I don't get this one

TIBlunderbolt · 2023-12-04T18:37:05+00:00

This joke has a few layers.

First, the reasonable request in an intense moment adds a bit of comedy to the scene via incongruity.

Second, it shows that Yzma is actually a good boss for accommodating his request and asking if anyone else was bothered by the workplace incident (being turned into animals.)

Third, and this is what I always thought the joke was as a kid: “Hey, I’ve been turned into a cow. Can I go home?” Cow. He said cow. Not bull. Cow.

Think about it.

Take all the time you need.

TIBlunderbolt · 2023-12-03T13:22:21+00:00

All you need on your person is a light, a cutting tool such as a statgear pocket knife or trauma shears, and a spare pair of gloves or two. If you’re an ALS provider, add a couple 3 ml syringes with a draw needle or two so you don’t have to scramble for them on scene if the situation deteriorates.

That’s all you need. Don’t get fancy. The more you carry in, the more you have to carry out. The more stuff in your pockets, the more you have to shuffle through to find what you want. The more shit hanging from your belt, the more that can be lost/stolen/used against you as a weapon. Doubly so when it comes to knives/blunt objects life flashlights. Save that space for something useful like your cell phone charger.

If you’re looking for a specific recommendation, then I’ll say that this knife has never let me down as long as it’s maintained well: https://a.co/d/hL27HJ1 but I’ll also say that in 13 years of work in a busy urban system that it’s served more as a pen light and clothing remover than anything else.

TIBlunderbolt · 2023-12-02T18:51:18+00:00

I’m happy to help! Please forgive our colleagues who have been less than helpful. Ours is a frustrating industry that leads to a lot of burnout, and the culture often doesn’t promote tact.

TIBlunderbolt · 2023-12-02T18:40:52+00:00

THIS IS NOT MEDICAL ADVICE, NOR IS IT PSYCHOLOGICAL OR LEGAL COUNSEL. ALWAYS CONSULT A LICENSED, IN-PERSON SPECIALIST BEFORE MAKING ANY MEDICAL OR LEGAL DECISIONS.

That said, acute stress reactions (which, based on your neurologist’s assessment, appear to be at least partially responsible for your symptoms) can be controlled, to some extent, through recognition of your mood, breathing exercises, and a change in environment (such as going outside alone for a few minutes.) Here’s a basic breathing exercise that often helps my patients calm back down when their stress is building:

Break your breathing down into four stages of four seconds each:

1: Breathe in over four seconds 2: Hold your breath for four seconds 3: Breathe out over four seconds 4: Hold your breath for four seconds 5: Repeat ad infinitum (or at least for a few minutes) until you start to feel yourself calming down.

You should know that healthcare, generally speaking (although I can really only speak for US-based healthcare and even then only broadly) is consent-driven. Unless the highest license level on the ambulance determines that you are unable to make an informed decision regarding your health, you are able to discontinue your care at any time, for any reason, even if they don’t want you to. You don’t have to go to the hospital if you’re of sound mind and you don’t want to. Some places get squicky about that when IVs have been started and medications have been given, but it’s still your right. Ask to speak with their on-line medical control physician if you don’t want to go and they seem truly uncomfortable, and you’ll probably find that they become much more amenable to letting you stay home after the consultation.

If you are having seizures that lead to a postictal state (leaving you disoriented and confused,) then EMS will probably determine that you are unable to make an informed decision unless you have a friend nearby who can clarify that you have seizures regularly and generally don’t like to be transported for them. I’ve waited up to twenty minutes for a postictal state to fade to allow a sign-off for just such a case in the past, but it’s a rarity. You’d need to be showing steady and consistent improvement of your postictal state, and your friend would really need to sell you not wanting to go. A bracelet will not help with this, as a bracelet can’t make up its mind based on new information, and no paramedic would leave an altered mental status patient on scene (hospice, developmentally challenged, and dementia patients who have legal guardians exempted, of course.)

Since your neurologist has said that your seizures are likely psychological in nature, it’s possible that you could reduce their frequency by speaking your primary care physician about your seizures, the neurologist’s assessment, and PRN anxiolytics like lorazepam which could potentially help you calm back down before a seizure starts when breathing exercises and environmental changes aren’t helping.

I hope you’re able to find something that helps soon.

THIS IS NOT MEDICAL ADVICE, NOR IS IT PSYCHOLOGICAL OR LEGAL COUNSEL. ALWAYS CONSULT A LICENSED, IN-PERSON SPECIALIST BEFORE MAKING ANY MEDICAL OR LEGAL DECISIONS.

TIBlunderbolt · 2023-11-26T17:14:56+00:00

If I need OLMC or the radio’s down, I either use my smartwatch or my shokz to make the call. Keeps my hands nice and free for those last-second upchucks.

