tag:blogger.com,1999:blog-41617515486884045612024-03-05T04:31:53.122-08:00MEDIC 914"MEDIC 9 on location, single story residence, nothing visible, MEDIC 914 establishing Oak Street Command, investigating, Division 1"9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.comBlogger12125tag:blogger.com,1999:blog-4161751548688404561.post-46544078220322879022013-05-27T18:42:00.001-07:002013-05-28T08:30:59.114-07:00Afghanistan Dustoff<iframe frameborder="0" height="350" src="https://www.facebook.com/video/embed?video_id=4498372745484" width="500"></iframe><br />9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com0tag:blogger.com,1999:blog-4161751548688404561.post-59065960785013899462011-04-26T12:22:00.000-07:002013-02-16T10:55:04.094-08:00Asking for it...<!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:DontVertAlignCellWithSp/> <w:DontBreakConstrainedForcedTables/> <w:DontVertAlignInTxbx/> <w:Word11KerningPairs/> <w:CachedColBalance/> </w:Compatibility> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
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I know, I harp on this occasionally, but I guess it is time to do so again. Slow down, people! </div>
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Slow. Down.</div>
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Mrs. Medic 914 and I were out and about the other day and we came within close proximity of an emergency call. The first emergency vehicle we saw was the fire truck entering the intersection ahead of us. They had both sirens and their air horns operating. The crew in the front was looking both ways as they eased into the intersection. And until they were sure everyone had stopped they did not proceed through. And they had the green light.</div>
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Then the ambulance came. Wow. Just…wow.</div>
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They came up from behind us. There was a line of cars and we were about fourth in line at the stop light. My wife was looking for them and started to do what the law says to do upon the approach of an emergency vehicle-pull to the right and stop.</div>
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Not stop in the middle of the road.</div>
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Not pull to the left and stop.</div>
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No, GS 20-157 states “ Upon the approach of any law enforcement or fire department vehicle or public or private ambulance or rescue squad emergency service vehicle giving warning signal by appropriate light and by audible bell, siren or exhaust whistle, audible under normal conditions from a distance not less than 1000 feet, the driver of every other vehicle shall immediately drive the same to a position as near as possible and parallel to the right‑hand edge or curb, clear of any intersection of streets or highways, and shall stop and remain in such position unless otherwise directed by a law enforcement or traffic officer until law enforcement or fire department vehicle or public or private ambulance or rescue squad emergency service vehicle shall have passed.”</div>
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So there you have it.</div>
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Anyway, as Mrs. 9-ECHO-1 was looking for this approaching emergency vehicle, she began to do what she was required by loaw to do. Pull to the right. Well, it is a good thing I happened to look in the mirror when I did. She had just looked in the right side mirror, saw that it was clear, and was checking the left side mirror, when I saw it and said “stop!”. Actually, I said “SHIT! STOP!”</div>
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Because there it was, coming up on the right- an ambulance coming up on the right at a pretty good clip. They went passed us on the right and then blew through the intersection. Actually, they passed us fast enough that the turbulence caused in the air shook our Tahoe.</div>
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There was at least one other car in our line that also almost pulled to the right and stop, as prescribed by law.</div>
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After Mario Andretti passed us we went forward with the rest of traffic, all the while making sure that another emergency vehicle was not coming from any direction. As we went through the intersection I looked at the front vehicle in line on the right as she pulled in front of us without looking, against the red light- late model Honda Odyssey with the driver (what we called a ‘soccer mom’ a few years ago) chatting away on the cell phone and what looked to be at least five young children (apparently unrestrained) in the front and back seats of the vehicle.</div>
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That would have been nice.</div>
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So why the big deal?</div>
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A lot of us just assume that everyone will hear our sirens and see the flashing lights. In this case we did not actually see ambulance until they were about two car lengths behind us and I barely heard the siren until they were just about on us (we had our radio on with all of the windows down and the sunroof open; they had their siren on ‘yelp’). If we had pulled over, as the law requires us to do, would two car lengths been enough room to stop a Chevrolet G4500 type II ambulance? Not hardly.</div>
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And who would have been cited in that instance? I am not sure who would have gotten the ticket, but I am pretty sure even a mediocre lawyer would have gotten me and the missus a good settlement. Maybe a new 2011 Dodge Challenger…</div>
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And what if that minivan had pulled out? Sure, she would have been at fault, but how would you like knowing you just plowed into a minivan full of kids? Especially if you could have prevented it by slowing your ass down a little bit! That would be a helluva picture to keep in your mind- your ambulance smacking that minivan and those kids flying out the other side…</div>
