risk.



I doubt I intend on staying in EMS and IF I do decide to stay in the EMS world, I do not intend upon staying a basic.


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## Recycled Words

Guardian said:


> Here are some ideas.  I don’t want to get rid of all basics, god knows we need them.  But, I am seeing a growing trend of more and more career basics.  What’s a career basic you ask?  To me, it’s someone who is happy to spend their life in basic mediocreville.  If you don’t feel comfortable moving straight to paramedic, I’m cool with that.  What I’m not sure about are the ones that remain at the basic level.  They wear the badge, call themselves “medics” or “emts” and ride around in ambulances with flashing lights and are perfectly content knowing as little about pt care as possible.  That’s apathy folks.  If these people were forced to move on to paramedic, it might help to weed out the apathetic ones who are putting people’s lives at risk.



Apathy isn't being content we being a basic, it's being a basic and not caring about the quality of care you're providing. I work as a volunteer EMT-B in my town. Our ONLY ambulance corps is a volunteer emt-b corps. Around here, ALS are based out of hospitals. Now tell me, with your idea in place, how would that work? Most volunteer corps would have to shut down because frankly, the paramedic course takes a hell of a lot longer. A good portion of our volunteers are students, how would that work out?

You can work part-time as an EMT without being apathetic. You can care a great deal about what you do and just not be able to put the time or money into furthering their education in that field. To imply that everyone who doesn't get past basic is _apathetic_ is outright insulting.


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## Luno

Rid, I agree with you yet again.  The state of EMS is degrading, but I don't believe that it's due to an initial apathetic response, I've seen that apathy that comes with banging your head against a wall, and nothing ever changing.  The majority of EMS personnel that I worked with when they got out of school, irregardless of how pathetic their skills were, wanted to learn, they wanted to help, they wanted to change the world...  This was beaten out of them by their preceptors, and field officers.  There is no helping people anymore, it's making it from call to call, it's keeping run times down, occasionally you might get a MI, or a brutal MVC, but the majority of it is monotonous, and if you aren't taught to learn something from every call, jump into it and even if it is above your skillset, know why, instead of shrugging it off to "well, it's above my pay grade," then you have apathetic EMS.  

Guardian, I think it's time for me to clarify what I meant.  I mean that if you accept the cert/lic in that area, you are accepting their protocols, how they are written, if you don't like them, don't work there.  Just like Rid said, he gave the reason that he wouldn't work in an area, the protocols are there, either accept or reject, but you can't have both.


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## Guardian

Luno said:


> Guardian, I think it's time for me to clarify what I meant.  I mean that if you accept the cert/lic in that area, you are accepting their protocols, how they are written, if you don't like them, don't work there.  Just like Rid said, he gave the reason that he wouldn't work in an area, the protocols are there, either accept or reject, but you can't have both.




I think it's time to clarify what I meant, again.  There have never been protocols written, nor will there ever be protocols written to satisfy me.  You can write a trillion pages of protocols, and I guarantee it won't be enough to prepare me for any situation I might encounter.  Thus, we have to be willing to think outside our protocols and even deviate from them.  If not, there will come a time when an ems provider lets someone die because a nationally recognized, easy treatment--well within their scope--isn't performed simply because it wasn't in their protocols.  Earlier in this thread, I outlined a very easy to understand example involving a tk and a 40 min entrapment that highlights this point perfectly.  This is basic, basic, stuff guys.  The world is not black and white.  Protocols at their best, are guidelines.  During the Apollo 13 incident, they used protocols to fly the rocket.  When an unexpected error occurred, the protocols went right out the window (figure of speech).  If they had continued following protocols at that point, those three men would have died.  They had to get together and do some critical thinking.  They had to find a way to make a CO2 filter out of extra crap they found lying around.  On the spot, they had to calculate how to use the lunar module rocket to propel the men around the moon and back to earth (something it wasn't designed to do).  They had done very extensive research and had thousands of protocols.  But to save the men, they were forced to deviate from those protocols.  Basic, basic stuff guys.


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## Glorified

I hope I never become apathetic in my career, and I hope my co-workers are caring individuals that care about the patients.  Once I am more experienced, I will be more active in improving protocols and EMS in general.

Back to the thread topic -  Was the guy really trying to kill himself? Most people attempting suicide would do it right on the wrist and not in the middle of the forearm. I haven't got to trauma yet in my class, so how should you deal with this situation? Direct pressure? arterial pressure?


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## Nycxice13

Glorified said:


> I hope I never become apathetic in my career, and I hope my co-workers are caring individuals that care about the patients.  Once I am more experienced, I will be more active in improving protocols and EMS in general.
> 
> Back to the thread topic -  Was the guy really trying to kill himself? Most people attempting suicide would do it right on the wrist and not in the middle of the forearm. I haven't got to trauma yet in my class, so how should you deal with this situation? Direct pressure? arterial pressure?



Direct pressure, elevation, pressure point.


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## Shabo

No, He wasn't trying to kill himself. It appears as though he slipped and cut/stabbed himself while making something to eat. He mostly bled out before BLS arrived, but they couldn't stop the bleeding either. I'm guessing that he was probably taking some kind of med that kept his blood from clotting (or he had hemophilia). Either way we were all shocked at how small of a wound killed this guy.


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## Jon

Ok... Guardian, I see your point, and Rid's too... Protocols can cover a lot... but they CAN'T cover everything... I like Rid's idea that sometimes we have too many protocols... on the same token, we shouldn't always have to call command for "simple" things... like 2mg of MS for Chest Pain...

I think the big thing we are all saying is that there are times we have to say "This protocol dosen't work" and call command... I think that is absolutly correct.


