All posts by kellyg

Rules of EMS, Part Two

  1. You fall, you call, we haul, that’s all.
  2. There are two kinds of EMS calls: “Oh, shit!” and “Bullshit!”
  3. When you join the kidney club, you usually cannot go.
  4. Common sense isn’t.
  5. The more reflective striping there is on your jumpsuit, the easier it is for the only drunk driver going by the MVA to find you.
  6. If you have a ride-along you want to show the real world, nothing will happen that shift.
  7. 95% of the time, EMS is simply thwarting the process of natural selection.
  8. Just because you’re paranoid doesn’t mean your supervisor is not around the corner.
  9. You can’t cure stupid.
  10. If at all possible, avoid any edible item that firefighters prepare, especially the tuna casserole.
  11. Heaven protects fools and drunks.
  12. We are all slaves to the god “Motorola.” And that god requires sacrifices of hot food at least once a shift.
  13. The address is never clearly marked.
  14. Avoid bringing your patients to teaching hospitals in July.
  15. EMS doesn’t save lives. We only postpone the inevitable.
  16. Even sterile water tastes great on a hot day.
  17. The stereo must always be louder than the siren.
  18. At the beginning of your shift, your main O2 tank, fuel tank, and stomach will be empty…but the call volume will be full.
  19. You know you are in trouble when the directions to a patient’s house include, “Turn off of the paved surface…”
  20. Anyone with a tooth: tattoo ratio of less than 5:1 is guaranteed to be drunk, on drugs, or both.
  21. Anyone with more than five listed drug allergies is automatically a psych diagnosis.
  22. Avoid hospitals with Saint, Mercy, or Memorial in their names. And St. Mary of Mercy Memorial Medical Center is a definite no-no.
  23. All arrhythmias eventually straighten themselves out.
  24. Dead is dead, leave it at that.
  25. Your seriously ill patient will miraculously get better after five minutes in the ER. We call this “fluorescent light therapy.”
  26. Periodically, aliens will abduct your patient and replace him with an exact duplicate with a totally different chief complaint and set of symptoms. This usually happens right after you call report.
  27. Don’t get excited about blood unless it’s your own.
  28. The pain will go away when it stops hurting.
  29. If nothing has gone wrong, you obviously don’t understand the situation.
  30. You should always stop CPR after the second “ouch!” from the pt.
  31. People don’t call an ambulance because they did something right.
  32. The quickest way to gather the relatives is to leave the primaries on while at the scene.
  33. Every nurse is right, as long as you are in their E.D.
  34. When in doubt, always take another set of vital signs.
  35. If your patient is violent, you can always use topical oxygen therapy. The green paint usually wears off in about a week.
  36. The larger the house, the furthest from a door the patient will be, and the sickest patients are always in the back bedroom.
  37. If the patient fell and was moved by the family, they will have moved them so that climbing stairs will be involved.
  38. The furniture will always be arranged so that a stretcher or stair chair will never fit easily.
  39. The problem won’t be that bad until a major disaster strikes: “You’ve had chest pain for three days and you waited until the middle of a blizzard to call?”
  40. History never repeats itself. This is never more apparent than in the E.D., when the nurse asks the patient the same questions you did five minutes ago.
  41. You’ve never been as sick as just before you stop breathing.
  42. If someone is pointing a gun at you, two things become apparent: 1) You should have waited for law enforcement; 2) You wish you just hadn’t made that wise-assed comment.
  43. Fellow medics always have a better story than yours.
  44. Just when you say, “You know, I have never had a hanging….” you will get one.
  45. The only time you go out on a limb (as a dispatcher), and not provide coverage so a crew can eat, a serious call will come in that area.
  46. The only time you need to fart is when you have your patient loaded in the elevator.
  47. The only time your pants split is when there are gorgeous police officers there to assist you.
  48. You will get caught sleeping, eventually.
  49. Never say the kind of call you are in the mood for in the beginning of the shift, because you will get it in the worst way, i.e. an MVC in the pouring rain.
  50. God made Paramedics and EMTs to give him a chance to change his mind.
  51. Beware when a firefighter says, “Y’all check this out.”
  52. Your driver will never hit a pot hole or curb unless your patient has a bad fracture.
  53. The worse your patient’s breath, the more quietly they will talk, forcing you to lean very close to hear them.
  54. If ever in doubt of which house you were called to, look for the stairs.