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Based on all of the research I see out there these days suggests that we don’t save lives by driving real fast. And we only save a very minute amount of time by using lights and sirens. And nowhere in our protocols (or anyone else’s, for that matter, do I see “drive real fast” as a treatment option.</div>
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When we are responding to emergency calls we need to keep in mind that the other people may or may not do what they are supposed to do. They may pull to the right. They may pull to the left. They may just stop. I have even seen them try and outrun us to the next intersection so they can pull over there (and block the intersection as prohibited by GS20-157!).</div>
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They may hear your siren. They may see your flashing lights. But I wouldn’t count on it. You see, with all of the so-called advances in our emergency warning systems, the sound insulation, sound systems, and tinted glass advances on today’s cars have made more advances, as well.</div>
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If you are driving ‘hot’ to a call, slow down. Those few seconds you are going to save probably are not clinically significant. Your ability to go home at the end of your shift should be your main priority. My ability (and my partner’s) to go home at the end of my (our) shift is mine- all other concerns are secondary.</div>
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And that means slowing down. </div>
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Anytime you are coming up behind traffic, slow down. You never know what they will do.</div>
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Anytime you are coming up on a controlled intersection, slow down. Just because you have the green light does not mean that the other people will not do something, well, stupid.</div>
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Anytime you are driving through an area with a lot of driveways, slow down. You never know who will back out of a drive way. And a lot of driveways mean houses, and there may be kids who will run out to see what all of the sirens are about. So slow down.</div>
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And that electronic siren you have on that ambulance? Set it on wail. Leave it. Stop playing with it. ‘ET’ can’t hear you. People will have a better chance of hearing you if you do.</div>
9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com0tag:blogger.com,1999:blog-4161751548688404561.post-75758870399615903282011-03-29T09:52:00.000-07:002011-03-29T09:52:56.986-07:00Pay attention...it's in the little details!<div style="font-family: Georgia,"Times New Roman",serif;"><br />
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</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">I don’t normally cite recent calls in my blogs, but, well, this one’s important. If you think you were with me, you weren’t. If you think you were the patient, you weren’t. If you think you know when this call took place, you don’t. So now that the disclaimer is out of the way…</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">A while back my unit was dispatched to a local assisted living facility for an ‘abdominal pain’, downgraded to an ‘alpha’ response (1A1) just after dispatch. Now, typically, when that comes over the MDT and the announcement comes from dispatch, you can sometimes hear the groans in the ambulance. Just sayin’.</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">So the patient presents as an elderly person complaining of lower abdominal pain. The patient is walking the halls of the facility because ‘it hurts to sit down’. The pain has been going on since early afternoon (it is now early evening, five hours after onset. A quick assessment showed a conscious and alert patient, oriented to person, place, time, and event. Vital signs were unremarkable (BP 132/84, HR 74, RR16, SPO2 99% room air, FSBG 126, ECG sinus rhythm). Skin was warm and dry with good color. There was a little lower abdominal distension and tenderness, and no history of nausea, vomiting, and diarrhea.</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">We determined hospital destination, placed the patient on the stretcher, gathered our paperwork, and began our 15-20 minute transport. During the transport, my preceptee (I’ll call him Jeffro) initiated an IV and got an ECG and 12-lead.</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">Now, I know a lot of paramedics that right about now would have sat down in the ‘captain seat’ and started on their report. Jeffro couldn’t because I was sitting there. Besides, I push my preceptees to maintain a rapport with the patient and since this one was C&A&O, it was easy to do.</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">Part of the way during transport Jeffro noticed that the patient’s speech started slurring. He went ahead and performed a stroke screen and sure enough determined right sided weakness, right facial droop, and the already noted slurring. We notified the ED of the original complaint and our latest findings, along with out less than five minute ETA. After a quick exam backed up our en-route findings, a ‘Code Stroke’ was called.</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">So how did it turn out? Turns out the patient had a prior history of CVA (the facility’s paperwork conveniently neglected to tell us that, as did the staff) and was subject to transient episodes of the slurred speech and right sided weakness two or three times a day. This was confirmed by the family and the patient’s primary care physician (of course, the facility did not tell us about that, either).