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medics, don't do this...

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medic report " I brought you a drunk with a scalp lac"

" did he pass out? "

"yup"

you have him in c-spine with a line? what's his cbg?"

" nope, just a taxi ride"

"ok"

 

Actual pt

gcs 10, almost intubated on arrival. took nasal airway without moving or complaint. moans to pain.

cbg=60

large scalp lac repaired

head/neck ct neg

chest/pelvis plain films neg

banana bag given

tox and metabolic workup other than very high etoh neg

 

so, yes. a drunk with a scalp lac skillfully disguised as a trauma.....still....that report and tx of this pt would have gotten me fired as a medic 20 years ago..

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There's been a big push away from c-spine unless there is clear and unambiguous cervical spine involvement. There is a theory that c-collar and boarding is causing more damage than preventing.

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There's been a big push away from c-spine unless there is clear and unambiguous cervical spine involvement. There is a theory that c-collar and boarding is causing more damage than preventing.

altered pts with head injuries can not reliably tell you they have no pain for purposes of c spine clearance.

did I mention this guy also has a known seizure d/o and was barely controlling his own airway...

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There's been a big push away from c-spine unless there is clear and unambiguous cervical spine involvement. There is a theory that c-collar and boarding is causing more damage than preventing.

 

We did away with backboards last year for most of our EMS patients, and ultimately aim to use it only as an extrication device.  There is no literature supporting their use, and plenty of literature showing the downsides (respiratory compromise, pressure sores, patient discomfort).

 

Our medics have also been doing selective spinal immobilization for several years, using NEXUS criteria to limit unnecessary use of cervical collars (although clearly this patient wouldn't have qualified and should have been immobilized).

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altered pts with head injuries can not reliably tell you they have no pain for purposes of c spine clearance.

did I mention this guy also has a known seizure d/o and was barely controlling his own airway...

 

It sounds like a board and c-collar should have been used for this patient.

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I gave up trying to say something to the big-city medics/EMTs who would bring us patients such as the above- I just did my due diligence and thoroughly screened for subtle presentations.  I've relayed these stories before on this board, but my two favorites were the man who was smoking "wet" (marijuana + PCP for the uninitiated) who was just lying on the curb with a traumatic subarachnoid, and the woman found down at her bar (yes, a bar she actually owned) who had full-blown TB.  Both were written off as "they're just drunk".

 

I hate to say it, but I tend to find that with true big-city EMS/Fire teams that the amount of effort put into EMS care is substandard.  It's in the rural or suburban environs that the interested and excited EMTs/medics tend to work.  And as long as fire departments use EMS as the red-headed stepchild, it will continue to be that way.  Not saying some great medics don't come up in those systems, as I met and worked with wonderful medics in the Philly and Houston systems

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I hate to say it, but I tend to find that with true big-city EMS/Fire teams that the amount of effort put into EMS care is substandard.  It's in the rural or suburban environs that the interested and excited EMTs/medics tend to work.  And as long as fire departments use EMS as the red-headed stepchild, it will continue to be that way.  Not saying some great medics don't come up in those systems, as I met and worked with wonderful medics in the Philly and Houston systems

yup, I agree. fire medics in general are not as good as dedicated ems only medics...

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yup, I agree. fire medics in general are not as good as dedicated ems only medics...

So true. We only have fire medics in the city I live in. I was just chatting with an ED nurse yesterday that got a patient from our city dept. with basically no assessment and a report of "not acting like herself" from the medics. She had a pulse of 30 and was hypotensive. When the nurse got chippy she said they looked at her like "what do you expect from us?". She was getting fired up just telling me the story. I work for a private ambulance company and if I did that, I'd be sent packing before my shift was over. 

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I noted during my rideout last summer with a local, formally nationally renowned city fire/rescue service that their medical assessments were almost non-existent.  I know what they were taught since I was going back through it myself for recert. purposes.  Primary question today is transport or not transport (and not because of medical need).

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What's the first thing you do before asking a firefighter to ventilate your patient?

 

Take away his axe.

and show him how to use a bvm.....which is hard to do in full turnout gear for a medical call...

fire ems for the most part in my experience is basically lifting assistance when the real medics arrive...those with 3 digit IQs...

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145507_web_FireTraining3.jpg

 

 

For those not familiar with the fire service, ventilation is the term for cutting holes in the roof (allowing heat and smoke to escape).  Have to watch what I joke about; after a 17 year break from the FD I'm in the process of joining my local fire department!

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145507_web_FireTraining3.jpg

 

 

For those not familiar with the fire service, ventilation is the term for cutting holes in the roof (allowing heat and smoke to escape).  Have to watch what I joke about; after a 17 year break from the FD I'm in the process of joining my local fire department!

you gotta love a pic of guys destabilizing a roof they are standing on over an inferno...I thought the new thinking was big exhaust fans after opening the front door....

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The problem is that the fire crew medics never wanted to do EMS to begin with. They got their ALS cert because the department required it or it meant more pay. The rural guys and gals who do EMS exclusively are there because that's what they actually want to do. Motivation makes a world of difference.

