The EMS Engine...How to be an EMS assault team.

The concept of the ALS Engine has been a great posititive impact on the fire service and the communities we serve. The engine's job on an EMS emergency is vital to the patient's outcome and needs to be approached with enthusiasm and preparedness. An engine medic is often on scene as the sole ALS provider for several minutes.  What the engine does in these precious minutes sets the stage for the incoming medic unit and therefore the entire path of patient care. I'm going to talk about the three biggest areas that make a great ALS engine and engine medic: working together as a team, good patient assessment skills and preparedness. 

Organizing The Team:

A suppression piece responding to an EMS emergency needs to be a functioning team. On any given fire event we all have very defined roles. One bucket is the nozzle man, the other is the pipe man advancing hose and backing up the nozzle man. One bucket is hook and can while the other is the irons. We need to be just as specific during an EMS emergency. There are four areas of responsibility in any standard patient care scenario: 1) Patient Assessment, 2) Patient treatment, 3) Patient removal, and 4) Overall scene management. Lets talk about these one at a time.

Patient Assessment:

In my opinion the physical assessment team from the suppression platform is made up of the two bucket people the engine medic and the firefighter.   They work together as a cohesive team performing the physical assessment, attaching the EKG monitor, and obtaining vital signs. Sometimes I walk into an EMS scene to witness  the lonely engine medic up to his elbows in EMS equipment interacting with the patient while the other three members of the crew stand and watch. If you are the firefighter on an ALS engine you play a vital role in all EMS calls. Get with the medic and find out how they operate and how you can be a part of the assessment and treatment team. Below is just one way of approaching the patient assessment of a medical patient. We are not addressing traumatic patients or technical rescue scenes in this article. The following assessment is what I have been teaching ALS interns to do for years. It gives you a good solid framework to operate from. Start by memorizing the steps and you will always be organized in your approach. 

Below are seven general steps to a medical assessment.  Although they are organized in a general sequential order the order may be modified to best address the patient’s specific needs and underlying medical condition.  The items marked with an (*) are best performed by the lead assessor who will be performing the physical assessment and actually touching and interacting with the patient directly.

• 1) General Impression

            As the assessment team approaches the patient they should ask themselves, does this patient look sick, in distress, bad, or good?  A general impression is a very important building block to the rest of the assessment, but should in no way lead the provider to jump to conclusions and cut corners on the rest of the assessment.  For example, you may have been dispatched to an unconscious diabetic emergency. Upon approaching the patient you see an unconscious person breathing deeply.  This does not mean the providers should jump to obtaining a blood glucose level and then immediately start an IV without measuring vital signs or any further assessment.  Jumping to conclusions and cutting corners is a common provider error during this step.  Neglecting to garner all the other very important and necessary information can lead to wasted time, effort, and improper treatment.  This tactic works most of the time as long as the dispatch information is correct, the patient has no other complications, and the treatment plan is straight forward.  When operating from a suppression platform alone It is much quicker to jump to a conclusion at this phase and perform all the needed ALS skills prior to the transport unit’s arrival thus it is an enticing option, but if we want to be quality EMS providers we need to be well disciplined and assure every patient receives a good patient assessment regardless of any preconceived notions or impressions.  Only after the full assessment is performed should the treatments be initiated.  The general impression phase is when providers very well may jump to a conclusion based on experience and clinical judgment. Instead of immediately acting upon that notion the providers should continue to perform the assessment, gather all the information, and prove the initial impression true or false.  If there are sufficient providers on scene interventions may be assigned throughout the assessment process, but the lead assessor needs to remain on task and complete the assessment to provide a full picture of the patient’s condition.  

• *2) Airway

            Does the patient have a patent airway? Are they talking? Are there any immediate interventions necessary to improve the airway? Does the patient require an NP airway, an OP airway, suctioning, or supplemental Oxygen?  Does the patient require intubation? Airways requiring intubation should be sized up using the LEMONS acronym. If any airway interventions are required they should be immediately provided.