</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">Anyway, my point is that this patient’s condition changed in a way unrelated to the original complaint. And until the information was obtained a while later, there was no way we could have known that this was not in fact a stroke. </div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">So what would have happened had my preceptee/partner taken the route of least resistance and plopped his a** in the captain chair and typed away? I know of at least one instance in my system where this happened, except the patient had ARRESTED and the medic did not know it. That is, not until they got to the ED and saw that sort of ‘dead look’ on the patient’s face.</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">I know, it is the path of least resistance. And I know the supervisors are always wanting us to clear the hospital in a hurry (some services and systems around these parts have a stopwatch running as soon as they get to the ED). And sometimes it is hard to carry on a conversation with someone in their 70s or 80s when you are in your 20s. But that is one of those things that is a part of your job. And I bet they did not tell you that in EMT school, did they?</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">Pay attention to little details. Just because the call started out as an abdominal pain doesn’t mean it is going to stay that way. Just like it is important to get more than one 12-lead, complete more than one stroke screen, and keep reassessing vital signs.</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;">Because things change.</div><div class="MsoNoSpacing" style="font-family: Georgia,"Times New Roman",serif;"><br />
</div><div style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: 11pt; line-height: 115%;">And if you don’t want to be the subject of blog fodder (merciless they are sometimes) or even the six o’clock news, you need to be on top of those changes.</span></div>9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com4tag:blogger.com,1999:blog-4161751548688404561.post-15472719369689490552011-02-23T18:30:00.000-08:002013-02-16T11:00:08.357-08:00Taking Care of People…<!--[if gte mso 9]><xml> <w:WordDocument> <w:View>Normal</w:View> <w:Zoom>0</w:Zoom> <w:TrackMoves/> <w:TrackFormatting/> <w:PunctuationKerning/> <w:ValidateAgainstSchemas/> <w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid> <w:IgnoreMixedContent>false</w:IgnoreMixedContent> <w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText> <w:DoNotPromoteQF/> <w:LidThemeOther>EN-US</w:LidThemeOther> <w:LidThemeAsian>X-NONE</w:LidThemeAsian> <w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript> <w:Compatibility> <w:BreakWrappedTables/> <w:SnapToGridInCell/> <w:WrapTextWithPunct/> <w:UseAsianBreakRules/> <w:DontGrowAutofit/> <w:SplitPgBreakAndParaMark/> <w:DontVertAlignCellWithSp/> <w:DontBreakConstrainedForcedTables/> <w:DontVertAlignInTxbx/> <w:Word11KerningPairs/> <w:CachedColBalance/> </w:Compatibility> <w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel> <m:mathPr> <m:mathFont m:val="Cambria Math"/> <m:brkBin m:val="before"/> <m:brkBinSub m:val="--"/> <m:smallFrac m:val="off"/> <m:dispDef/> <m:lMargin m:val="0"/> <m:rMargin m:val="0"/> <m:defJc m:val="centerGroup"/> <m:wrapIndent m:val="1440"/> <m:intLim m:val="subSup"/> <m:naryLim m:val="undOvr"/> </m:mathPr></w:WordDocument> </xml><![endif]--><!--[if gte mso 9]><xml> <w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
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Over on <a href="http://happymedic.com/2011/02/22/hmjr-is-home-and-why-i-shouldnt-leave-you-alone-anymore/">The Happy Medic</a>, San Francisco Fire Department Paramedic Justin Schorr writes about his family’s recent experience with a child’s medical emergency. And of course, Justin zeroes in on some EMS related issues. Be sure and go over to read his blog. Good stuff, it is.</div>
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But anyways, it kind of got me to thinking. How well do we <i>really</i> take care of people?</div>
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It depends upon what you think it involves. Of course, we have protocols to follow, skills to do, and on and on and on. But there are other things that we need to do that are just as important. And they have nothing to do with starting an IV, reading a 12-lead, or any of that other stuff you learned (hopefully) in paramedic (or EMT) school. It’s all about how you take care of people.</div>
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Justin mentioned something in his blog about warming a stethoscope. So just how many times do you take the time to warm up a stethoscope before you place it on a patient? Especially in the winter time when it has been hanging in the back of an ambulance, probably on that catch-all-netting at the head of the bench. Even when it is wrapped around your neck it gets cold. Little kids and elderly patients are kind of sensitive to that cold stethoscope. And guess who makes up a large number of our patients? Yep, you got it. So take a few seconds, tuck the bell under your arm. Probably would be a good thing to do when you are introducing yourself to your patient. You <i>do</i> introduce yourself to your patient, don’t you?</div>
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Over on 9-ECHO-1, I mentioned that the entrance to Walmart is smoother than the entrance to most of this area’s Emergency Departments. So, do you take it easy over those entrances, or just bump on across? Based upon what I have seen, most of us just bump on across. Probably feels really good with that broken hip, bone cancer, or any one of many maladies that hurt when you move. </div>
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And when entering the ambulance entrance to several of the area EDs, it seems that the worse part of the trip is when you are turning into the ED. And we know doubt know it since we do it enough. So how many of you just turn on in, bumping and swaying? And how many of you think about your patient (and partner) in the back of the specialty vehicle you are driving that is NOT known for its smooth ride? If you are the one that just drives on in without consideration for your passengers, I bet you are the one that does not slow down and ease across railroad tracks as well.</div>