  55. If there aren’t nurses around when you get called to a nursing home, go to the last room in the hallway. That’s always where the sickest patients are.
  56. Never start putting your stuff away before you are told to go home, because you have just given yourself another call.
  57. When in doubt, let your partner handle it.
  58. When getting a TMJ (too much Jesus) call on a Sunday, never say it around your patient. It sucks when you have to tell them what it means.
  59. If the patient pukes, it is not unprofessional to puke along with them, it is sympathetic puking. You have something in common with your patient and can relate to how they feel. This is why they made the big step well by the side door.
  60. If the patient only moans when you listen to lung sounds, they aren’t as sick as they want to be.
  61. If a patient calmly tells you they are going to die, you had better believe them.
  62. When the patient is really sick, remember that the ambulance has wheels for a reason.
  63. 911: The government’s answer to Dial-A-Prayer.
  64. The more addicted your patient is to morphine, Demerol, Fentanyl, etc…. the more allergic they are to Toradal.
  65. You can have circulation with no breathing, but you can not have breathing with no circulation.
  66. On trauma calls, survivability is inversely proportionate to social worth.
  67. How you know an unconscious is a DOA: 1) If it weighs over 300 pounds… DOA; 2) if it lives more than three flights up in a walkup apartment… DOA; 3) if it’s less than 30 minutes left in the shift… DOA.
  68. EMS providers know how to say “got shoes?” in 7 different languages.
  69. At haz-mat scenes, remember to use the Copological Indicators: If the stripe on the officer’s trouser leg is vertical, it’s safe to go in. If the stripe is horizontal, wait for the haz-mat team. At a gas leak, send the cop in with a lit road flare. If the cop passes out and the flare goes out, it’s an asphyxiant. If the cop explodes, it’s a flammable.
  70. Never go past the first dead cop.
  71. There will be no dying or multiplying in the back of my unit.
  72. The worse you have to use the restroom, the farther the distance it will be from the location of the call to the hospital.
  73. If you haven’t yet had to use a patient’s bathroom… you haven’t been in EMS very long.
  74. Some people can do this job, some can’t. Pray your partner is one who can.
  75. All rhythms will eventually degenerate into one you will recognize and can treat.
  76. If God had intended you to have a rapid response to the call, you would have been parked in front of the location.
  77. Upon arrival at a code, check your own pulse first. If it is still there, everything else is easy.
  78. As soon as you finish cleaning the rig up for a parade, you’ll have to drive ten miles down a muddy, unpaved road for a difficulty breathing.
  79. If you ever go to a call and find the cops laughing on the front lawn…worry!
  80. Remember, it’s the patient’s emergency, not yours. Try to keep your pulse rate lower than theirs.
  81. If you drop the baby, fake a seizure.
  82. The most effective prehospital fluid for trauma patients is a diesel bolus.
  83. Sometimes people will die despite our best efforts.
  84. Dead people very seldom get any better, but they never get worse.
  85. “Can you walk? Have you tried?”
  86. If EMS workers never eat, sleep, or go to the bathroom, nobody would ever get sick or injured.
  87. Better to be looking at it than looking for it.
  88. Go to work expecting to get screwed. You will occasionally be pleasantly surprised, but you will never be disappointed.
  89. The size of the IV needle and the number of attempts is directly proportionate to the patient’s attitude.
  90. All people eventually die.
  91. If there is a God, you are not him. This even applies to paramedics.
  92. The patient’s need of medical attention is inversely proportional to the amount of noise he/she is making.
  93. If the patient says she’s in labor, it’s a UTI. If the doctor said it was a UTI, break out the OB kit.
  94. If she says the baby is coming, believe her.
  95. If a patient presents you with a problem you don’t know how to treat, change it into something you do.
  96. All bystanders, and the majority of your patients, have more medical training, experience and knowledge than you. And they’re never shy about offering advice.
  97. The best way to make a bystander go away is to ask for help.
  98. The amount of vomit produced always exceeds the size of the container by at least a factor of 2.
  99. The seriousness of an injury is inversely proportional to the number of escorts wanting to accompany the patient to hospital.
  100. When your patient says, “I’ve called my doctor, and he’ll be meeting us at the hospital,” this actually means, “I am a hypochondriac and my doctor doesn’t have caller ID.”

