ckroll

Interesting and amusing. How many health care workers have run into MRSA? All of us. On a regular news cycle, the press trots out disease of the month. Hep C in firehouses, E. coli in in hamburgers, samonella in chicken, parasites in fish, Norwalk virus on cruise ships, Lyme/babesiosis/ehrlichiosis. For special occasions they run the plague/ebola panic ..... [if its a slow flu season] and the oldie but goodie, mad cow disease. [The next big thing will be CWD in New York deer... you heard it here first.] First, the world is a filthy place and second, a lot of this stuff, like staph, is part of the natural biological make-up of our epidermis. There are a thousand reasons to be careful about anything you touch. As for precautions, for MRSA, nothing more than the usual BSI... pair of gloves changed regularly and removed before I touch anything else and handwashing. Things that REALLY terrify me..... 1. The thought of being trapped on a cruise ship with 1000 drunk strangers looking to swap spit. 2. Salad bars...like a sneeze guard ever stopped anything, 3. Door knobs in restrooms. ... door knobs anywhere. 4. Touching money.... credit cards can save your life. 5. 'Air' in airplanes.... just try opening a window up there. Do you have ANY idea where the produce in the grocery store has been before you buy it.... in three countries, on four trucks, a boat and handled by at least 8 people who have not recently washed their hands. Ever seen a fish market? Before that $20 a lb Chilean sea bass was lying in a display case, it was lying in a really old box drawing flies on a dock. Do you have any idea what that lobster was eating before you ate it? Commercial hamburgers are called fast food for a reason.... leave it on a table and it can crawl away on its own. About the only safe stuff out there is a good ripe cheese, because it is so encrusted with fungus that nothing else can grow on it. So yes, MRSA is worth paying attention to, but its got a LOT of company.

The problem with good research is that so few people will volunteer to have their hearts stopped and then be assigned to a treatment or control group. Animal studies, in addition to being morally repugnant, do not provide data on return of sentience, what we as humans consider most important. Awareness of ventilation/perfusion is critical and I think idiot lights are a terrible idea. How often an idiot squeezes a bag has nothing to do with adequate ventilation and may distract the idiot from actually looking at the patient, seeing that the mask fits properly and that there is chest rise... and that there is oxygen attached and that the tank isn't empty. CAPNOGRAPHY. Get it, learn it, use it. It's instant feedback that is quantifiable that tells the crew if compressions are effective, if the tube is in place, if ventilations are adequate, if perfusion is happening. I was part of a crew responding to a critical injury with delayed transport. The patient needed to be ventilated with a BVM for an hour and capnography was essential. Watch the monitor and ventilate to stabilize CO2 levels. I can't say enough good things about it. If the patient needs hyperventilation, it can be in a controlled manner, not guesswork. Oxygen in is almost meaningless, CO2 out tells you what you need to know. It is THE vital sign.

We just did an extrication on a Campagna T Rex. Wow... double Wow. It's worth looking up if you've never seen one. One wheel in back and two in front with a fiberglass shell. Not recommended on the Taconic Parkway in the rain.....

Save for the crush medicine, it sounds like standard fire service trench/ high angle/confined space. I'm thinking there may be a lot of medics that are already trained to rescue, if not actually called rescue medics. It might be useful to keep lists locally of those who can 'drop in' on a patient. The issues I see as paramount are teamwork and continuing training. One medic can't rescue, it will take a trained, coordinated team of 4 people to make a rescue medic effective. Keeping skills current will be a huge undertaking. Once a rescue goes vertical, gravity is your constant companion, and there is no room at all for error. It will require a LOT of dedication on and off job for medics to keep that many skills sharp. I wonder how often, the best course might be to focus on doing the rescue first and treating later? The tragedy would be if rescue were delayed to treat in the field when good or better outcome might be obtained by sticking with rescue basics. I don't know how many of you have packaged a patient in a cave, but it's a nightmare. I can scarcely imagine trying to successfully add ALS skills. That said, more preparation and more training is always a good thing. How are the teams to be managed and deployed? Will they be available out of region?