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But what about other things along the lines of ‘taking care of people’? </div>
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Do you explain what you are going to do and why you are going to do it? As I get older I am exposed to the healthcare system just a little bit more. At my colonoscopy I saw a wide variety of ‘explaining’ and the lack thereof. The nurse that started my IV had a good technique (well, her tourniquet technique sucked) but she barked out orders like Gunnery Sergeant Hartman- “Put your arm down”, “Make a fist”, “Hold still”. And when she was done she just walked away. Oh yeah, and there was that introduction- “I’m gonna start your IV”. </div>
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Well, she did tell me what she was going to do. And what do to. In no uncertain terms. But ‘why’ would have been nice. So would a personality.</div>
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I always tell my patient (even if they are unconscious) what I am going to do, why I am doing it, if it’s going to hurt, etc. And you should too. It is part of the reassuring process. For a lot of people (I like to think most of them) the whole process of getting hurt or sick and calling 9-1-1 is a pretty stressful and frightening event. A big part of our job is reassuring them and alleviating their fears. And to do that you must tell them what you are doing, why you are doing it, and quite frankly, if something is going to hurt. Before we do it.</div>
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And how well do you ‘relate’ to your patient? You know, that rapport that you have to establish early on to gain their confidence. I have seen some people that are really good at it, while others…well, some people are really good at it. It’s all of the stuff above, and a little more. In my old system we used Panasonic TOUGHBOOK laptops to complete our call reports. And there was a natural tendency to type as you rode. And that is OK if you can pull it off. By 'pull it off' I mean that you have to maintain that rapport, that relationship, with the patient. And that means you have to talk to them. Pay attention to them. And, egads, reassess them. </div>
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Reassess means more than let the Zoll's blood pressure monitor recycle every few minutes and take a look at the pulse oximeter reading every few minutes or so. It means talking to them. It means asking them if they feel better, if the oxygen is helping them. Of if they’re feeling worse. And you CAN’T sit in the ‘captain seat’ and do that. And sitting in that captain seat, typing away, and asking your patient, from behind them, without making eye contact, if they are OK, to me, is worse.</div>
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Taking care of people is a total package. Sure, starting that IV and reading that 12-lead is important. But being nice (because nice matters) is just as important. Maybe more so. In the end, it is the total package that matters. It is the total ‘A’ game.</div>
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And you have to bring that total ‘A’ game to every call, every time.</div>
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<span style="font-family: "Calibri","sans-serif"; font-size: 11pt; line-height: 115%;">Anything less is not doing your patients (or their families) any favors.</span>9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com2tag:blogger.com,1999:blog-4161751548688404561.post-80053716049342974832010-08-09T07:27:00.000-07:002010-08-09T07:27:49.835-07:00Stroke stuff...Don't you just love it when the powers-that-be try to make everything fit into a simplified process? Kind of like everyone thinking that the Cincinatti Stroke Screen is the end-all and be-all to assessing a potential stroke patient.<br />
<br />
<br />
<em>"A good man's got to know his limitations" H Callahan.</em><br />
<br />
Well, it IS useful. And pretty good to use MOST of the time. But it does have it's limitations. Seems that there are those other times, that, well, just tend to screw up plan A.<br />
<br />
Over on Ambulance Driver's site, he recently entered <a href="http://ambulancedriverfiles.com/2010/08/hemi-inattention/">this</a> reminder that everybody does not fit into the 'normal' parameters and sometimes, well, you just gotta think about stuff.9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com0tag:blogger.com,1999:blog-4161751548688404561.post-32850117835671679282010-01-21T18:02:00.000-08:002010-01-21T18:02:46.442-08:00Over on Paramedicine 101......there is a good<a href="http://paramedicine101.blogspot.com/2010/01/professionalism-what-we-say.html"> post</a> about professionalism. Mostly, it is about how we conduct ourselves in front of our patients. It is must reading for all of you.9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com0tag:blogger.com,1999:blog-4161751548688404561.post-60011969022991357722010-01-02T19:19:00.000-08:002010-01-07T09:38:47.886-08:00WAIL-YELP-WAIL-YELP-WAIL-YELP-CHIRP-CHIRP-CHIRP-WAIL-YELP-WAIL-YELPThis afternoon me and my other half were out and about. At one point we were sitting at a stop light in the second biggest city in our county, in front of the great big mall. Now we were sitting on the front row at the stoplight when I saw RESCUE 2 coming down the road with red lights going. There was a moderate amount of traffic and on their approach they went to the outside lane (passing on the right). As they approached, out of curiosity, I turned down the radio.<br />
<br />
After they passed, I asked the missus when she heard the siren. The same time that I did- <b>after they were already in the intersection<i></i></b>.<br />
Later, we were in another one of the smaller towns, sitting at another stop light, when I heard a siren approaching from the rear. I looked in my rear view mirror and saw a deputy sheriff approach from behind. As he approached he came up on my left, stopped, then eased out into the intersection before proceeding.<br />
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I heard him coming from a distance of about one and a half football fields.<br />