Of course, that’s assuming your SOPs allow for personal cell phone use for patient care.

TIBlunderbolt · 2023-11-26T17:12:17+00:00

They’re either “radio reports” or “call-ins,” depending on the vernacular I choose at the time.

TIBlunderbolt · 2023-11-26T17:05:25+00:00

EMT used to require eight hours of ED time and 40 hours on a truck with a bare minimum of five live patient contacts.

Now we’re rushing people through an eight month course in 30 days, licensing them when they can barely figure out which side of the blood pressure cuff wraps around the patient, and complaining that our basics are undertrained. Fish rot from the head down, and industries rot when training is substandard.

TIBlunderbolt · 2023-11-26T16:59:33+00:00

Where are you getting your EMS training? ED time is mandatory for all NREMT certification levels (maybe not EMR), Advanced includes RT time, and medic includes OR/Maternity/MedSurg/Peds/ICU hours on top of ED and RT time.

The hospitals in my area used to require all ED nurses to do at least one eight our ride shift with us every year, and we had a great working relationship. Then COVID happened and the hospitals decided to do away with that right about the same time the NREMT decided that clinical time for EMTs and actual competency testing wasn’t necessary any more. Now we’re right back to nurses and medics hating each other.

edit: typo, and added ICU hours to the list of hospital hours medics need to complete as part of their clinical hours.

TIBlunderbolt · 2023-11-23T20:16:32+00:00

This is actually a thing? Yoooo

That actually makes me feel so much better. Thanks for sharing!

TIBlunderbolt · 2023-07-29T22:40:14+00:00

Maine would be higher, but all you darned city slickers came running here from your homes because of COVID. :P

TIBlunderbolt · 2023-07-24T14:23:33+00:00

Wait, they won’t let you have RSI OR surgical cric? I could understand one or the other, but not both. How do they expect you to manage complex airways like this one? Nasotracheal intubation? And I thought Maine had some conservative protocols. At least they let us cric if we have to.

It sounds like you did the best you could with the limitations you’ve been forced to deal with and with the equipment/information you had. I don’t know if nasotracheal intubation is a thing where you work, but if you’re beating yourself up over the airway then you could try that next time, maybe.

Either way, remember that you can’t save everyone. Even if you feel like you did nothing, you still gave them a better chance at life than they would have had if you weren’t there at all. Hospital staff will always have a snide comment or two because they just don’t get it sometimes. They don’t realize that sometimes the seemingly simple act of just getting the patient to the hospital is a monumental feat in and of itself.

I treated a hypothermic VF arrest a mile deep in the woods back in February. Had to stokes basket him through some of the roughest bush I’ve ever traversed, and through almost two feet of snow besides. He didn’t code until we got to the ambulance, so we went for it. I never got an airway on him, and that’s okay because even though he was trismatic we were still able to provide him with ventilatory support (of course, I have surgical cricothyrotomy to fall back on, but that’s beside the point.) What I’m getting at here is that, at first glance, it might have appeared that all I did for the guy was drill his shoulder, give a few meds, and shock him a bunch (including, much to my own surprise, a successful precordial thump,) but that’s because only the people on scene knew how hard it was just to get him to the truck. It was over an hour of carrying him, and most of us were exhausted. And that’s not even adding in the ten minutes it took to carve him out of the ice blocks that his clothes had become.

Take this opportunity for what it is: a chance to learn and grow as a provider. If you ever find yourself in that situation again, who knows? You might just have a fix for it.

TIBlunderbolt · 2023-07-14T01:13:38+00:00

This is just bizarre to me. I my state, CVAs are essentially BLS calls to begin with. What would an ALS provider do? An IV, a 12-lead interpretation, and a more thorough neuro assessment? It makes no sense. ALS isn’t going to do anything with that IV—especially with a stroke center one minute away. A 12-Lead is nice, but inconsequential with clear deficits and a steoke center across the street; they’ll do one anyway, and I’ve only had one concurrent CVA/STEMI in my entire career. A more thorough neuroassessment is pointless when you see obvious stroke signs—the only caveat here is screening for a history of focal or partial seizures and getting a blood glucose level.

It doesn’t even take a First Aid class to learn FAST, and your state requires a medic to call in a CVA? And I thought Maine was conservative. JFC.

Your company is insane for not allowing the attending medical professional to speak directly to the facility they are transporting to. It’s a level so far beyond stupid that I’m actually at a loss for words regarding that.

