Question to the experienced

[LongTranspot]

I’m 36 and a freshly minted EMT. I ran my first trauma today, a single vehicle MVA. The PT was obviously injured: deformed nose, bleeding and compromising his airway, crepitus in the chest, decreased lung sounds on R, and deformation to the R femur. Our service area is ~1hr from anywhere, so we called for a helicopter. We did what we could for a guy that was having one of the top five worst days of his life.

When the flight medics arrived, one of them was, well, salty at best. We had made good progress with the PT by simple communication, e.g. “I have to suction your mouth, man. It’s not going to be pleasant.” He didn’t seem particularly combative to my inexperienced eye. The flight fella took a different tact, barking, demanding, and complaining under his breath.

I’m not trying to judge the medic; I just want to understand his position and I can’t exactly ask him. I know he’s in a hurry and I believe he knows what he is doing, but is this necessary? Heck, maybe he was just having bad day. Any insight anyone has would be useful.

Thanks in advance.

 

[StCEMT]

I mean without seeing it or knowing what he said, it's kind of hard to tell you anything. It falls on anyone running the call to make decisions and give people their roles. Maybe it's your perception? Maybe he was having a bad day? Maybe he is just a ****? Can't really tell ya anything beyond that.

 

[LongTranspot]

That’s fair. I can’t adequately illustrate the tone and timbre of the situation. Honestly, I’m not sure what I was asking for when I started this thread, unobtainable insight, or trying to get the burr out from under my saddle, perhaps.
Thanks for the reply, I’ll just see how it goes in the future.

 

[mgr22]

LongTransport, I see you're 36, so I'm assuming you've had a few jobs and worked a few places. Although I like to think the mission of EMS is distinctive, people in our industry are pretty much like anywhere else -- maybe a bit more assertive and a bit less compliant with pettiness, but basically what you're already used to. As StCEMT said, it's hard for anyone who wasn't there to know what you were dealing with. No matter how you size up the people around you, though, if you treat patients the way you'd want to be treated, know your job, show up ready to do it well, meet commitments, stay ahead of changes in your field and make time for life outside EMS, you should do fine.

 

[NomadicMedic]

One of the hardest lessons to learn in EMS is, “not everyone is nice”.

Sounds like you got a pretty good example of that today.

 

[DesertMedic66]

Without knowing the system or what actually happened on the call it is hard to say why. Maybe he was being salty or maybe you understood it that way without that being the actual intent. Without being on scene as an objective 3rd party it is very hard to say what actually happened and not may have just been perceived.

For the flight side, depending on company, we try to adhere by company policies/guidelines. For my company the ideal scene call has a patient bedside time of 10 minutes so things have to move pretty quickly which means I am going to be direct and say exactly what I need. Depending on what aircraft I am in is also going to play a huge part into my decisions on the ground. If I’m in a 407 then there is very limited space to do anything at all for the patient so I need to make sure I have done everything I need to on the ground and also have a plan on how I want things situated inside the helicopter. If I’m in a 412 or 145 then that is not a huge concern since I can access much more of my patient.

Add into all of that and the flight crew was probably highly considering to RSI this patient due to the fact you have to keep suctioning, the high potential for airway compromise, the patients clinical course, and the injuries sustained. Also add in that they are possibly thinking about doing a needle decompression or inserting a chest tube. It’s a lot of stuff to do while trying to limit our on scene time as much as physically possible.

 

[VFlutter]

Always try to be as pleasant and professional as possible even in stressful situations however a lot of times people come off curt or demanding unintentionally when they are trying to be expeditious. As mentioned they are quickly thinking about the multiple interventions that need to be done, in what order, what needs to be done now vs in the helicopter, etc with a patient that has AMS, facial trauma, airway bleeding, pneumo, possible internal bleeding, etc. That patient would stress out most providers and presents a lot of challenges that need to be quickly addressed.

 

[SpecialK]

Suctioning is over-rated and overused. Most patients you can turn on their side and they will actively keep blood or fluid out of their own airway by spitting it into a vomit bag. If there's a lot or the pt has a decreased level of consciousness then a bit of suctioning the mouth is usually all that is required.