The difference? The fire unit had their siren on yelp. The deputy had his on wail.<br />
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And we had the radio in the Tahoe turned up so we could listen to the hockey game when the deputy approached.<br />
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I don’t know the science behind it. But at some point we were taught that this crap of changing tones and stuff made us more easily heard. That it would move traffic out of our way better. That it was safer.<br />
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Purely anecdotal evidence at this point, but it holds up time after time after time.<br />
<br />
I know. I harp on this. A lot.<br />
<br />
But it is amazing how many wrecks involving emergency vehicles I have heard of that the other driver “never heard them coming”. On yelp. Or phaser. Or that cutesy switching back and forth stuff.9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com1tag:blogger.com,1999:blog-4161751548688404561.post-52192871616953249922009-11-04T07:50:00.000-08:002009-11-04T07:50:54.617-08:00Situational Awareness and Responding to an Ambulance CallNo doubt you have read about the Northwest Airlines jet that sort of missed their airport by a few miles. By now, they are saying stuff about laptops, schedules, and what not. So they were not paying attention, and I have to ask the question-<br />
<br />
“JUST WHAT IN THE **** WERE YOU GUYS THINKING UP THERE?”<br />
<br />
There. Done.<br />
<br />
OK. So what does that have to do with situational awareness (SA)? Actually, nothing. But one of the fire service blogs I read from time to time tried to compare the Northwestern incident to situational awareness back before we found out they just were not paying attention.<br />
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There are a lot of definitions out there of SA. Having read them, to me SA can be defined as a combination of knowing and understanding what is happening around you, being able to predict how this activity may/will change what is going on around you, and understanding how that (those) change(s) will affect you. There is also the essence of “being at one” with your environment and the dynamics that are driving it.<br />
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The military learned a long time ago that sometimes fighter pilots were overwhelmed with everything going on around them. Think about it. For a fighter pilot in an F-15 or F/A-18 in level flight there is a lot going on. There are all sorts of inputs that provide information to the pilot. Now, throw in a couple (or more) enemy aircraft, maybe a SAM or two, and the dynamics of the situation have changed. Dramatically. And the pilot has to be able to manage all of that information in order to keep flying and neutralize these threats. Being over loaded with input had some detrimental effects on SA. So the military did some things to alleviate it, in a fashion. As an example, the “heads up” displays in the cockpit were a part of this situation.<br />
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Now, operating an ambulance is not as dramatic. Or is it? Think about it- when we are responding to a call we have all sorts of information that is being fed to us, whether we are paying attention or not. From the driver’s perspective, think about these-<br />
<br />
1. The vehicle’s instrumentation. There is the speedometer (hopefully you are paying attention to this), the tachometer (can tell you a little about your vehicle’s performance; pay attention), the fuel gauge (which you should have been paying attention to before now), the oil pressure gauge, temperature gauge, and volt meter (you need to pay attention to them, too).<br />
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2. The radio (not the AM/FM). Hopefully there is information coming to you this way, whether it is from the dispatcher, the first responders, or other EMS units that are on scene.<br />
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3. Your partner. He/she should be calling out traffic situations on his side and to the front. He/she should also be paying close attention to the radio (you have your hands full driving the vehicle).<br />
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4. Your own senses. Obvious you have to be keeping a sharp lookout to your side, to the front, and to the other side, as well. After all, you are the driver and you are responsible. There are things you hear (radio, your partner calling out traffic, other vehicles’ horns or sirens, etc.)<br />
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In my EMS system, we also have a mobile data terminal (MDT) that provides in-vehicle navigation (IVN) and computer-aided dispatch (CAD) interface. IVN is a good tool, and the program we use is OK, to a point. I think there are some things that could make it better, but that is another day. Also, the CAD interface we have can provide good information, at times, but there are some things that need to be improved with there, also.<br />
<br />
So with all of this information coming in, you have to sort it out and prioritize it. If you are driving, you have to ‘limit’ your ‘heads up display’ so to speak (no, we do not actually have a HUD and I would hate to see the incarnation of it on an E450). When I am driving, I concentrate on six things- the traffic on my left, the traffic ahead, the speedometer, the traffic on my right, my partner, and to a degree my other instrumentation. When I am riding in the right front seat, I limit my attention to the traffic on my right, the traffic ahead, the radio, and the MDT. If I need it, I also concentrate a map book (but I always know where I am going BEFORE the ambulance moves).<br />
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Yes, there is a certain amount of overflow between the driver and the passenger. I guess that is a way of the two positions becoming “one with the situation”. But I am amazed at the low level of overflow when each is maintaining their own ‘sphere of responsibility”. For example, if I am driving, I always look right, even when my partner calls “clear right”. I may not take a long look, because I am depending on them, but I at least take a quick look. It’s the safe and prudent thing to do.<br />