Fear of litigation should not be driving our health care decisions. If it is that big of an issue, then those individuals need a career path with less jeopardy. Doing right by the patient will be infinitely more effective at avoiding bad outcomes. The 4 treatment scenarios are: needs glucose, gets it; doesn't need glucose, gets it; needs glucose, doesn't get it; doesn't need glucose, doesn't get it. The only killer one is not giving glucose when its needed. What we should be concerned about is not missing opportunities to give needed glucose. A glucometer doesn't help with that in the EMS setting. The standardization of 70-120 is referenced to symptoms for the average person. The body adjusts to its circumstances. Someone who lives with routinely low BG may tolerate a reading of 40 well and a person who has routinely very high BG [ I was told, haven't searched it] can have personal 'hypoglycemia' in the 70-120 range if sugar drops precipitously [ fever, sepsis, extreme exercise ] So a glucometer is much less useful for patients at the extremes. I got called for chest pains, 8/10. Alert, oriented, not well. The older patient had a long history: cardiac, renal failure, needed to be dialyzed, was warm to touch. About the only thing the patient didn't have was diabetes. I did a 12 lead EKG which was unremarkable for ischemia. 30 minutes after arriving at the hospital the blood work came back with a BG of 40. Nobody had anticipated that. It also wasn't the primary problem. The take home lessons, for me are: I didn't give glucose and it didn't change outcome on a person who was not symptomatic. No one ever has just one problem. Hypoglycemia can be anywhere and as the population gets older and fatter, diabetes related issues and renal issues will be more common. So now I check BG on lots of patients, not so much to catch the life threats, but to isolate secondary issues. That is more an ALS role than a BLS one, though. I also remember a wild day with a heat wave and a power failure. The ER, the only AC in town, was long past capacity with patients with difficulty breathing. We were asked to treat as much as we could in the field. That day, OJ and a glucometer and a call to MC kept several of people out of the ER. So a glucometer really has a place in overall treatment, but perhaps not as a first line of defense under normal circumstances.

Just keep current with your training. They could make it 250 hours every decade and there will still be people running around the last month like they had no idea it was coming. Every 5 years just gives people 2 more years to goof off. License medics and make a continuing education requirement. Require all agencies to provide free or reasonably priced continuing education. 5 years just sounds like more rope with which to hang ourselves.

"Give me your tired your poor, your huddled masses yearning to breathe free. Send these, the homeless tempest tossed to me, I lift my lamp beside the open door.'' Why don't we just trade in Liberty's torch for an up raised middle finger and a sign that reads "Sucks to be you". What makes/made America great is/was tolerance and compassion. I'm proud to be liberal and proud that just because my family got here 150 years ago instead of last week that I don't think that makes me special. Don't confuse luck with superiority. In point of fact, the Spitzer proposal was intended to bring NYS in line with the recommendations of the 911 Commission. What allowed the individuals responsible for 911 to be identified was that they had gotten driver's licenses..... as legal aliens. Might add, if you eat fruits and vegetables, thank an illegal immigrant. And for those of you how love the English language so.... Lurn to spel.

I'm guessing you didn't hear the questions.