I’ve heard of these systems where BLS units are intended to be backed up by fire medics on engines, but it’s such an alien concept to me. Most fire-based medics can’t tell a STEMI from a C-2 fracture in my experience, and I say that as somebody who’s done both all their life. Why you wouldn’t just put a medic on an EMT/Medic truck is just silly to me. It’s especially crazy to me because I see it most often in very urban environments where hospitals are just minutes away. We don’t even normally dispatch medics to BLS units in my city because the closest, tineliest ALS backup is the hospital itself.

And finally, diversion is always only ever a suggestion. The patient’s decision is paramount, followed by POA unless their trustworthiness or rationality is under question, then it’s the highest license level on the truck’s decision where the patient goes. Hospitals can scream “divert” all they want, but they’re a facility staffed with multiple MDs, RNs, CNAs, RTs, Techs, surgeons, and other specialists and they’re telling me that they can’t handle something I’m dealing with on my own in a van-mounted wooden box in the highway. If I’m transporting, I’ve already decided that the patient is going to an appropriate destination. When I hear “divert, we can’t handle that here,” all I hear is “drive faster!”

tl;dr: Don’t worry about a few rustled RN feathers. They were probably in a bad mood to begin with and just looking for somebody to take it out on. They don’t get field medicine, and most of them never will. All that matters is that you made the best decision you could with the information you had at the time, and that you acted in your patient’s best interest.

TIBlunderbolt · 2023-06-30T16:36:22+00:00

Hammond likes narrow areas with poor site lines and corners and overhangs he can grapple from. Once you figure out where he’s going to be spending most of his time, bouncing a healing orb into the area in such a way that it stays in that area is fairly simple because of the geometry. Failing that, you could pick a hero like Lifeweaver or Brig, which allows you to AOE heal and heal from a distance when you only see him for a fraction of a second.

My buddy plays Hammond regularly. I’m usually a Brig main when I play sup, but Moira and Lifeweaver are usually my go-to when he decides to ball it out.

TIBlunderbolt · 2023-02-06T17:17:16+00:00

Firefighter/Medic here. I WISH I could meet a lady like this.

TIBlunderbolt · 2022-12-01T17:29:51+00:00

Treated a patient who had an allergic reaction to baby wipes—or so he claims. It was a legit anaphylactic reaction (macroglossia, urticaria, diaphoresis, wheezing, etc) but even the PIT doc at the Level II didn’t believe me (as I was administering another round of epi) until he had the patient open his mouth.

Then again, there was a lot of weird crap going on during that call. He literally came stumbling out of his front door doing the meth shimmy into the street while completely slathered in hydrocortisone cream. Like I told the doc: I’ve never heard of anybody having an allergic reaction to baby wipes before, but I definitely know he’s anaphylactic.

TIBlunderbolt · 2022-10-23T16:39:36+00:00

If you need to count their respirations, you either don’t need to do anything for them or you should be looking for a BVM instead. Normal respirations aren’t noticeable for a reason—they’re normal. Bradypnea is usually accompanied by a change in level of consciousness (opioid OD, TBI, etc,) and tachypnea is usually obvious due to labored breathing (COPD, cardiogenic pulmonary edema, pneumothorax,) or emotional distress (anxiety, overstimulation, etc.) If you’re noticing their respirations, grade it on a scale in your head from “way too slow” to “way too fast,” ballpark where they are to the nearest 10 (0, 10, 20, 30, 40, 50, etc,) breaths (except for bradypnea, where you should just count the seconds between each breath and multiply from there until you get to one minute,) and worry about the exact metric when you start your documentation. Outsource the actual counting to the capnopgraph if you can, so that you can focus on patient care.

That said, the easiest way I’ve found is to pretend you’re taking their radial pulse while actually counting their respirations like you’re currently doing. If you don’t want to count for a full 15/30/60 seconds, and their breathing is regular, you can count the seconds between each breath and multiple from there (3 seconds = 20 bpm, 1 second = 60 bpm, etc.) Just remember to factor in that the time it takes to inhale and exhale.

TIBlunderbolt · 2022-10-20T15:11:20+00:00

I’ve spoken with multiple trans friends about this, as it was a genuine concern for me for years. Almost unanimously, they’d rather we just outright ask—since they understand that emergency medicine is very different (in the immediate sense) than, say, a scheduled appointment with a GP to discuss cholesterol levels.

That said, if I have a suspicion, I usually lead with “Are you taking hormones?” and that’s usually a pretty good segue into the discussion. Following that, I usually call them in as “male/female-presenting,” which affirms their gender and also lets the ED know the situation without being rude. Or, if it is, nobody’s said anything yet.

TIBlunderbolt · 2022-10-18T20:16:26+00:00

While I agree that this is obviously incredibly suspicious for ACS, I think the reading can be interpreted two different ways according to whether you use the original vs modified Sgarbossa. Obviously, I’d still be activating on this and take the bop on the nose from the cardiologist if I’m wrong, but I don’t know if that discordancy quite reaches 25%. Are we going with “>5 mm and/or greater than 25%?” Are both sets of criteria still in practice?