But back to the subject, what are some of the things that can be challenges to SA?<br />
Well, there is the siren. No, I am not talking about the big screaming Q2B found on most fire trucks around these parts. No, I am talking about the multi-tone, multi-position electronic sirens that most ambulances use. You know, the ones with wail, yelp, phaser, hi-lo, ex-wife nagging, screeching cat-in-heat, etc. A lot of times the driver seems to want to control the siren. To me, that is a no-go. First, both of your hands should be on the steering wheel. Second, your gaze should be focused on traffic, the speedometer, your gauges (occasionally), and traffic. You are responsible for moving 15,000+ pounds of steel, aluminum, plastic, rubber, and my flesh and bones through traffic. Safely. So, if you are working the siren (and you shouldn’t be if you have a partner up front, set it on wail and forget it. It is one less thing to distract you from what is going on around you.<br />
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MDT updates. I know not everyone has MDT’s, but my system does. And they have two annoying habits. First, they are ‘updated’ every few moments, which requires you to depress a button on the screen to get the latest information (which may or may not be relevant). Second, there is a lot of other stuff that comes up on the screen that is totally irrelevant to what we are doing. The reason that I say this is distracting to the driver is that we have a natural tendency to want to know what is going on; what kind of information is being passed along. Is it now a ‘code’? Are police on the scene? What’s going on? It’s distracting. I try and always turn the MDT away from me when I am driving. And if I have to view it for directions on IVN/MARVLIS, I STOP THE TRUCK. What more can be more distracting to my situational awareness as the driver than looking at a computer screen?!?!?<br />
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If I am not driving, the MDT is turned towards me. I’ll call out directions. <br />
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The radio can be distracting. Sometimes the radios are on scan. In my system, it is desired that we switch at least one portable radio over immediately to the appropriate TAC channel. But then someone else may say something on the main channel that your mobile is still tuned to, that is not relevant to your call, but sounds like it is, then you get distracted, then you are filling out incident reports on the wreck you just had. Some people may disagree (and that’s alright, you can’t help it), but I work to set all of the radios to the assigned TAC channel. Leaving the main radio on the dispatch channel can even be distracting to me in the passenger seat. Nothing like turning your head and saying “What did they just say?” as a minivan plows into your side.<br />
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I won’t even mention much about cell phones, iPods, and Blackberries. Unless God personally is calling you, you do not need to be talking on some other <br />
communication device while you are driving my ambulance ‘hot’ to anywhere.<br />
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So much for SA while driving. I could talk more, but you get the idea. Do what you can to make your job SAFE. Your ultimate goal must always be going home at the end of your shift. All other concerns are secondary.<br />
<br />
M9149-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com0tag:blogger.com,1999:blog-4161751548688404561.post-36664665596979636092009-10-29T19:59:00.000-07:002010-01-25T15:37:23.461-08:00A picture is worth a thousand words...<div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9_Luh_kyrrwjWvuIMqLSIe0hw7FiqXELf1CC_cy5aHqmy83_79Inu3boGqFKvVfUuhjBXmbxW7ywwXEkvt3Qb82m3IMQa29XBS6wft5v6SFnnp4LTr75up9khHyb6CTP5O4XH8FW-yKo/s1600-h/Blocker+I.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9_Luh_kyrrwjWvuIMqLSIe0hw7FiqXELf1CC_cy5aHqmy83_79Inu3boGqFKvVfUuhjBXmbxW7ywwXEkvt3Qb82m3IMQa29XBS6wft5v6SFnnp4LTr75up9khHyb6CTP5O4XH8FW-yKo/s320/Blocker+I.jpg" /></a><br />
</div>A picture is worth a thousand words. And the last thing that I want is for you or me to be the subject of a picture like this. All it takes is a few seconds to make sure you have a safety blocker in place, or at least on the way.<br />
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Vests, flares, traffic cones, flashing lights, and chevrons make you visible. <i>To the driver who is paying attention.</i><br />
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But what about the one(s) who is not paying attention?<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjcIN6MgIoEkP462lBlIn3apYyfr0F_kPTTzdJ7Qyp3Ropw4N2eOmd84n9jPMwLFgwH8xBTu75Di24I5mQHPVbxgosUKJ8FuxLmw2Yz8OefbDzD-Z2Td_GKI1tuhPGlfF1F1mO5QWULK80/s1600-h/Blocker+II.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjcIN6MgIoEkP462lBlIn3apYyfr0F_kPTTzdJ7Qyp3Ropw4N2eOmd84n9jPMwLFgwH8xBTu75Di24I5mQHPVbxgosUKJ8FuxLmw2Yz8OefbDzD-Z2Td_GKI1tuhPGlfF1F1mO5QWULK80/s320/Blocker+II.jpg" /></a><br />
</div>What would the result have been if this car had struck the ambulance? Especially if you and your partner and a couple of first responders were loading a patient into the ambulance.<br />
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On arrival at a scene like this, pull ahead. This allows the fire truck that arrives after you do to pull into position between you and the motoring public. If the fire guys are already there, pull around in front of them.<br />
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Either way, you have something between you and the motoring public. 9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com0tag:blogger.com,1999:blog-4161751548688404561.post-15885766941631855342009-10-10T14:45:00.000-07:002009-10-10T15:00:14.827-07:00Rituals can be a good thing...Contrary to some belief, I think some 'rituals' are a good thing, even here in EMS. Sometimes those rituals get us into good habits. And as long as they are based on sound goals and objectives, well, they can be good.<br />