Rules of EMS, Part One

  1. Skin signs tell all.
  2. Sick people don’t bitch.
  3. Air goes in and out, blood goes round and round, any variation on this is a bad thing.
  4. About 70% of the battery patients more than likely deserved it.
  5. The more equipment you see on a EMT’s belt, the newer they are.
  6. When dealing with patients, supervisors, or citizens, if it felt good saying it, it was the wrong thing to say.
  7. All bleeding stops… eventually.
  8. If the child is quiet, be scared.
  9. EMS is extended periods of intense boredom, interrupted by occasional moments of sheer terror.
  10. Always follow the rules, but be wise enough to leave them sometimes.
  11. If the patient vomits, try to hold the head to the side of the bus with the least difficult-to-clean equipment.
  12. If someone dies by chemical hazards, electrical shocks or other on-scene dangers it should be the patient, not you. (Also known as rule 1313)
  13. Any EMT, FF, LEO and/or scene chief who is more drunk than the patient is the real problem.
  14. There will be problems.
  15. The severity of the injury(s) is directly proportional to the difficulty in accessing, as well as the weight, of the patient.
  16. Make sure the rookie EMT knows that a med patch is a radio term, and not a medicated bandage.
  17. Paramedics save lives; EMTs save Paramedics.
  18. If the patient looks sick, than the patient is sick.
  19. If the patient is sitting up and talking to you, then the patient is not in V-Fib, no matter what the monitor says.
  20. It is that bad.
  21. Full spinal precautions were custom made for obnoxious drunks. So were NPAs.
  22. If you absolutely must vomit, than it is probably best to turn your head away from the patient.
  23. It is generally bad to use the words “holy s***” on scene, in reference to the patient’s condition.
  24. Patients that crash in separate vehicles should be transported in separate vehicles.
  25. Just because someone is fully immobilized doesn’t mean they can’t be violent.
  26. If I’m up, EVERYONE is up!
  27. Better them (another unit) than me.
  28. I saved the patient… from the fire department.
  29. When responding to a call, always remember that your ambulance was built by the lowest bidder.
  30. Never get into the front of the ambulance with someone that is braver than you are.
  31. When in doubt, use industrial strength therapy.
  32. If it’s stupid, but it works… then it ain’t stupid.
  33. Algorithms never survive the first thirty seconds of patient contact.
  34. Always honor a threat.
  35. Always know WHEN to get out of Dodge.  Always know HOW to get out of Dodge. Don’t go INTO Dodge without the marshal.
  36. The important things are always simple.
  37. The simple things are always hard.
  38. If the patient is going to vomit (especially projectile) be sure to aim towards any bystanders that would NOT clear the scene. (This also works for OIC’s)
  39. Sometimes it’s easier to beg forgiveness than get permission.
  40. You can’t please any of the people any of the time.
  41. They said, “Smile, things could be worse.” So we smiled and sure enough, things got worse!
  42. Always answer a newbie’s questions. You once asked them, too.
  43. Always trust bad feelings
  44. Touch no one’s genitalia but your own.
  45. The number of drugs a patient has on board is directly proportional to the number of knuckles tattooed. If the patient has every knuckle tattooed, the drug screen will simply say, “YES.”
  46. PVC’s can be eliminated by sending a strip to the hospital.
  47. The likelihood of a lethal arrhythmia increases with the distance of the paramedic from the “SHOCK” button on the monitor.
  48. The ultimate QA program in EMS is an autopsy.
  49. Best time to work a code: overtime.
  50. Pain never killed anyone.
  51. All fevers eventually fall to room temperature.
  52. A patient’s weight is directly proportional to the chances the elevator will be non-functioning.
  53. Here is a simple ETOH test: Hold your hands about 6 inches apart with thumbs and forefingers touching and ask the patient what color string you are holding. If he indicates a color, it is a positive test.
  54. A tourniquet around the neck solves all problems.
  55. If you drop the baby, pick it up.
  56. Oxygen is good, blue is bad.
  57. Never trust an ER doc with anything sharper than a tongue depressor.
  58. GCS less than 8, intubate.
  59. Asystole is a very stable rhythm.
  60. A patient’s weight is in direct proportion to their altitude in the building.
  61. A patient’s weight is directly related to the number of stair flights between him/her and the bus.
  62. “When in trouble, when in doubt, run in circles, scream and shout”.
  63. EMS RULE OF THREES (as it relates to codes) 300 pounds; <30 minutes to shift change; 3 stories up in the building.
  64. Whoops: 1) the monitor just fell down the stairs, 2) the cold and flu patient just coded; 3) the wrong house. (Hint: the one with the Lab probably didn’t call 911)
  65. Rules: 1) Don’t get dirty, 2) Don’t run, you may violate rule #1, 3) If it looks like you might get dirty doing something, let the new guy do it.
  66. For every ALS skill we learn, we forget a BLS one.
  67. The fire tetrahedron consists of the following: heat, oxygen, fuel, chief officer. Take any of them away and the fire goes out.
  68. “Compassion kills.” Don’t dive into incidents.
  69. If there is little to be gained, there is little to be lost. If there is a lot to gain, there is a lot to be lost.
  70. If you lift an inch, crib an inch.
  71. What do you call a medical student who finishes last in their class? Doctor.
  72. If you think the cost of education is expensive, check out the cost of ignorance.
  73. If it’s wet and sticky and not yours, leave it alone.
  74. Death is a stabilization of the patient’s condition.
  75. Every emergency has three phases; PANIC, FEAR, REMORSE.
  76. You are bound to get a call either during dinner, while you are on the can, or at 02:00 in the middle of a great dream.
  77. Training is learning the rules, experience is learning the exceptions.
  78. Good judgment comes from experience, and experience comes from bad judgment.
  79. Rocket scientists that get into stupid car crashes are the first ones to complain how bumpy the ambulance ride is.
  80. “Poke & Hope” = blind sticking
  81. Why do fire chiefs where white helmets? So you know where the Preparation H goes.
  82. Never trust your bus, drug box, or airway bag to be fully stocked, in spite of the assurances of the off going crew.
  83. If you don’t have it, don’t give up. Adapt, improvise, overcome. And if that doesn’t work, call for a second unit.
  84. There is no such thing as a “textbook case.” Patients don’t read the textbook.
  85. Newbies always look for large things in the smallest compartments, and vice versa.
  86. There is no such thing as a bad call, only calls that didn’t go the way you planned.
  87. Just because someone’s EMT or Paramedic original license date is before yours, does not mean they know what they are doing.
  88. There are very few paramedics with 20 years of experience. There are thousands of paramedics with 1 year of experience, repeated 20 times.
  89. Truckies are people who are over 6 feet tall and their hands drag the ground while walking upright.
  90. Newbies have their own way of doing things.
  91. When it comes to needles, ’tis better to give than to receive.
  92. Listening to some EMTs talk on the radio makes you wonder why they don’t become professional auctioneers.
  93. For every 25 calls you run, only 1 will be exciting.
  94. Take comfort in the fact that most of your patients survive, no matter what you do to them.
  95. The old EMS constant; no matter how bad the politics get, the doors go up and the trucks go out.
  96. ALS really stands for “absolute loss of sense.”
  97. Many of your patients will be healthier than you are.
  98. Being in emergency services means you get to celebrate your holidays with all your friends, while on-duty.
  99. Being an EMT means you get to expose yourself to rare, exotic and exciting new diseases.
  100. EMS does not save lives; EMS is to care for people. It is 95% of what we do.

