Radial Artery Bleed

[Jon]

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 ).

 

[Jon]

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.

 

[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.

 

[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?

 

[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

 

[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.

 

[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.

 

[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.

 

[Ridryder911]

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

 

[fm_emt]

I blame all of the bloodsucking lawyers!

 

[Jon]

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.

<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.

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!

 

[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.

 

[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

 

[Nycxice13]

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.

 

[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

 

[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.

 

[Guardian]

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.

 

[Nycxice13]

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.

 

[Recycled Words]

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.

 

[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.