Think L-E-M-O-N-S When Assessing an airway that may require intubation. 

Look externally. There may be some physical clue or foreign object that portends difficulty.

Evaluate using the 3:3:2 rule. Can the patient fit three fingers between the incisors? A mouth that can open that far has good temporomandibular joint mobility. Is the mandible length three fingers from the mentum to the hyoid bone? That's a nice, normal length; either shorter or longer makes ventilation or intubation trickier. Last, the distance from the hyoid to the thyroid tells you something about neck length--two fingers' distance is ideal.

Mallampati classification. If the patient can cooperate, ask her to stand or sit up, open the mouth, stick out the tongue, and say, "Ahh." The structures that are visible compose Mallampati class I (the easiest airway), II, III, or IV (most difficult). If you see the tonsillar pillars, that's Mallampati class I. If all you can see is the palate, that's class IV.  In order to gain any beneficial information from this assessment tool you need to perform this while the patient is still conscious so you need to 

The classification correlates with the Cormack-Lehane laryngoscopy grades. A Mallampati class I will be a Cormack-Lehane grade I in 99%-100% of cases. You can proceed with paralyzing the patient to establish an airway without any concerns.

A Mallampati class IV always will be a Cormack-Lehane grade III or IV. This is going to be tough, and you need to be thinking about what your alternatives will be.

Obstruction. Look for anything that might get in your way. The enemies of airways include soft tissue swelling from smoke inhalation, burns, broken necks, trauma to the face or neck, foreign bodies in the airway, and excessive soft tissue from obesity.

Neck mobility is desirable. Unfortunately, many patients who need resuscitation in the emergency setting require cervical collars or have compromised neck mobility, and you may not be able to move them into preferred positions for establishing a definitive airway.

Emergency providers have the luxury of thoroughly evaluating only around a third of patients who need an airway established, because most are too sick or injured to allow much evaluation.

Most important, ask yourself, "Will I be able to ventilate this patient" with a bag valve mask? Also ask yourself, "Will I be able to intubate this patient? Could I do a cricothyroidotomy if I needed to?”

Saturation:  What is the patient’s O2 saturation? Are they on supplemental oxygen? Be sure to preoxygenate with an NRB and a NC with ETCO2 monitoring.  Keep the NC in place during intubation as this will provide passive oxygenation and help maintain the patient’s O2 saturation during intubation.

Even a thorough advance evaluation will help you identify difficult airways only about 50% of the time, so be prepared in any case (Boschert, Norris)

• *3) Touch patient, radial pulse (skin color, temp, moisture)

            This is the time to introduce your team and ask permission to touch the patient if necessary.  A good beginning is to feel the patient’s radial pulse.  By just taking a radial pulse you can determine if there are signs and symptoms of shock.  Is the pulse fast or slow? Are they cool and clammy to the touch? Is there skin moist or dry?  Is the radial pulse even palpable?  If not, do they have a brachial or carotid pulse?  Are the pulses equal in strength on both sides?  At this point you should have enough information to form a good impression of the severity of the patient’s condition.

• *4) Check eyes for reactivity and conjunctiva.

            Ask the patient to close their eyes.  This will tell you if they have the ability to follow simple commands.  Then ask them to open their eyes.  By doing this, most times you can see the reactivity of the pupils without using a pen light.  If needed use a pen light to measure the pupillary response.  While you are examining the eyes pull down the lower eyelid and examine the conjunctiva. Is it pale (hypoxia), pink (normal), jaundice (hepatitis/liver failure), or is there any subconjunctival hemorrhaging (severe vomiting or choking).

• 5) Gown the patient at this time if feasible

            By putting the patient in a gown now you will have full access to the upper part of their body to listen to lung sounds, apply EKG electrodes, and perform an abdominal assessment.  If there is no gown readily available then take this time to expose the chest as necessary to perform the assessments.  This step is particularly important for pediatric or infant patients as it gives us the opportunity to expose the patient and examine the entire body for signs of abuse or neglect.  With an infant patient remove all the clothes. Remove and examine the diaper for saturation or signs of abuse or neglect.  Then work with the caregivers to replace the diaper.  This will build a good rapport with the caregivers and allow you the opportunity to thoroughly examine the patient. 