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Checking-off the ambulance at the beginning of your shift is an important thing. It is a ritual of sorts. We should be doing it at the beginning of every shift. I guess in a perfect world you could trust your off-going shift to be diligent in ensuring that you and your unit can take that call that comes in immediately after you go on duty. But usually, that is when I get my nastiest surprises. You see, as much as I like them, sometimes, well, they forget stuff. Or in some cases, they just don’t care. Yes, I have worked with some of those people during my career.<br />
<br />
So I take matters into my own hands. Some surprises are good, but others are not. First thing, you need to arrive at work with enough time to check a few things before going on duty. So, if your shift changes at 0800, then you need to be at work NLT 0730. Change at 0700? Be there at 0630. No, you are not going to get paid for it. Not money, anyway. But it can pay you dividends that you can appreciate it. More on that in a few minutes.<br />
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The first thing I check is the main onboard oxygen cylinder. The second thing is the defibrillator batteries (those actually in the defibrillator and the spares). The third thing is my portable oxygen. A quick look around the unit to verify that things seem to be in place takes care of my ‘initial’ check.<br />
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The next thing I do is change the portable radio batteries (unless I know that they were changed just prior to me receiving the radio).<br />
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I try and get some sort of turnover report from the off-going crew, then, I or my partner start on the complete check-off. If we get a call in the middle of it, then, my partner or I can continue the check-off while the other is completing the report at the ED.<br />
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There are things that you can do to make the check-off easier. At my service, we seal certain items with a numbered seal tag. The things we seal are the ET kits, the pediatrics bag, our drug box, and our Mark I kits. Other things could be sealed, like cabinets with little-used items (OB kits, burn sheets, etc.).<br />
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The rest of it is just a matter of finding things on the checklist and then finding them in the unit. Of course, after only a few days you should know where just about everything is, so it should not take a lot of time.<br />
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And somewhere up there at the beginning, before the other shift leaves, I like to verify my narcotics and controlled drugs. There is nothing quite like discovering a morphine or fentanyl that has not been accounted for. After the other shift has gone home. And of course, no documentation is available, and the last shift’s call reports are in the ‘HIPAA box’.<br />
<br />
But back to the check-off. Usually, it can be done before or shortly after our official shift begins.<br />
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So what other benefits can be gained by this? Well, if you establish the standard, maybe the other crew(s) will reciprocate. After all, if you are there at 0730 and a call comes in at 0745, then you should take the call. Again, you probably are not going to get paid for it, depending on your agency’s HR policies or your union contract. But the other crew does not have to take that late call, and they should be appreciative. Enough so to return the favor the next day. I know I would, since <br />
<br />
I really hate those 0745 calls. Seems like they only come in when I have to be somewhere at a specific time.<br />
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But what if they don’t return the favor? Well, several of the crews I work with are like that. And that’s OK. At my old service I always tried to arrive between 0730 and 0740 for an 0800 shift change. My new job has an 0700 shift change, and I want to be there between 0630 and 0640. It hasn’t worked out thus far since the other half and I have been down to one vehicle for a little while now. But as soon as I get the 9E1-mobile back, then I will be leaving home at 0620-ish.<br />
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Rituals can be good. As long as we have solid goals behind our rituals.9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com0tag:blogger.com,1999:blog-4161751548688404561.post-47449666566454027112009-09-21T10:06:00.000-07:002009-09-21T10:07:36.535-07:00The Code CommanderI remember back when we in EMS did not do anything like ICS. Hell, we did not do anything like ICS in the fire service, either. And looking back I come away with two thoughts. First, it's amazing we did not get more of us killed and hurt. Second, it was pretty damn funny to watch.<br />
<br />
But then Chief Bruno wrote his book and it all changed. Maybe not overnight, but it did change.<br />
<br />
Well, not quite.<br />
<br />
How many resuscitations have you seen that were 'less than organized'? There was a lot of yelling going on, a lot of equipment being thrown around, but not much getting accomplished. Yep, I have seen a plenty of them, too. Even participated in a few of them.<br />
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Well, the answer is right in front of us. Apply the concepts of ICS and designate a Code Commander.<br />
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No, we do not need any special hats, vests, or badges. The code commander is the one watching the monitor. Calling the shots. Making sure stuff is getting done.<br />
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And the concept works. <br />
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Your system's design will determine hwo the concept works for you. In ours, we have resources. Lots of resources. Most of the time. <br />