Helicopters are very overrated and overused. If you are one hour by road from hospital, then think of it this way: it'll take 5 minutes for the helicopter to get airborne (assuming the crew are immediately with the helicopter and this is not always the case), sounds like about 15 minutes for the helicopter to fly to the scene, another 5 minutes for it to land, personnel to get out, and do a handover, another 10-15 minutes to assess and do anything to the patient (e.g. pain relief), 5 minutes to load, 5 minutes to take off, 15 minutes to fly to hospital, and 5-10 minutes to offload the patient.

So, in this scenario, it sounds like you were no closer to hospital by just putting the patient in the ambulance and taking him there v using a helicopter and you've potentially severely limited the treatment the patient can receive because helicopters are cramped and noisy. The exception to this is obviously if the patient needs something (for example RSI) which you cannot do and the fastest way is to get it there by helicopter.

 

[VFlutter]

Helicopters are very overrated and overused.

So, in this scenario, it sounds like you were no closer to hospital by just putting the patient in the ambulance and taking him there v using a helicopter and you've potentially severely limited the treatment the patient can receive because helicopters are cramped and noisy. The exception to this is obviously if the patient needs something (for example RSI) which you cannot do and the fastest way is to get it there by helicopter.

Rapid transport is only one consideration for utilizing air transport. HEMS is more than just a fast ride. Many times it is quick access to critical care that is otherwise not available. Many ground ambulances in the US do not have RSI and even fewer have blood products, TXA, etc. Not to mention the overall level of care provided.

I agree there are places that overuse helicopters and in some regards can be considered overrated however the argument that the patient will get the hospital about the same time Ground vs Air does not necessarily mean they will be in the same condition on arrival. In most places the quality of resuscitation is a benefit.

A similar argument would be an officer tossing his partner in the back of the cruiser and booking it to the ER because he will get there about the same time the ambulance would even though he very well might be dead from an arterial bleed that needed a tourniquet on scene that the ambulance could have provided.

 

[SpecialK]

I agree there are places that overuse helicopters and in some regards can be considered overrated however the argument that the patient will get the hospital about the same time Ground vs Air does not necessarily mean they will be in the same condition on arrival. In most places the quality of resuscitation is a benefit.

Agreed. If the fastest way to get a specific skill which the patient needs is by helicopter then use the helicopter, if it's by backup coming on road then use that. Of course remembering to factor in the time to get to the helicopter, get airborne (assuming crew are immediately with the helicopter, not always the case), fly, land, etc.

Helicopters are super badass; the problem is they're often a bit of a white elephant when it comes to not being as super badass as people think.

 

[akflightmedic]

A similar argument would be an officer tossing his partner in the back of the cruiser and booking it to the ER because he will get there about the same time the ambulance would even though he very well might be dead from an arterial bleed that needed a tourniquet on scene that the ambulance could have provided.

Actually your comparison is accurate, yet proven to be of benefit. I was reading an article the other day where I think it is Pittsburgh police often transport before EMS even arrives. It is part of their Scope of Work, they train for it and are expected to do it...throw them in and transport. I think this also has to do with a trauma center being on every corner, however they have been doing this practice for well over a decade. Other police departments follow similar protocols...so there is tremendous merit in the police just throwing them in and transporting and not waiting.

This is just a JEMS article on it, however there are plenty of other studies on the practice.

https://www.jems.com/articles/print...tients-be-transported-by-police-officers.html

 

[Gurby]

Helicopters are very overrated and overused. If you are one hour by road from hospital, then think of it this way: it'll take 5 minutes for the helicopter to get airborne (assuming the crew are immediately with the helicopter and this is not always the case), sounds like about 15 minutes for the helicopter to fly to the scene, another 5 minutes for it to land, personnel to get out, and do a handover, another 10-15 minutes to assess and do anything to the patient (e.g. pain relief), 5 minutes to load, 5 minutes to take off, 15 minutes to fly to hospital, and 5-10 minutes to offload the patient.

So, in this scenario, it sounds like you were no closer to hospital by just putting the patient in the ambulance and taking him there v using a helicopter and you've potentially severely limited the treatment the patient can receive because helicopters are cramped and noisy. The exception to this is obviously if the patient needs something (for example RSI) which you cannot do and the fastest way is to get it there by helicopter.