• *6) Count Respirations and Auscultate Lung Sounds

            Listen in three places in the front and at least 4 places in the back.  The right middle lobe is best heard with your stethoscope directly under the right breast midaxillary. Most disease processes are present in the lower lobes which are best heard from the posterior as these lobes overlap the frontal lobes with the largest part of the lobes taking up the majority of the posterior side as you can see from the illustrations below. 

• 7) Obtain vital signs and perform diagnostic tests: 

B/P, Pulse, Resp, Temp, SAT, Dexi, EKG, 12-Lead EKG

Patient Treatment

The treatment of the patient is dictated by local protocol and directed by the lead medic on the scene.  Just as the Medic and firefighter are the assessment team they are also the primary treatment team. More critical calls such as a cardiac arrest may call for the driver to become engaged in patient treatment as well, but the treatment of most emergency patients can be handled very well by the bucket medic and firefighter team. 

Patient Removal

The driver of the engine is in the best postion to be in charge of the removal of the patient from the scene. As the assessment and treatment team go to work they can be be scoping the best and easiest way to extricate the patient from the home. They should meet the incoming EMS transport unit and communicate any equipment needs for removing the patient from the scene giving the EMS crew a short briefing on the location and general condition of the patient.  Regardless of the driver's level of EMS training he can tell if the patient is really sick or doing ok, and the driver will know if a stair chair is needed, what the best entrance to the home to use, etc.  

Overall Scene Management

Overall scene management and safety is the job of the engine officer.  The engine officer should be interacting with the family in a positive manner, taking notes on the assessment findings for the assessment crew, and keeping a wary eye out for any safety concerns. 

Preparedness:

The engine medic may find himself in some precarious remote locations rendering patient care such as upside down in a car, over an embankment 20 feet below the road, in the middle of a creek bed, or behind mounds of personal belongings in a horder's home.  Sometimes its difficult to carry all of our equipment and bags to such areas.  A prepared engine medic has all the essential assessment and treatment equipment close at hand at all times.  Ask yourself, what do I need to fully assess someone and save a live in the first 5 minutes of an emergency.  The best engine medics I know carry some sort of small personal go bag packed with all the essentials.  Below are pictures of one such bag. 

The contents of mine are what I need to assess a patient, some PPE, and items to bandage and control minor to severe bleeding.

Assessment Tools
Stethoscope
Adult B/P cuff
Small flashlight (Penlight)
Finger Pulse Ox
PPE
Safety Glasses
Surgical Masks
N95 Masks
Hand Sanitizer
Bleeding Control
4x4's
a 5x9
a tourniquet

Below are pictures of one such bag carried by a top notch engine medic from the Fairfax County Fire Department in Virginia.  What are your thoughts and feelings on tricks of the trade, methods, and techniques on how to be a better engine medic? Comment below.

References

·       "A Practical Guide to Clinical Medicine." A Practical Guide to Clinical Medicine. Ed. Charley Goldberg, MD. University of California, San Diego, 16 Aug. 2008. Web. 05 June 2013.

2000;109:59-61.

·       Boschert, Sherry, and Robert L. Norris, MD. "ACEP." Think L-E-M-O-N When Assessing a Difficult Airway. N.p., Nov. 2007. Web. 25 Feb. 2013.

critical review. Am Heart J. 1998;136:10-18.

·       Druelinger, Linda, and Keme Carter. "CDEM Student Portal." CDEM Curriculum. N.p., n.d. Web. 21 Feb. 2013.

·       Henry JA, et al. Assessment of hypoproteinaemic oedema: a

·       Kothari, RU, and A. Pancioli. "Result Filters." National Center for Biotechnology Information. U.S. National Library of Medicine, Apr. 1999. Web. 21 Feb. 2013.