Could someone explain to me how BLS glucometer testing is going to improve patient care? Testing, especially invasive testing, should be limited to situations where the results of the test will change treatment. The alert patient with suspected hypoglycemia gets a tube of glucose or a glass of OJ, no testing necessary. If a person is not alert, then none of us can give oral glucose, no testing necessary at the BLS level. AEMTs need to test BG prior to dumping in 50% dextrose because that is an insult to the system. BG is part of more comprehensive ALS testing to distinguish between overdoses, or stroke, but in the the BLS arena it isn't going to change treatment. Look at the patient. The cold, pale, sweating, angry person standing at the deli counter who doesn't know why he's there needs a soda NOW. The drooling person in fetal position in aisle 5 needs ALS. I don't see what a glucometer in the hands of BLS does to change outcome save that it may delay treatment while someone fools with the machine. And if the glucometer is wrong....... not that that's ever happened...it might well delay treatment when a soda or glucose is not likely to hurt anyone. Sometimes there is a very short window where a hypoglycemic person can still manage to swallow. Don't miss it looking for the glucometer and trying to remember how to use it. What would be extremely useful would be for urban/suburban EMS,--now that ALS so handy,-- is to start looking at EMTs as proto AEMT's and put more emphasis either in the basic course or region by region into familiarizing EMTs with AEMT protocols and skills so that they can participate more effectively on critical calls and have a better understanding of what will come next in terms of patient care. Should EMTs know how to use a glucometer? Absolutely. They should know how to spike a bag and how to assist the AEMT in drawing bloods or securing IV access, and how to hook up the EKG monitor, the list goes on. Any AEMT can tell you that a good EMT can add immeasurably to the call. AEMTs save patients and EMTs save AEMTs. I think EMTs need to know how to do lots of stuff, but I'm not convinced sending them out alone with a glucometer is going to help anyone. If I'm wrong, educate me.

Yeah, where does the fabricated news conference fit into the NIMS ICS. .......It's a TASK FARCE!!!

"Very interesting info ckroll, but I think the issue with cardiac arrest is just the opposite of the issue with COPD pts. The %100 O2 being administered during an arrest is taking too much CO2 out of the blood and making it basic. Normally the blood is slightly acidic, and the majority of the cardiac meds we administer are suppose to be in an acidic environment. I'm just spit balling since I really don't know and don't have any access to the right sources." It's two different mechanisms and apologies if I did not make that clear. There's ventilation, moving air in and out of the lungs and then there's gas exchange where O2 and CO2 move independently across the alveolar membrane into and out of the bloodstream. I don't think oxygen per se takes dissolved CO2 out of the blood. My understanding is CO2 is lost from the body in urine and through passive diffusion across the alveolar membrane. If anything, oxygen drives buffered CO2 off hemoglobin and into the blood stream. [ where if there is adequate/hyper adequate gas exchange, it leaves the body through the lungs and if there is not good gas exchange, it remains in the blood deranging pH downward.] Assuming an arrest is not due to respiratory issues and that the airway is patent and there has been no aspiration.... Driving off CO2 by hyperventilating an arrested person causes vasoconstriction and that reduces perfusion in cardiac arrest. I do not know if the alkalosis is responsible for the vasoconsriction or not. I think at least one issue is too much ventilation, not that it's too much oxygen. Second unrelated thought is that COPDers cannot drive enough CO2 out of the body due to loss of alveolar membranes, among other things. If you increase oxygen available to the blood dissolved CO2 levels increase because there is preferential binding of O2 over CO2, so you drive CO2 off the heme but not out of the body hence increasing acidosis. This problem is not enough air exchange compounded by too much oxygen. The point I had intended to make was that we need to be mindful of ventilation rates as well as oxygen saturation since ventilating with high flow O2 delivered at a rate of 20 breaths per minute is manipulating both O2 and CO2 when sometimes we don't want to do that.....and to point out that most Lifepak 12's let you monitor CO2, if we remember to use it. There is excellent information available on capnography and waveform analysis. It lets you monitor effectiveness of CPR in real time, tells you if the tube is properly placed and stays there and when it is time to cease resuscitation. Early monitoring can tell you if the heart or the lungs stopped first and if there has been extended down time. I looked up free radicals. I found Stroke-- 'Oxygen radicals in cerebral eschemia' from AHA, among others. There is a wealth of information, much of it old, about free radicals. During reperfusion in animal models there appears to be some damage, but this is not an EMS issue. Oxygen is not a free radical and free radicals aren't all bad. They will be formed in the mitochrondria as a part of metabolism. It sounds like a longer term issue, not one we would encounter in the heat of a resuscitation. Certainly someone who is poorly perfused will be deprived of oxygen and to limit it further would be a mistake. The bigger take home lesson may be that anything in excess and without monitoring has the opportunity to do more harm than good. Oxygen saturations in the mid 90's and CO2 pressures in the mid 30's ought to be the goal. Measure and titrate both oxygen and ventilation to desired effect.