I forget if you're in the UK or Canada or something where the entry level to EMS is like a bachelor degree. OP is "a freshly minted EMT" which in the USA means he recently finshed a 120-hour high school level course, and was thrown out into the wild with no experience and no ability to perform any interventions beyond external bleeding control, O2 and transport. This is not the person you want sitting in the back for an hour with a potentially very sick patient. It sounds to me like given the circumstances OP did a great job just to recognize he was in over his head here and call for help.

Your point is well taken though.

 

[kaisardog]

just curious: would you 'turn this pt on his side ' to keep his airway clear with those sx: " deformed nose, bleeding and compromising his airway, crepitus in the chest, decreased lung sounds on R, and deformation to the R femur..."

 

[CCCSD]

Cops carry tourniquets.

 

[DrParasite]

I forget if you're in the UK or Canada or something where the entry level to EMS is like a bachelor degree. OP is "a freshly minted EMT" which in the USA means he recently finshed a 120-hour high school level course, and was thrown out into the wild with no experience and no ability to perform any interventions beyond external bleeding control, O2 and transport. This is not the person you want sitting in the back for an hour with a potentially very sick patient. It sounds to me like given the circumstances OP did a great job just to recognize he was in over his head here and call for help.

Your point is well taken though.

OK, your statement is insulting for many reasons:

1) EMT classes haven't been 120 hours since the 90s. Most classes are closer to 180 hours; my current classes is 240, and is technically a hybrid, so includes a lot of work that is completed at home. It's still could use a lot more, and should have more hands on practical/clinical time, but that's an above my paygrade decision.

2) What would you, Mr super paramedic, have done that is so much different than the freshly minted EMT? started a line? maybe a needle decompression if you thought it was a pnemo? Even on this trauma there is very little a paramedic can do, and the studies show that these people need surgeon, not a paramedic. Don't get me wrong, paramedics can do more stuff than EMTs; but an EMT can do the stare of life with a hep lock started just as good as an EMT. In all cases, we are doing the best we can with the tools at our disposal. Stop being so judgmental

3) I've been in the back with very sick patients. No paramedics. If I wasn't there, than it's likely the patient would still be laying on the ground. or in bed. or in the doctors office. it sucks, but it's better than nothing. Even if there were paramedics with those sick patients, guess what: the patient might still end up dying. So paramedics don't always save the day, despite what fire departments out west seem to think. Most places don't operate with an all ALS system; in fact, the studies showed that tiers systems are often better, because the EMTs learn to identify sick patients, and manage them, vs always have a paramedic deal with sick patients, and the paramedics only see sick patients, so they aren't tied up on BLS calls all day.

This new EMT had a sick patient, who needed a surgeon to fix the damage, with a (potentially) compromised airway and decreased lung sounds, and when he called for a helicopter, the flight medic was grumpy that he actually had to do his job.

@LongTranspot, it sounds like you did your job, did exactly what anyone else would have done (heck likely would have done what a medic would have done), and he was just an ***. Don't lose sleep over someone else who was cranky because they had to do the job that they were being paid to do.

 

[StCEMT]

How is it insulting? 120 hours or 180 hours, it's still gonna be a potentially overwhelming situation, especially with long transport times.

You're right a surgeon is needed, but in a rural environment you can't expect entirely equal outcomes. Being able to decompress a pneumo is better. Being able to give blood is better. Like Vflutter said, there is a difference in resus abilities and that can be significant down the road. That's not to detract from their work on this call, but it's realistic.

 

[DesertMedic66]

OK, your statement is insulting for many reasons:

1) EMT classes haven't been 120 hours since the 90s. Most classes are closer to 180 hours; my current classes is 240, and is technically a hybrid, so includes a lot of work that is completed at home. It's still could use a lot more, and should have more hands on practical/clinical time, but that's an above my paygrade decision.