·       McGee SR. Physical examination of venous pressure: a

·       Naccarato, Mary, MSN, RN, CEN, CCNS, Sherry Leviner, MSN, RN, CEN, Jean Proehl, MN, RN, CEN, CPEN, FAEN, Susan Barnason, PhD, RN, APRN, CEN, CCRN, CNS, CS, Carla Brim, MN, RN, CEN, CNS, Melanie Crowley, MSN, RN, CEN, MICN, Cathleen Lindauer, MSN, RN, CEN, Andrew Storer, DNP, RN, ACNP, CRNP, FNP, Jennifer Williams, MSN, RN, CEN, CCRN, CNS, and AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN. "Emergency Nursing Resource: Orthostatic Vital Signs." (n.d.): n. pag. Emergency Nurses Association. Dec. 2011. Web. 21 Feb. 2013.

·       Rockson SG. Lymphedema. Am J Med. 2001;110:288-295.

·       Sapira JD. The Art & Science of Bedside Diagnosis.

simple physical sign. Br Med J 1978;890.

·       Tseng, Elaine, MD. "Thoracic Aortic Aneurysm." Thoracic Aortic Aneurysm. Medscape, 3 Oct. 2012. Web. 21 Feb. 2013.

Wiese J. The abdominojugular reflux sign. Am J Med.Williams & Wilkins, Baltimore

Oh the Humanity...Hauling the Homeless

Each patient, whether you work in a 911 system and encounter repeat callers or you work in a non-emergency transport system where you routinely ferry patients to and from nursing homes, requires your utmost attention. Be ever diligent. Anyone can be a good paramedic on the good days. You need to be a great paramedic every time you begin a new patient encounter, regardless of the number of patients you have already seen in the shift, regardless of the number of meals you have skipped, regardless of the time of day or your fatigue level.  Never forget the person in front of you is much more than just a patient. They are someones mother, father, sister, or brother. There is someone in the world who loves them very dearly, with all of their heart, and you should imagine that person is looking over your shoulder demanding your best at every turn. Treat every patient as if they were one of your own family members.  Remember the little things. Sometimes a smile or simply being treated like a human being is the greatest and most important treatment the patient can receive. This is the philosophy I use to stay focused and try to give everyone I encounter everything I have to offer.  Sometimes it's not easy, but you have been called to a vocation that is best developed with humanity, intelligence, compassion, and respect for our fellow man. With this in mind I would like to describe a patient population in the City of Fairfax I encounter on a regular basis which is a good example, the homeless.

The City of Fairfax and Fairfax County, Virginia collectively have the second highest homeless population in the National Capital Region second only to the District of Columbia.  A large number of the Fairfax County homeless population are arrested at one time or another and charged with some sort of misdemeanor alcohol related offense.  They are taken to the Fairfax County Jail by their arresting officer.  After spending a warm night in jail they find themselves walking out to a bright and sunny morning smack dab in the middle of the City of Fairfax. They discover two major issues at that particular time in their lives.  They are hungry and they are shockingly sober.  In their minds these two situations require immediate attention.  So what to do? Hit up one of the many 7-11 convenience stores for problem number one.  But what to do about food? If they pay for food then they won't have enough money later for another trip to 7-11. Either by experience or by talking to one of their peers they learn of an establishment that feeds the homeless during the day.  This establishment is actually providing an amazing service to the community. They are a church based group that has daytime hours.  They offer food, showers, christian counseling, and help to get a man, down on his luck, back on the right path. They discourage drunkenness and offer a helping hand to any in need. God Bless them. A byproduct of this service, however, is after the doors shut and the sun goes down where does a guy get his next meal? Best bet is to just wait until morning for breakfast when the doors open up again. This behavior has created transient pockets of homeless tent communities throughout the city. Not everyone who frequents this establishment meets the description above, but I wanted to give a good descriptive example of one possibility as to why a small city in the suburbs of Washington D.C. could have such a high homeless population. 