As for apathetic basics... I think Guardian and Recylced Words both make good points. I, for example, tried and failed to complete medic school... I'm not a medic... but I can be an asset on a scene... and often end up letting some eager new EMT do compressions on a code, while I stand back and help the single-provider medic (spiking bags, prepping meds, etc) I have one medic I occasionally work events with at the part-time job... we did the Auto Show this year... at one point... I was working up a weakness patient... and came to the conclusion that it was an ALS call... I looked at him, I said it's ALS... he looks at me "you know how to hook up the monitor"... he was catching up on other paperwork when the Pt. walked in to our office... I did most of the workup... he just listened and got handed the strips by me...

I strive to be a caring, compassionate provider (I sometimes fail - espicially with system abusers) but I do my best to make sure every pt. gets the care they expect when they call 911...


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## BossyCow

fm_emt said:


> I blame all of the bloodsucking lawyers!



The bloodsucking lawyers wouldn't have a chance if the insurance companies who collect money from both sides of every conflict didn't pay off those large settlements.  Think about it.... the hospital has liability insurance to cover their liability for when a patient sues them.  The patient carries health insurance to cover the rising cost of healthcare that results from the increased cost the hospital has paying its liability insurance.  The materials providers and pharmaceutical companies all have huge liability policies to cover their butts in case of suit.  Now.. my insurance company insists that if you are hurt on a location, not your home, they want the name of the insurance company of the location where you were injured so they can recover some of their 'losses'.  The local hospital is now collecting that information routinely on all accident cases.  And who is it who pays off all those settlements that make the legal profession so interested in filing suit?  The insurance companies do.  So, they make a few huge settlements a year showing all the other suckers the importance of having insurance in case they get sued!  Don't talk to me about lawyers..... kill the insurance companies!


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## Medic's Wife

Nycxice13 said:


> NYC is thinking about the fact that everyone and everywhere are close to hospitals, so certain things in their opinion aren't as necessary as they would be with a more rural system.



Here's what struck me as I was reading that:

Where is the contingency plan?  That whole 5 minutes from a hospital plan only holds true if all the "normal" conditions are in place. I would think that in NYC of all places (after the first WTC bombings, and the 9/11 attacks) there would be a strong understanding of the fact that $hit happens.  If there ever was a situation that was of a grand enough scale that would get in the way of a 5 minute transfer, lives could possibly be lost because they are turning out a whole generation of EMS personnel that would be ill equipped to deal with that scenario.  I personally would feel much more comfortable with a medic taking care of me that could keep me for several hours, if need be, not just 5 minutes!

*ducking for cover now*


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## Nycxice13

The contingency is me.

If such a situation should arise, pretty much every city/state protocol goes out the window.


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## Medic's Wife

And I'm sure you and other experienced folks could do just fine, but what about the brand new guys that never learned the protocals that they're doing away with?


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## Nycxice13

Medic's Wife said:


> And I'm sure you and other experienced folks could do just fine, but what about the brand new guys that never learned the protocals that they're doing away with?



I was trained with the knowledge that even though tourniquets are not part of NYC protocol, that we need to know how to properly use them either way.


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## Guardian

Nycxice13 said:


> In NYC protocols are to be followed, and not used as guidelines.
> 
> Sure, testify against me in court, I have the state on my side.







Nycxice13 said:


> The contingency is me.
> 
> If such a situation should arise, pretty much every city/state protocol goes out the window.





I don't understand the difference between my scenario and hers.  Both are dealing with saving life/lives.  Why the different answer?


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## Nycxice13

Because I woke up on the other side of the bed this morning?

No, she was talking about contingencies, not the run of the mill MVA.


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## Guardian

She was talking about an unexpected occurrence that could result in human loss if protocols were followed.  I was talking about the exact same thing.  A mva with the only injury being an uncontrollable arterial bleed and 40 min entrapment in not run of the mill.


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## Nycxice13

Does it bother you that I change my answer? In a different situation...


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## Guardian

Nycxice13 said:


> Does it bother you that I change my answer? In a different situation...



no, it just bothers me that you change you answer in the exact same type of situation like you just did here.


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## Nycxice13

Well, good for you.


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## wendyloo

Shabo said:


> Guys,  I recently completed an ER clinical where we had a pt arrive by BLS truck with a 1-2 cm lac to the middle of the rt forearm. The elderly pt had apparently been bleeding for a while before help arrived. Pt was Alert upon BLS arrival and the bleeding was uncontrolled. They attempted to stop the bleed but couldn't and wrapped it in gauze and a cravat for transport. The pt completely decompensated before arrival to the ER and resuscitation was unsuccessful. I was hoping that you could help me with a few questions.
> 
> 1. How long do you think it would take to bleed out from this wound? (meds unknown)
> 2. Is there a reason a tourniquet wouldn't be applied?
> 3. What would your response have been?
> 
> Thanks,
> Shabo


Hi Shabo,

 it took a 33 year old man, 15 to 30 minutes to bleed out, the patient was conscious when found,  but died shortly after, despite CPR.  He was in a psychiatric hospital and had been checked on half an hour before. the incident.


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## COmedic17

wendyloo said:


> Hi Shabo,
> 
> it took a 33 year old man, 15 to 30 minutes to bleed out, the patient was conscious when found,  but died shortly after, despite CPR.  He was in a psychiatric hospital and had been checked on half an hour before. the incident.


This thread is 9 years old.


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## Gurby

This thread is such a trip.  It was against protocol to use a tourniquet in NYC in 2007?  Are you ****ing kidding me?


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## akflightmedic

Holy toledo! I think this is the greatest save to date!!!  Has anyone beat 9 years yet? We had a few close ones but I think this is the one!!


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