Lights and sirens are useless. All they do is increase the level of anxiety for patient and crew and encourage drivers, [ambulance and public] to do rash things. Save for unsecured airways and major trauma, it should no longer be an emergency once a medic is there. What an EMT at any level has to bring to a patient is a mindful assessment, the relief that comes from thinking that the emergency is controlled and on its way to resolution, and patient advocacy. Not even the best of us can make good decisions without good information. Consistently asking oneself, is there something here I can work with? [and by this I mean, something to improve outcome, not for show], and actively looking for treatable problems means that at the end of the list, if all the answers are 'no.' , then the transport decision will likely be a good one. I love 12 leads and do them on anything reasonable that doesn't move faster than I do. You might be amazed by how many elderly patients who 'can't shake this flu' have ST depression in multiple leads. I had a 50 year old writhing in pain and bawling for his mommy. Classic panic attack [ as was pointed out to me by 3 people in the ER, not particularly kindly, might add.], --accompanied by a 6 pack of tombstone T's. How the patient presents and how we present the patient can be a 20 minute difference in time to the ER evaluation. We underestimate how much a hospital, especially when it is busy, will rely on the paramedic or EMTs initial assessment. Make it a good one. A friend put a large name on his small fishing boat. I asked why and he said ' Two boats call for help, the " Put, Put 2" and the "Glomar Challenger"... where do you think the Coast Guard is going first?' 'Not doing well.' sent in BLS or 'Not doing well with EKG changes.' sent in ALS. Where do you think the ER is going first? If we aren't advocating for the patient we're bringing in, at least initially, the ER isn't going to either. EMTs and paramedics can't fix much...but we can try to find it and point it out to someone who can. That's good assessment and good advocacy.

OK, we know more about this call than we think we do. The pt went via BLS ambulance to a community hospital [ website says 450 beds, full service] and was air lifted to a medical center. 'where he died.' Distances around DC are not large. One can assume the full service community hospital saw something it didn't like and couldn't treat and that the patient was stable enough for air transport to definitive care. Last I checked, any community hospital is better equipped than a paramedic and staffed by MD's as well. It appears the patient had contact with a BLS crew, a community hospital, a flight crew and a medical center between the time the paramedic evaluated him and his ultimate demise. We know nothing about how long the patient was with any of them. That he lasted as long as an air flight to definitive care says that the list of people who had a chance to change an outcome is exceedingly long.

It wouldn't think it is automatically ridden in, but if an adult has a HR consistently over 150 with symptoms, then an ALS evaluation is in order if an ER is not around the corner. There is much we do not know about the call, like everything except the outcome... 150 is a whole lot different than 200, how long was the rate elevated, does the pulse match the heart rate, was there dehydration, heat exhaustion, or pharmaceutical complications. As we all know, 160 bpm is about where the heart exceeds maximum output. Beyond that the asystolic phase is insufficient for the heart to perfuse itself adequately. Failure to return to acceptable levels in 5 minutes would be a significant indicator. Under any circumstances, a young male with an elevated heart rate should always be checked for undiagnosed WPW. Not having been there, it is not mine to judge if the care was adequate. Lots of calls fall into the gray zone where we either look for reasons to ride it in or to send it BLS. I am betting if she had it to do over, she'd ride it in.