Inevitably the fire department becomes involved in the lives of the homeless when they become too inebriated to walk or go to jail.  They may trip over a curb, discovered sleeping in the park in a near comatose state, or worse, involved in a traumatic accident.  When this occurs in rush the firemen and paramedics who encounter a great number of different homeless personalities on a regular basis. Sometimes the same personality two or three times a day every day for several weeks or months. As a paramedic you often get to meet people on the worst day of their lives. The homeless population seem to have these days on a regular basis.  


Regardless of their present physical condition, the fact they are alcoholics or mentally ill, homeless people are patients too, but above all else they are human beings and should be treated as such. They have all the same medical issues any other human being may have except all the signs and symptoms are clouded by alcohol and poor hygiene. Their lifestyle places them in a much higher risk category for all the major illnesses.  What I hate to see is a paramedic becoming complacent with the local drunk and overlooking a major medical emergency.  Paramedics dealing with a homeless population need to be ever diligent all the time. Regardless of the number of times you may have transported Otis to the hospital he requires, no he demands, your full attention because without another full patient assessment you have no idea what is transpiring with his current medical condition. 

The astute homeless immediately complain of chest pain when aroused by local police. Many times this pain is non-existent or actually upper abdominal pain from an overworked liver or pancreas, but it is not our place to assume this is the case. I have discovered more than one case of V-Tach and more than one acute MI from just such a situation. If I had just assumed Otis was drunk again and trying to avoid arrest I would have missed a serious emergency and provided a horrible service to the public. 

It's easy to be a good paramedic on a bright sunny spring day when all of your patients are pleasant and personable. The best paramedics are great all the time regardless. The next time you feel the pangs of burnout as you dread the next call or a certain type of patient remember what I have said and be a great paramedic, one that your mother would be proud of. 

The Paramedic's Most Important Job

The single most important role a paramedic can play in any patient's healthcare experience is to properly set the stage.  Yes, we must all be proficient in the recognition and treatment of immediate life threatening conditions, but that is just the beginning. Unfortunately this is the area most paramedics mistakenly concentrate all of their efforts. Have you ever heard a paramedic say something like this with a confident tone, "Nothing to that one! Show me something like V-Tach or SVT and you will get my attention." This attitude couldn't sicken me more. Every patient should have all of your attention for the entire incident.  The most underutilized skills I see in prehospital medicine are compassion and a good thorough patient assessment.  The topic of compassion is for another blog.  Today I want to talk about setting the stage and patient assessment. Setting the stage is done by performing a good patient assessment and interview, observing the surroundings and living conditions of the patient, and passing along the information, as well as, your opinion of the underlying cause to the receiving physician.  Paramedics were intended to be the eyes and ears of the emergency physician and I think we have strayed from that mindset.

The future of EMS is bringing the emergency room the the patient's living room.  With overcrowded hospitals and wait times growing we need to train the nations paramedics to think and act like physicians.  When an EMS provider examines a patient in their home they need to have a high index of suspicion for any condition that warrants further evaluation in the hospital setting.  When paramedics transport a patient to the emergency room they need to observe the initial actions and evaluations of the receiving physicians.  If the paramedic's assessment did not agree with the physician's assessment then I can guarantee you one thing.  One of them has something to learn.  If the physician performs any treatments or interventions in the first five minutes after paramedics transfer the patient then ask yourself, "Should I have done that? Is that something we can incorporate into future EMS protocols?"  The profession is it's own worst enemy.  I have heard too many paramedics say, "Why do I need to know that? It won't effect my treatment of the patient."  A more detailed medical education may not effect what treatments we allow paramedics to perform in someones living room, but it will give paramedics the knowledge to assure no patient is left at home with a potentially life threatening condition.