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I saw this in Orange County California.  There were some great medics, but a lot had the attitude "I am a fireman".  I thought it was funny that they would say that when 85-93% (at the time) of calls were medical aides.   I remember the same medic who on two different calls.  First one a guy tries to kill his wife by throwing her off the 2nd story stairs, no C-spine.  Next call days later 5mph rear ending accident- full C-spine.   I worked in Orange County for a while on the ambulance.  I can not tell you how many of the EMT's just wanted to get their one year of experience to go to paramedic school.  Once they had their Paramedic they could get on the FD.  I would ask all the time "Do you want to be a medic?"  They almost always said no, they just wanted to be a fireman. Since they were the new guy they had to work as a medic and a lot of times it showed.   I personally think it is a bad system.  On the flip side I have some good friends in the Sacramento fire dept who are amazing medics trying to make things better.

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I saw this in Orange County California.  There were some great medics, but a lot had the attitude "I am a fireman".  I thought it was funny that they would say that when 85-93% (at the time) of calls were medical aides.   I remember the same medic who on two different calls.  First one a guy tries to kill his wife by throwing her off the 2nd story stairs, no C-spine.  Next call days later 5mph rear ending accident- full C-spine.   I worked in Orange County for a while on the ambulance.  I can not tell you how many of the EMT's just wanted to get their one year of experience to go to paramedic school.  Once they had their Paramedic they could get on the FD.  I would ask all the time "Do you want to be a medic?"  They almost always said no, they just wanted to be a fireman. Since they were the new guy they had to work as a medic and a lot of times it showed.   I personally think it is a bad system.  On the flip side I have some good friends in the Sacramento fire dept who are amazing medics trying to make things better.

L.A. County was the same way. medic school was part of the fire academy and they needed to get a C in medicine to be a fireman...and most of them did....LA city on the other hand used to have a dedicated ems unit that rocked...I hear it went away unfortunately...

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having broken my back,   T-9 burst fracture with unstable fracture into the column, I walked out of the woods

I knew I had broken something and was doing everything with in my power to splint my own injury - this was natural instinct, not training.

 

Worst thing in the whole process was the damn back board - medic knew it and apologized and let me suck down a huge amount of nitrous.... even then he was saying that the data really does not support using back boards. and this was in 1997

 

back boards help move, help restrain, help extricate - but they do not help the patients..... 

 

so if you have no distracting injury, clear mentation, no major head trauma, no palp deformity or tenderness, I would consider forgoing the back board....

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Agree with ventana... Too many times I have seen an otherwise normal patient ( eg not drunk, high, no distracting inj) WALKING AT THE SCENE, taken down by EMS, c-collared and the strapped on the backboard. My feeling is, if you put 'em on the board, you take it off ASAP you arrive at the ED.

 

Putting an unstable or burst vertebral burst fracture or a fractured pelvis on the backboard ( in a sober patient who can protect his corpus and airway) is an unnecessary form of torture. Unless you have a bivalved back board ( one which separates into two halves), rolling such a patient off the board is extremely painful, and in fractured pelvis, potentially vascularily dangerous.

 

Depending again on level of consciousness and sobriety, if significant trauma I would still like spine until I can clear the spine.. But the back board in a non extricated patient should become yesterday's tool.

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Every place I've ever worked (EMS 3rd service), if a injured patient even thought about the word back pain they get a collar and board. No excuses per protocol.

 

Medical directors play a huge role in this and it really doesn't change unless they do; not really the medics' choice. But some of the MoIs you guys are talking about really make shake my head as to why they were not fully immobilized.

 

 

Inviato dal mio iPhone utilizzando Tapatalk

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same medic, same facility as prior case....guy in his 30s with L elbow posterior dislocation. site not visualized or splinted. no IV and no analgesics. no mention of neurovascular status in oral or written report. I cut off the guy's sweatshirt on arrival to see the obvious deformity. Reduced easily with propofol after a bit of fentanyl for pain control and ativan for anxiety.

report made to ems medical director. hopefully the guy will lose his job or go back to some sort of remedial training...in theory this guy is a senior medic and field training officer...

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Look guys, real sorry about your poor experiences with fire medics. But I have to honestly say I am shocked at the bashing going on. Surely you don't believe that because you experienced something, it can be extrapolated out to an entire group of professionals.

Some of the best and most experienced medics in the country are fire based. These same medics are on the cutting edge of EMS based on their research participation.

Yes, I am obviously biased, being a former fire medic. Feel free to blow me off if you wish. But I would hope you would think clearly and objectively before making assumptions based solely on personal experience alone.

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Some of that is simply volume. There are many more fire based EMS systems out there than non fire based. So of course there will be good medics working in a fire based EMS environment. It's just a question of numbers. That doesn't mean the fire based EMS model is the one that should be used.

 

Are those medics involved in EMS research voluntarily? Or is it simply because docs in their system are making them do it because of their (the doc's) research? Research participation does not make one a cutting edge medic.

 

Until FDs stop treating EMS as a second thought, start dedicating resources commensurate with call volume, stop making it a promotion to go from EMT or paramedic to FF, stop forcing people who signed up to fight fire to do EMS, a job they don't want to do, stop throwing their medics under the bus and recognize they run an EMS based fire system instead of the other way around then fire departments nationwide will continue to run EMS into the ground and prevent it from becoming a recognized and respected branch of emergency medicine.

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