You may be referencing "hyperoxia-induced hypocapnia". [Too much oxygen causes too little carbon dioxide] Oxygen is only half the equation and it may not be the important half. Increasing oxygen saturation from say, 90% to 100% takes a lot of added ventilation and may not be necessary in the emergency environment. We cannot drive up oxygen without also driving off carbon dioxide. By driving down CO2, we may cause vasoCONSTRICTION and this will affect perfusion at the cellular level. What may be at issue is that too much ventilation can cause localized vasoconstriction due to loss of CO2 so that the added oxygen isn't getting to tissues. It's really interesting. As a side note, hypoxic drive may not be what is going on with COPDers either. These individuals, at least some of them, are 'retainers' which means they have ventilation/perfusion mismatch and have too much CO2 in the blood stream. This makes the blood acidotic. The body has several mechanisms for buffering the acid [prior to it being blown off hopefully, in the lungs] and one of them is within the hemoglobin. So.... a person may be in distress as much because of the acidosis as the oxygen. Adding high flow oxygen causes the hemoglobin to dump the CO2 it is buffering to pick up the oxygen. Because the person cannot blow off the CO2, it stays in the blood, so the effect of high flow O2 may be to make an acidotic patient even more acidotic, leading to catastrophic system failure. Current thinking in some quarters is that when one says "I put oxygen on the COPD patient and he crashed" that this is a response to increasing acidosis, not hypoxic drive.' Evidence for this among others is that you can't bring these people back by ventilating them. If it were strictly loss of drive, bagging them should turn it around, and it doesn't. This is pretty much basic physiology and is addressed in BLS protocols...don't hyperventilate unless there is evidence of brain herniation. Lifepack 12's monitor CO2, if one uses it. There is a lot of recent interest in being as mindful of CO2 levels as we are of oxygen. I'm no expert on the subject, so if there are some out there, please educate us. Searching hypocapnia, copd, hyperoxia, ventilation, perfusion... will get you headed in the right direction. Great question.

Goodness! I can't even remember back to 34. Love it, enjoy life and family. You will never be younger than you are now. One more year to the top of the hill, if memory serves.....You're not getting old you're getting better. Youth and enthusiasm is no match for old age and treachery. Wishing you all the best.

Neither is brute force a substitute for thought and ingenuity. It is the rare exception when the fire service or the public benefits from either 'brute' or 'force'. Firefighting... and the myriad of other tasks firefighters are called on to do... requires strength and agility, thoughtfully applied. A good firefighter gets the job done, goes home at the end of the call. Great ones make it look graceful, effortless, doing as little damage as possible and having the people we serve appreciative of the job we do. I'm a 51 year old woman who weighs 125 lbs. No, I can't advance charged deuce and a half up a flight of stairs. In my small town I haven't needed to either. I can cut a car with the best of my beefy brethren; I'm better than many at bucking up trees because I keep my chainsaw sharp and know better than to fight physics. We don't go bare handed. We have chains saws, and jaws and cutters and an entire truck worth of leverage and mechanical advantage and duct tape. If the job calls for someone who can work tight spaces, any department is well served having someone who can access a 7" space and work in a 12" one. Our department has 10,000 acres of state park. For searches and brush fires, it is the small and the quick.. and the fit... that do the best work. What irks me to no end is the inherent laziness of 'testosterone is the only thing that matters' point of view. It is the nature of being human to see value in who we are. It is the bigotry of small minds to think that one person is better than another based only on how he is born. A remarkable number of people I have met who feel that the balls make the man, use it as an excuse... to not think, to not stay in shape, to not train. Having nuts, a 48" waistline, and staggering 4 letter vocabulary doesn't make a person a firefighter. I don't even think it helps. Dedication, willingness to train, to stay fit, the ability to learn new things, and the strength to apply them, the wisdom to know when to beat the door in and when to turn the knob, courage, compassion, love of the profession, wanting to be the best and to do the best each and every call... those things make a firefighter. It's what's in your heart and your head -- not your scrotum-- that matters, boys.

The fiberglass shell disintegrates on impact and leaves a go-cart cage in front of a single rear motorcycle tire. The tubular steel cut like butter and could be bent back by hand. No doors, no windshield, no airbags, no roof simplifies extrication. The occupant did remarkably well considering the total deconstruction of the vehicle. Had it flipped it would have been a different story, but given the outboard front wheels and low CG, maybe they don't. Obviously ripping up the vehicle absorbed a lot of energy and resulted in a reasonably soft landing. Not a bad safety design, which is remarkable given how little vehicle there is and how fast they can go.....infinitely superior to doing the same thing in a motorcycle.