I just read this blog on Facebook from EMS12Lead.com

http://ems12lead.com/2010/06/81-year-old-male-cc-cold-and-shaky/
  

Its an interesting EKG but all I see is that paramedics let a STEMI walk out their door.  Why did that happen?  Was their index of suspician high enough for this situation? Should they have performed a more detailed patient assessment? Should they have asked different questions or performed more diagnostic tests?  I think in hind sight we can all answer these questions.  Don't let it happen to you.  Be curious! Be inquisitive! Ask more questions more often! Don't rest until you understand!

Just encountered another BLS abdominal pain...NOT

Elderly female 24 hours status post lap cholecystectomy having abdominal pain from the surgery. Not so much! Don't let the elusive MI slip by you.

RSI Part 1...Rapid Dosing for RSI...S,M,L,XL

I have been performing RSI in the field for ten years now.  I have developed systems for each phase of the incident to make this low-frequency high-risk call go smoothly with positive outcomes for both the patients, as well as, the providers. 

I will be covering each aspect of this process over several blog posts.  Today, I am going to explain my system for dosing adult patients in need of rapid sequence intubation.  This procedure can be stressful for prehospital providers. Anything we can do to keep it simple so the provider can focus on the big picture is helpful. 

Weight based dosing in the prehospital arena is guesswork at best.  Unless you were a carnival worker in a previous life your weight estimates will be anything but accurate.  With this in mind I have observed many a paramedic give their absolute best effort in estimating a patient's weight.  We are mostly type-A perfectionists.  Of course we will do everything we possibly can to determine the patient's weight and drug dosing so it will be absolutely accurate.  I've watched providers look at a patient and say 150lbs or 175lbs, and then they begin the calculations to kilograms, consulting complex dosing charts that are in five pound increments.  Using this method wastes valuable time and effort. If you are currently doing this type of calculation I submit you are simply wasting brain cells.  Brain cells that could be used to figure out more important things such as the underlying cause of the patient's condition.  Use those brain cells not to miss the potentially hyperkalemic patient (new onset kidney failure, rhabdomyolysis in an elderly patient laying on the floor of their house for two days, etc.) It is these types of patients that your succinylcholine will most certainly be the kiss of death.  

When I am faced with an adult patient needing RSI the first thing I do is classify them as either a small adult (60 kg), a medium adult (80 kg), a large adult (100 kg), or an extra-large adult (120 kg).  If you are off by 10 or so kilograms; if they are a little smaller or even a bit larger, trust me, it won't matter.  They will still drop like a rock and you will still be able to control their airway without issue of drug effectiveness.  The drugs used to induce anesthesia in patients for RSI have a wide margin of error in dosing.  Use this to your advantage and estimate their weight in a simple even number of kilograms so your calculations will be easy to perform and easy to confirm.  

Take the dosages and drugs you use for RSI and write out a chart for all the sizes given above.  You will notice a pattern that forms, as each size increment is exactly 20 kilograms.  Once you commit this to memory you will be able to remove this stressor from the incident and be able to concentrate on other aspects of the call such as: safety, airway size-up, delegation of responsibilities, overall scene management, assuring each team member is able to perform their respective functions, and backing-up each team member to assure success!

Once you become accustomed to this type of dosing you will be able to quickly and easily draw up medications for the majority of the population without a second thought.  You will be able to determine dosages in your sleep, which may be helpful for that 3:00 AM call of your life.

Another tip for drawing up medications for RSI is to use different size syringes for different types of drugs.  I always use a 20 cc syringe for Etomidate, a 10 cc syringe for the paralytic (either Succinylcholine or Norcuron), a 5 cc syringe for Versed, and a 3cc syringe for Fentanyl.  An addded bonus for where I work is the order of administration is largest syringe to smallest syringe.  This way when the drugs are laid out beside each other they are clearly visible as to their function, order of administration, and should not be confused.  I have watched paramedics use several syringes of the same size and place labels on each syringe.  This is asking for confusion and just another waste of time.

Just a few thoughts on how to make this type of call go more smoothly for you.  Hope it was helpful!  Be safe out there!             

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!