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Usually, fire units arrive first. Most of the time the first arriving fire unit brings at least three personnel to the scene (in some instance two, in others four or more). They initiate chest compressions and early defibrillation (if indicated).<br />
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The next arriving unit is typically an ambulance, staffed with at least one paramedic. That's your initial 'code commander'. The code commander is tasked with making sure that adequate chest compressions are ongoing and makes sure the monitor is attached to the patient. If ALS resources are initially short, the first arriving paramedic can place the IO.<br />
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Place the King airway. In our system EMT-Bs can do this. Attach the ETCO2 and verify the waveform.<br />
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Sit back. Oversee.<br />
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Other resources will arrive. In our system at least a second ambulance, a district supervisor (EMT-P) and/or an additional supplemental response vehicle paramedic.<br />
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If desired, the code commander role can be transferred to another arriving paramedic. But if the first person is getting it doen, then leave it alone. No sense fixing something that ain't broke.<br />
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One code I worked recently found the patient on the screened in back porch. Resources arrived quickly and everything was getting done. I was the code commander, so when our medical director arrived (he checks in on calls, drives a marked response vehicle, etc.) there I was, sitting in a chair, LP12 in my lap, good view of the scene, and my feet propped up on an ottoman. All that was missing was a drink and someone to fan me!<br />
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The concept works.<br />
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And something else that helps is the 'checklist'. Below I have the 'cardiac arrest checklist' that is in use in my system-<br />
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Cardiac Arrest Checklist:<br />
____ Code Commander is identified<br />
____ Monitor is visible and a dedicated provider is viewing the rhythm with all leads attached<br />
____ Continuous compressions are on-going<br />
____ O2 cylinder with oxygen in it is attached to BVM<br />
____ Mask travels with bag, regardless of what airway is in place<br />
____ EtCO2 waveform is present and value is being monitored<br />
____ ITD is in place if appropriate<br />
____ Access has been obtained (IV or IO)<br />
____ Gastric distention is not a factor <br />
____ Esophageal temperature probe is in place and temperature is visible<br />
____ D50 and sodium bicarbonate have been considered and/or administered<br />
____ Tension PTX has been considered<br />
____ Family is receiving care and is at the patient’s side<br />
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I'llget pictures up pretty soon. More later on the whole checklist thing.9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com0tag:blogger.com,1999:blog-4161751548688404561.post-18079987255438535082009-08-29T05:48:00.000-07:002009-08-30T14:13:33.195-07:00Good morning...So here we are. Blog #2.<br />
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I have really enjoy doing the 9-ECHO-1 blog. But like I said over there, there is something I wanted to do that really would not fit, at least I didn't think so, on the 9E1 pages. So here I am.<br />
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Most everyone knows what 9-ECHO-1 stands for and where the name comes from. BUt where does MEDIC 914 come from?<br />
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Several years ago I was a volunteer paramedic with my town's rescue squad. We all had individual radio numbers assigned, and mine was 914. When my agency began providing paramedic level service, I would use the call sign MEDIC 914 whenever I was communicating on a non-unit level.<br />
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At that time, the concept of Incident Command had not caught on much. OF course, that led to some pretty darn humorous stuff on the radio. And so, in the interests of being the "class clown" and calling attention to myself, a lot of times, when my unit arrived on the secene of some "less than life threatening medical situation" you might here something like "MEDIC 9 on scene, we have a two story wood frame apartment complex, nothing visible from the outside. MEDIC 9 has Butterfly Apartments Command, we're investigating, Sector 5". And always, I would get a chuckle or some sort of remark from the 9-1-1 center personnel.<br />
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Everyone thought that was kind of funny, the way I did that. But of course, when I rolled up on the "thoroughly life threatening medical situation", it went something like this "MEDIC 9 on scene, we have a single vehicle rollover crash. I have multiple patients in the north and southbound lanes. Traffic is blocked in both directions. MEDIC 914 has I-95 South Command at MEDIC 9. I need 10 ambulances to the scene and 10 helicopters to the pad".<br />
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Let me clarify one thing. This took place back when we thought helicopters were life saving creatures. Back when all things in a resuscitation effort ceased while the <strike>paragod</strike> paramedic intubated the patient. Back when MAST trousers were life saving pieces of equipment. You know, just a few short years ago.<br />
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But anyway, I hope you enjoy the new blog. Don't forget to check out the other one, but keep coming back to this one. And please, offer comments, ask questions, or argue. <br />
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I love a good argument.9-ECHO-1http://www.blogger.com/profile/10146575729985891696noreply@blogger.com0