Auscultation in High Noise Environments

Some reports I get from first responders at emergency scenes always peg the skepticism meter. Whenever I hear those things, I nod inscrutably, thank the EMT for his help, and make a mental note to verify what he told me, because the information cannot be trusted.

And nothing is more untrustworthy than a perfect set of blood pressure readings.

Whenever an EMT reports a blood pressure reading of 110/70, or 120/80, or I notice a pattern where that EMT always reports systolic and diastolic readings that end in zero, I begin to suspect his readings. Real patients are rarely that perfect, even when their blood pressures are within normal ranges.

Likewise, a reading with odd numbers also invites skepticism. Take a look at the gauge on your manual BP cuff; all the increments are in even numbers. Whenever I hear blood pressure readings like 133/75, I know that EMT is guessing.

Honestly, you’ll be more credible if you simply say, “I’m having a hard time hearing a blood pressure, but I palpated one at 144 systolic.”

See, that one is believable. Every experienced EMT has been in a situation where, for whatever reason, it was difficult to auscultate a blood pressure or hear breath sounds. We can believe you when you admit fallibility. What we can’t believe is an EMT who gets a too-precise reading, every single time. Sometimes, you have to resort to less accurate methods, like palpating a blood pressure.

By the way, unless your name is Liz Hyde, if you give me anything other than a systolic reading when you palpate a blood pressure, I won’t believe you either. Liz was my boss when I first became an EMT oh-so-many years ago, and she is the only person I have met or even heard of in the years since, who could consistently obtain an accurate systolic and diastolic blood pressure by palpation.