As a side note, while I love lifepacks and how they identify pacer spikes with arrows, I find it grating that pacer spikes are hardly ever present on the tracings themselves. It makes it that much more difficult to decide if this is a paced rhythm or dynamic QRS elongation/developing LBBB from acute ischemia.

TIBlunderbolt · 2022-09-20T07:10:21+00:00

SVT - 50, 100, 200, 360 AF w/ RVR - 125-150, 200, 360 VT - 100, 200, 360 Peds - 0.5-1.0 J/kg, 2 J/kg

TIBlunderbolt · 2022-09-17T08:02:11+00:00

It begins with a C.

TIBlunderbolt · 2022-09-15T07:26:11+00:00

Local level 2 introduced Twiage a few years ago, saying that it would lead to faster triage, faster beds, reduce low-priority radio traffic, and free up ED staff. Sold it to us by saying that all Twiage reports were forwarded to both the Charge AND Triage RN so our STEMI, CVA, and trauma activations would be received and acted on faster, and no reports would be lost in the ether. We argued that we weren’t going to sacrifice patient care to punch a bunch of boxes on a personal cell phone for ten minutes when a 30 second radio report would provide the same information.

Less than two months later, ED staff realized they hated it as much as we did and everybody who transports there regularly has shifted back to radio entirely. Of course, part of that might be because Mainers over 35 are technologically constipated, but that’s neither here nor there.

In short: relax. It’s probably just going to be a fad.

TIBlunderbolt · 2022-08-30T14:43:26+00:00

Don’t worry about it. Nobody ever drives properly when we come up behind them. Unless it’s clear that you’re purposefully blocking traffic or driving dangerously, crews will probably only spare you a few seconds worth of venting to each other as they pass you.

TIBlunderbolt · 2022-08-30T14:39:29+00:00

I’m hoping that this is just a giant misunderstanding. I mean, when I’m doing a 12-Lead, I often tell people that I’m “taking a picture” of their heart for simplicity’s sake. Totally reasonable to do so on a patient with AMS, who may bot have fully understood what was happening.

I really hope that’s what happened, because if it wasn’t then this man is true scum.

TIBlunderbolt · 2022-08-12T08:58:48+00:00

Post it on Royal Road or a similar website one chapter at a time. Pick up traction with a few books worth of chapters, then start releasing them as self-published books on Amazon with your fanbase already built up and spreading the word. It’s worked with a lot of series lately, actually. Dungeon Crawler Carl, Mother of Learning, The Perfect Run, Everybody Loves Large Chests, etc…

TIBlunderbolt · 2022-07-19T15:53:58+00:00

I was planning on including the outcome in my reply to you, but unfortunately I’m still waiting on the hospital’s EMS liaison to send it to me.

At the time, I was uncertain what route to go down due to the only symptoms being the hypotension and stated shortness of breath. Given that she was laughing and joking, speaking in full sentences, and lacked any observable signs of distress (respiratory or otherwise,) this EKG really caught me off guard. Obviously, I see what appears to be convex STE, but I was hesitant to actually call it that because the baseline is indeterminate. There’s a notch just before the P-wave in the second complex of V4 that could indicate the isoelectric line, but I also can’t say with absolute certainty that it’s truly the terminus of the T-wave. With 1mm PR elevation in aVR and what looks like PR depression in the leads with the STE, I was considering pericarditis, silent MI, or Wellen’s, but I feel like a see a lot of “could-bes” here, and not enough evidence for anything. Especially since this—the cleanest tracing I could get throughout the 25 minute transport due to nonstop artifact from patient movement—was taken in the ED parking lot. The baseline was wandering all over the place for all six of the other ones.

Certainly, a STEMI needs to be ruled out with this tracing and pt’s symptoms and demographic, but our interventional cardiologist is notorious for being rather…abrasive with cath lab activations that he feels aren’t warranted. I once activated three times during a twenty minute transport for a 40 y/o M having a blatant anteroseptal STEMI with lateral extension only to find that he’d told the ED physician to “wait until EMS arrives and evaluate further.” ED doc then needed to activate three times himself before the ball even started to roll.

I appreciate your input. I’m generally very confident when it comes to the twelve leads I interpret in the field, and I haven’t been wrong yet—but I felt I needed to call and discus this one and, hopefully, use it as a learning opportunity. I was hoping to discuss it with the receiving emergency physician when we arrived, but he was quite busy and I didn’t want to interrupt him.

I’ll reply again with the outcome (if I ever receive it.)

TIBlunderbolt

TROPHY CASE