Advocating CPR is always a good thing. If a poorly educated general population envisions CPR as having to lock lips with a drooling dead person and therefore, they don't want to do it, then getting the word out that CPR is drier and easier is, in my opinion, a step forward. Help or hinder? Unlikely to hinder and if it buys the patient an extra 5 minutes of circulation and makes the situation salvageable, then it saves a life. I don't know about your territory, but I cover 46 to 90 square miles on a good day, I'm not getting there in time to turn an arrest around unless bystanders have stepped up.

The focus now is on quality compression. Rightly so, without circulation, the other skills are meaningless. In a perfect world we do not stop there, but we have to start there. What I took away from retraining was that the first 5 or 10 compressions got the pressure up to where subsequent compressions were effective at moving blood, hence more good compressions at 30:2 than 15:2. That said, the suggestion that rescuers switch out every cycle is awkward. Part of the movement away from focusing on the breath I think has to do with a better understanding of how much air exchange is needed, and it is not as much as many of of were trained to deliver-- or ended up delivering in the heat of the moment. It isn't just oxygen in, it's also CO2 out, with some awareness of blood chemistry. Capnography. What a useful and underused tool! If we want to know how effective CPR is --and will be-- in the effort to reach ROSC [return of spontaneous circulation], then measure elimination of the byproduct of metabolism. It tells you that circulation is getting oxygen to the cells, that cellular exchange is happening, that pulmonary exchange is happening, and it tells you something about blood chemistry, as well as being a real time indicator if circulation is restored, or if restored when it fails again. It monitors tube placement in real time as well. Waveform analysis when taken with the raw CO2 value is a window into the patient and record showing how successful the various components of CPR are. It can also tell you when best efforts have been exhausted and termination needs to be considered. If monitored early in the resuscitation, it can even distinguish between respiratory failure leading to cardiac arrest and cardiac arrest leading to respiratory arrest. And a whole bunch of other things.. In short, capnography with waveform isn't just for technology buffs anymore. There's a lot of good material about it on the net. Please, read it, use it, and maybe take your game up notch.

Excellent question. Under any circumstances a minor has to be left with a major. If a minor is capable of making an informed decision, [ I define this as any child that out weighs me, but this will not work for all medics.] then I will call a parent and have child and parent agree on a go forward strategy. If a van load of brownies has had a fender bender and one has cut her lip on her braces and the mom is comfortable with the driver continuing with the care of her child, I will document, document,document and let it go. If a child does not know who or what a president is and is still in the age of 'magical thinking' then they cannot tell you if they are hurt, or at least cannot be expected to understand the consequences of injury. That makes them incompetent to make a decision on their own. Armpit/facial hair is considered defining for adulthood and CPR, but I am not sure if I want to go there. If the 'little shaver' is shaving, I'd call him/her an adult irrespective of chronological age. Key is understanding the consequences of a decision. Not even all 'adults' can do that. Ask good questions, look at every patient in terms of trying to rule in transport, not ruling it out and you will seldom stray off the path.