And even Liz can’t explain how she does it.

In Ron’s last post, he noted his improving skill at auscultating a blood pressure. One of the most difficult things for a newbie is learning to interpret what your ears are picking up. Is the patient making that noise, or is it artifact? If it is the patient making that noise, are the sounds normal or abnormal?

As it is with so many things, there is no substitute for practice. Check blood pressures on enough patients, eventually you’ll learn to discern the difference between Korotkoff sounds and ambient noise. Not only that, but you should assess breath sounds on every patient you encounter, especially the ones who have no respiratory complaints. Only when you understand what normal sounds like, will you be able to recognize abnormal sounds.

While you’re learning to recognize what normal sounds like, you can educate yourself on abnormal breath sounds over at the Rale Repository.

However, you will soon discover that obtaining blood pressures and listening to lung sounds is far easier in a quiet classroom than at a chaotic, noisy scene or in the back of a moving ambulance. Ambient noise and motion artifact tend to drown out everything we want to hear.

There are, however, a few things you can do to limit the amount of ambient noise you hear. First, and foremost, is a quality stethoscope with properly fitting ear tips.

If your stethoscope has hard plastic ear tips, ditch them and get some quality Gelseal ear tips that conform to your ear canal. Replace your old, hard plastic diaphragm with a disposable Safeseal diaphragm. This diaphragm will result in significantly louder and clearer sounds than your stock diaphragm, but you will have to use a lighter touch to notice the difference.

Next, make sure your stethoscope fits properly. For the best results, make sure the binaurals (those are the metal ear pieces) are angled forward slightly. If your soft ear tips fit properly, you should notice a substantial reduction on ambient noise when you fit them in your ears.

For an even better seal, close your mouth, pinch your nostrils shut, and try to breathe in. The resulting negative pressure will suck the soft ear tips deeper into your ear canals.

The next step is to isolate yourself and the patient (actually, whatever part of the patient you’re auscultating) from the surrounding environment. When you’re in a moving ambulance, the tires on the road, vibration from the suspension and body of the rig, and vibration from the stretcher all combine to form a distinct, low-frequency roar that often makes it impossible to hear those equally low-frequency breath sounds and Korotkoff sounds.

So, to minimize that low-frequency roar, you must minimize contact with the ambulance itself. Now you may ask, “How do I minimize contact with the ambulance if both of us are in the ambulance?”

Simple – you remove the patient’s arm from anything that vibrates. Don’t allow it to lay on the stretcher rail, or even your leg. If you hold their arm in yours, don’t rest your arm on your leg. Don’t place your feet flat on the floor. Instead, rise to your tiptoes, minimizing contact with that vibrating, moving floor.

You can avoid artifact noise from BP cuff tubing by placing the cuff on your patient’s arm upside-down, with the tubing nearer to the shoulder than the wrist. It won’t make a difference in accuracy as long as you have the artery marker correctly aligned, and it will keep those tubes out of your way. Position the cuff high enough that it doesn’t rub against the bell of your stethoscope.

This, incidentally, is the same technique you’ll use to start IVs in a moving ambulance, should you ever choose to become a paramedic. It’s just your hand, the needle, and the patient’s arm – just a fixed point in space – while everything else is moving around you.

When you’re listening to breath sounds, try to have the patient sit up, if possible. With their back pressed against the stretcher mattress, much more ambient noise is transmitted through their chest via vibration. Move clothing out of the way so that it does not brush against the tubing or bell of your stethoscope. Avoid listening through clothing if you can.

Using these tips should make it substantially easier for you to hear in the back of a moving ambulance, but if not, sometimes you must resort to less accurate, but still effective means. Palpate your blood pressures if you must. If you can’t hear breath sounds, try assessing for tactile fremitus instead. It takes practice, and it isn’t nearly as accurate as actually listening, but it’s better than nothing.

Good luck!



Korotkoff sounds: arterial sounds heard through a stethoscope applied to the brachial artery distal to the cuff of a sphygmomanometer that change with varying cuff pressure and that are used to determine systolic and diastolic blood pressure.

Artifact: noise or interference not naturally present in the matter being observed, but formed by artificial means.

Tactile fremitus: The vibrations felt by a hand placed on a chest during vocal fremitus. Place your hands on either side of the patient’s chest, and have them say, “Ninety-nine.” You should feel equal vibration on both sides of the chest.