When to Put on Your Fireman Suit

Over the years I have noticed that persons assigned to an EMS unit have a habit of wandering around dangerous environments in half of their PPE or even worse no PPE.  When we are assigned to a suppression piece and the tones drop everyone is very clear as to when we dress and when we don't.  So why is there such a wide variance of PPE from EMS personnel?  Regardless of the reasoning I am going to attempt to remove some of the fog from this issue.

There are three distinct incidents that I feel personnel assigned to the EMS unit need to arrive in PPE and ready to perform.

1) First Due Building Fire
When you are the first arriving medic unit to a building on fire you need to be fully dressed in your fireman suit and ready to work.  Your primary responsibility is not to make the nozzle, ladder the roof, or run around and try to prove what a great fireman you are.  You can do this when you are assigned to the engine, truck, or rescue.  Your number one responsibility is to locate, triage, and treat any civilian injuries.  In order to do this properly you need to be fully dressed so that you can safely approach and work in and around the scene.  Large crowds are often found all around a fire scene.  In these crowds you will find witnesses, homeowners, civilian rescuers, green linemen, and many of them may be walking wounded.  It is your job to figure out what happened, how many are injured, and relay to command all of this information along with any additional resources you will need to begin to develop the EMS branch of the incident.  Look for soot running out of nostrils or on clothing, torn or ripped clothing, citizens without shoes, cuts and scratches, or obvious burns.  Adrenaline will be running high with victims and they will be ignoring any and all pain or discomfort. As you are doing this by no means should you neglect the kink in a hose line, but do not expect to be fighting fire.  It is not a glorious job but a very important one.  Everyone on the incident has a specific job to do and the EMS unit is no exception.  If there are no civilian casualties your number two responsibility is to function as the initial RIT medic unit for any firefighter injuries or deaths that may suddenly occur.  It has been said that the word "MAYDAY" is the most frightening thing that can be heard over a fire ground radio.  It is your job to be prepared for and expect this event on every fire.  Be familiar with the egress points and make a plan to evacuate any civilian or firefighter casualties from each exit point.  Some tricks of the trade I have learned over the years are:

• Place your cot in the down position in an area easily accessed by all egress points
• Only bring essential EMS equipment away from the unit to perform the initial key functions in a cardiac arrest (airway, IV, defibrillation), everything else can be treated in the unit after the victim is evacuated from the scene.
• Use a reeves stretcher or a large soft stretcher such as a Shamu to evacuate victims.  They work much better over hose lines and around common obstructions found on a fire scene than trying to roll the cot everywhere. 
• Be diligent, be prepared, and expect the worst.  Everything else will be no problem  

2) Vehicle Fire
It is very important for the EMS crew to be dressed and ready to work on a vehicle fire. Not so they can smoke the engine with a dry chem, but to perform and/or assist in any victim rescue from the vehicle.  It is a rare occasion, but the reason an EMS unit is dispatched on a vehicle fire is for just this reason.  When you do roll up on an incident with a screaming victim hanging halfway out the drivers window with black smoke billowing all around them you better be ready.  If you are not already dressed and able to easily and quickly don your SCBA you will be way behind the eight ball.  Some tricks of the trade I have learned over the years are:

• Be ready to break glass and cut seat-belts.
• If you have an extra SCBA place it on the roof and give the victim air.  We carry three on our units in case we have an intern.
• Bring a dry chem to the car (to help extinguish the interior fire around the trapped victim). They will appreciate this even more if you have a mask on them so they don't suffocate from the dry chem as well as the smoke
• Be mentally prepared for "whatever it takes!" If you have ever run an incident like this you know that it can be one of the most trying and stressful incidents you will ever run. There is nothing quite like being face to face with another human being while they claw and scream at you because they are burning alive.  This image alone should be reminder enough for you to get dressed before you leave the house.
• You may need to enter the vehicle while it is on fire from the opposite side to remove the victim.  This is an impossibility without full PPE and SCBA.

3) MVA with Extrication
On an extrication it is the rescue's job to either remove the victim from the vehicle or remove the vehicle from the victim.  It is the job of the EMS crew to access and treat the victim during the rescue.  This cannot be done unless the EMS crew is in full PPE.  There should be no one in the action area around the vehicle without the proper PPE, but too many times you see a member of the EMS crew popping in and out wearing a station uniform and a traffic vest.  This is unacceptable and should never happen. Some tricks of the trade I have learned over the years are:

• Be ready to break glass and cut seatbelts
• Absolutely do not try to enter a vehicle that has not been stabilized
• Coordinate with the rescue officer
• Wear a low profile rescue helmet rather than a suppression helmet.  It allows you to move around the interior of the vehicle more easily. 
• Carry a small amount of essential EMS supplies with you when you are the interior EMS.  Be prepared to control an airway, start IVs, control bleeding, place tourniquets, etc. 

These three types of incidents are when EMS personnel need to arrive absolutely without question in full PPE and ready to perform.   

Prehospital Abdominal Assessment Part 4..MI?

For the upper right quadrant we are not going to concentrate on bleeding ulcers, any stomach disorders, or the spleen.  As I have said before paramedics are experts on what is going to kill you in the next 20 minutes, and the most devastating disorder we can encounter in the upper right, or any quadrant does not even originate from the abdominal cavity, it is a myocardial infarction.

You must scrutinize any and all abdominal pain for the presence of an MI, regardless of what the patient is telling you, regardless of the quadrant, regardless of your gut instinct as to the origin of the pain or discomfort.  Not long ago a woman walked into a hospital complaining of gallstones.  She had a history of gallstones.  She told the triage nurse the pain was more to the upper left quadrant and she was sure it was her gallstones.  The patient stated she should of had her gall bladder removed years ago but did not and now she is paying for it.  The nurse and the patient had a very thorough conversation regarding the patient's history, all signs and symptoms pointed to the gallbladder.  After the patient was escorted to a room the doctor ordered a routine EKG and found the following:

 
This was no gall stone!  The only reason we perform 12 lead EKGs in prehospital medicine is to quickly identify the presence of an acute MI.  We cannot successfully do this unless we get in the habit of rapidly (within 5 minutes of patient contact) performing a 12 Lead EKG on all patients at risk of having an MI.  That means all chest pain, chest discomfort, dizziness, syncope, shortness of breath, nausea, and yes abdominal pain to name a few.  There are few medical patients that you can absolutely rule out the risk of an MI.  If you are going to perform a 12 lead EKG on a patient it should be done quickly and efficiently.  Train your partner and crew to make this part of their initial physical assessment and acquisition of vital signs.  A well trained paramedic should never say, "do you want to get a 12 lead now or wait till we get to the unit?"  My response to that question is, "exactly how long would you like to wait to determine the patient is having an MI? Would 10 more minutes suffice?"

Don't let an MI slip through your fingers just because the patient describes abdominal pain.  You do not want  to be THAT medic!