2) What would you, Mr super paramedic, have done that is so much different than the freshly minted EMT? started a line? maybe a needle decompression if you thought it was a pnemo? Even on this trauma there is very little a paramedic can do, and the studies show that these people need surgeon, not a paramedic. Don't get me wrong, paramedics can do more stuff than EMTs; but an EMT can do the stare of life with a hep lock started just as good as an EMT. In all cases, we are doing the best we can with the tools at our disposal. Stop being so judgmental

3) I've been in the back with very sick patients. No paramedics. If I wasn't there, than it's likely the patient would still be laying on the ground. or in bed. or in the doctors office. it sucks, but it's better than nothing. Even if there were paramedics with those sick patients, guess what: the patient might still end up dying. So paramedics don't always save the day, despite what fire departments out west seem to think. Most places don't operate with an all ALS system; in fact, the studies showed that tiers systems are often better, because the EMTs learn to identify sick patients, and manage them, vs always have a paramedic deal with sick patients, and the paramedics only see sick patients, so they aren't tied up on BLS calls all day.

This new EMT had a sick patient, who needed a surgeon to fix the damage, with a (potentially) compromised airway and decreased lung sounds, and when he called for a helicopter, the flight medic was grumpy that he actually had to do his job.

@LongTranspot, it sounds like you did your job, did exactly what anyone else would have done (heck likely would have done what a medic would have done), and he was just an ***. Don't lose sleep over someone else who was cranky because they had to do the job that they were being paid to do.

Your brand new EMTs must be completely different than ours are out here. Yes they both (new and veteran) have the same exact skills they can preform however their assessments are probably going to vastly different and the veteran will probably feel a heck of a lot more comfortable and will possibly be even more competent.

Now that that is said I would rather have a medic taking care of me in that situation and if it was a rural area I would much rather have a HEMS unit for both higher level of care and faster transport.

 

[DrParasite]

How is it insulting? 120 hours or 180 hours, it's still gonna be a potentially overwhelming situation, especially with long transport times.

it's insulting because the information is wrong. Show me an EMT class that is only 120 hours. I mean, a paramedic class is only 800 hours, so while it's more because they can do so much more, but it's still no where near enough.

You're right a surgeon is needed, but in a rural environment you can't expect entirely equal outcomes.

so we agree, whether you have an EMT or medic, what the patient really needs is a surgeon.

Being able to decompress a pneumo is better. Being able to give blood is better.

what they really need is a chest tube. but we will agree that a needle decompression is better than nothing. I've read about helicopters that were carrying blood, but very very few ground units.... how common is it for ground paramedics to be carrying and administering blood to trauma patients?

Your brand new EMTs must be completely different than ours are out here.

based on what I have heard on here about pay rates, competency levels, job descriptions and working conditions, I would be inclined to agree with you.

Yes they both (new and veteran) have the same exact skills they can preform however their assessments are probably going to vastly different and the veteran will probably feel a heck of a lot more comfortable and will possibly be even more competent.

no arguments there. any experienced provider will feel more comfortable doing anything. the same could be said for a 1st year resident MD compared to a 20 year attending MD.

Now that that is said I would rather have a medic taking care of me in that situation and if it was a rural area I would much rather have a HEMS unit for both higher level of care and faster transport.

me too. a medic can give pain meds, which would make me not hurt as much. But the sooner I get to the trauma surgeon, the better my chances of survival.

 

[StCEMT]

I found two universities on the first page of Google that say to expect 120-150, one of them being UCLA....ok....and I don't disagree nor do I find that insulting. The bars for both should be set higher.

Yes I agree. However, you need someone who has tools to help get that person to a surgeon alive. Surgeons can't do anything if a patient tensioned to the point of arrest and nobody was there to (temporarily) fix it for a significantly prolonged time.

Wasn't specifying ground, more so just ALS capabilities in general when in the right hands.

 

[DrParasite]

I found two universities on the first page of Google that say to expect 120-150, one of them being UCLA....ok....and I don't disagree nor do I find that insulting. The bars for both should be set higher.

Wow. @DesertMedic66 , I was wrong, I guess that does explain the differences between the east coast and the west coast. I'm surprised UCLA's is that short.

Just for comparison, my local community college's course in NC is 190 hours. Neighboring county is 204 hrs. If I look back at NJ, it's 220 hours through Atlantic Ambulance. My former employer in NJ (who has since been absorbed by a major conglomerate) runs a class that is a minimum of 190 hours