If it is medical and we are responsible, then NYSDOH has it in writing. Policy statement 02-05, Pre Hospital Care Reports, page 5 lists meaning of all disposition codes. 008 No Patient Found " If a service arrives at a scene and there is no one there with any complaint or injury, this code should be used. This would include being dispatched to a motor vehicle crash at which there are no persons who require any evaluation or care to. Document completely under comments. 005 Refused Medical Aid and Or Transport " Any time contact is made and a person is evaluated, to include such procedures as vital signs being taken, or any treatment provided...." Definition of patient: 1. a person who is under medical care or treatment. 2. a person or thing that undergoes some action. 3. Archaic. a sufferer or victim. Definition of victim: 1. a person who suffers from a destructive or injurious action or agency: a victim of an automobile accident. 2. a person who is deceived or cheated, as by his or her own emotions or ignorance, by the dishonesty of others, or by some impersonal agency: a victim of misplaced confidence; the victim of a swindler; a victim of an optical illusion. If one does not undertake action involving a person-- by providing treatment or care--, then that person is by definition not a patient. Document under comments. If it is one's intent to make a call billable, then by all means touch the individual and take vital signs, thereby making them a patient. If you do, you need to know what your agency requires and what the ramifications will be. NYSDOH is specific that pre-hospital providers explain to individuals the outcomes of their decisions. If a person asks to be "checked out" and this will result in a fee for service, then the provider needs to make that clear. To provide care defined as "to watch over, to be responsible for" means that we as providers of care do not take advantage of others misfortune. Following an MVA, police will be dispatched, as will fire and BLS ambulance service, and a tow truck. It is commonly understood that one will not be getting billed for police activity, or fire services, or ambulance service unless it is used. Towing and ambulance transport are recognized as billable events. If one works for a paid service that intends to bill for services, then that needs to be made clear so that the individual can make an informed decision. Billing for services is fine; the process just needs to be clear. To do less falls into the second definition of victim--a person who is deceived or cheated, as by his or her own emotions or ignorance, by the dishonesty of others--. Individuals who have experienced an MVA are not supposed to be rendered victims AFTER we get there. If the sole purpose of a PCR is to cover the assets of the pre hospital provider, then that care is directed to the provider, not the individual for whom you were called, and you should be putting your name at the top, not his. [ and perhaps getting billed] None of which addresses the issue of minors. Ethics and common decency ought dictate that a minor be left in the care of a competent, legal adult and that a legal guardian be the primary decision maker. Back to NYSDOH, however, if the individual has no complaints or injuries and is competent, then it is not at all clear to me that a minor is a 'patient' in need of MEDICAL care. More than one police officer or school nurse has tried to make their problem my problem by claiming there is some law that all children belong in hospitals. I cannot find it and would be forever grateful if someone out there could direct me to it. What is expected of us, as care providers, is that we make good decisions in accordance with protocols, that we keep everyone informed of our actions and the consequences of those actions and that we document what we do.

If memory serves, 'transporting' agency would only go to closest, which was not appropriate in this case. A 40 minute ride would have ended badly, so it was a lucky break. Again, I wasn't there, but it brought up a discussion locally concerning thinking harder about destination hospitals and OB emergencies. 10 minutes may seem like an eternity in the back of an ambulance, but if there is defense in depth waiting for you at the ER, it is worth it.

I do recall from labor and delivery rounds in paramedic class that any time a woman said that she wanted a natural, no drugs delivery that inevitably it was her first child. The ones yelling that they wanted their epidural and they wanted it NOW, were repeat customers. Back in the day, when handling proto mothers with limited prenatal care, I ask whether they want a boy or a girl and if they've chosen names. Anyone who goes on for a couple of paragraphs about boys vs girls and names... well she isn't delivering any time soon. If she looks at you with hate in her eyes and yells back, ' I WANT IT OUT!' that one is having a baby.

It is not my story, but it is one that bears repeating. PIAA. Car is off road, has hit a tree and a woman is sitting on a stone wall, self extricated, a laceration on her forehead and no recollection of the accident. Interview reveals she is 8 months pregnant, no complications or pain. The medic calls for stat flight to the medical center, is given some grief for this being as it is a stable, ambulatory, patient. He gets a call several days later, expecting a complaint, is told that the woman's placenta abrupted, she delivered in the ER, mother and child -- in neonatal unit-- doing fine. The medic involved is excellent, claims there were no physical findings, only mechanism. Anything unusual needs to be viewed as a potential emergency and any potential OB emergency where fetus is viable needs to be not at any hospital, but one that can manage neonates. After his experience, I take all third trimester patients with complaints other than expected, uncomplicated, full term delivery to WMC. If they are not at the destination facility, the option is possibly having to separate mother and child post partum. I did a couple of those transports, and it breaks your heart to watch a mom say goodbye to a sick new born so he or she can be sent to a better facility.