# SF medics at Duke



## Devildoc (Nov 26, 2015)

Nice article.  I have chatted some of these guys up over the months/years they have been at Duke.

Green Beret medics train at Duke


----------



## Kraut783 (Sep 5, 2016)

This is very cool, props to Duke.

"In addition to the workshop, Duke helps train Special Forces medics by hosting them for one-month residencies.
Dr. Mark Shapiro, chief of acute care surgery at Duke, said up to four Green Berets are working in the hospital at any given time."


"Nearly 50 medics have trained at Duke since that partnership began in 2014, Shapiro said. That includes soldiers from the 1st, 3rd, 5th and 7th Special Forces Groups.
"It's really a big source of pride for Duke," Shapiro said."


----------



## Gunz (Sep 5, 2016)

_*"When you want to get to know folks and earn their trust, one of the best ways is to do some tailgate medicine," Hines said. "You build that rapport and that trust by going out and helping folks."*_

Absolutely. Well done. Good on Duke.


----------



## Red Flag 1 (Sep 5, 2016)

i


----------



## Devildoc (Sep 5, 2016)

Red Flag 1 said:


> FWIW, Duke was the first University to define the "Advanced Practice" programs. The Advanced Practice programs are the Physician's Assistant, and Nurse Practitioner rolls. Duke took a select number, I think it was five, of Naval Corpsmen, and ran them through the first PA program. Advanced practice for nurses began much earlier by training RNs to administer Anesthesia, a position that is now called Certified Registered Nurse Anesthetists (CRNA).



Yes...a source of pride the PA program started with 5 Corpsmen; and at Duke.

Regarding this program, Mark (Shapiro, whom I know well) is very pro-military and is a huge advocate of SF specifically and the military in general.  He is good people.

Now if we could just get Duke to buy into trauma and emergency medicine as well.  It isn't a cash cow like cancer or cardiology so it's not as sexy.  If Duke could give up its trauma center status it would.  But that's a whole 'nother thread.


----------



## policemedic (Sep 5, 2016)

Devildoc said:


> Yes...a source of pride the PA program started with 5 Corpsmen; and at Duke.
> 
> Regarding this program, Mark (Shapiro, whom I know well) is very pro-military and is a huge advocate of SF specifically and the military in general.  He is good people.
> 
> Now if we could just get Duke to buy into trauma and emergency medicine as well.  It isn't a cash cow like cancer or cardiology so it's not as sexy.  If Duke could give up its trauma center status it would.  But that's a whole 'nother thread.



Penn successfully transferred its Level 1 from one campus to another specifically to avoid the drama associated with the knife and gun club once they went whole hog on CA, proton therapy, and other high dollar stuff.  It's amazing how that happens when money becomes the driving force instead of providing care to the community and training the next generation of physicians and nurses.


----------



## Red Flag 1 (Sep 5, 2016)

policemedic said:


> Penn successfully transferred its Level 1 from one campus to another specifically to avoid the drama associated with the knife and gun club once they went whole hog on CA, proton therapy, and other high dollar stuff.  It's amazing how that happens when money becomes the driving force instead of providing care to the community and training the next generation of physicians andnurses.


----------



## TLDR20 (Sep 5, 2016)

BST and University of Maryland are separate hospitals, but across the street from each other. Keeps the guns out.


----------



## Devildoc (Sep 5, 2016)

policemedic said:


> Penn successfully transferred its Level 1 from one campus to another specifically to avoid the drama associated with the knife and gun club once they went whole hog on CA, proton therapy, and other high dollar stuff.  It's amazing how that happens when money becomes the driving force instead of providing care to the community and training the next generation of physicians and nurses.



Unfortunately for Duke it's the only show in town.


----------



## Devildoc (Sep 5, 2016)

Red Flag 1 said:


> *There are benefits in having a high end ER program. *It brings cases in for the Residents of just about every specialty but Derm & Allergy. Unless a lot of Grant, and other funds come with it, it can become a black hole to support that kind of care, as @policemedic points out. It also becomes a burn out rotation for Nurses and Med Techs.



Duke's EM program is buried within the Dept of Surgery.  I think it's the least funded of all the divisions in the department.  Many in the Dept of Surgery still think, after 12ish years of of having EM residency, that the ED is in the purview of surgery and EM doesn't have a place at the table.


----------



## policemedic (Sep 5, 2016)

Devildoc said:


> Duke's EM program is buried within the Dept of Surgery.  I think it's the least funded of all the divisions in the department.  Many in the Dept of Surgery still think, after 12ish years of of having EM residency, that the ED is in the purview of surgery and EM doesn't have a place at the table.



Interesting.  EM is near and dear to my heart, so it pains me to hear the EM residents and docs are treated that way at Duke.


----------



## Devildoc (Sep 6, 2016)

policemedic said:


> Interesting.  EM is near and dear to my heart, so it pains me to hear the EM residents and docs are treated that way at Duke.



The culture, it is a'changing.  It is definitely much better than it used to be, but still far from where it needs to be.  There are a lot of intra-organizational issues with EM here...(relative) low pay for docs, they can't admit so ED admit holds take forever to dispose, the docs sit at the kid's table with regard to major hospital committees.  The nursing side isn't much better.  Awesome director but he has a shit-load on his plate, good manager, very weak mid-management, enormous turnover.

I will say the ED is very EMS-friendly and has a good relationship with local EMS, which is very nice.  When I was a medic there were some ED's who had horrible relationship with EMS and patient care really suffered.  Duke is medical control with local EMS, and several docs are former paramedics.


----------



## Red Flag 1 (Sep 6, 2016)

Devildoc said:


> Duke's EM program is buried within the Dept of Surgery.  I think it's the least funded of all the divisions in the department.  Many in the Dept of Surgery still think, after 12ish years of of having EM residency, that the ED is in the purview of surgery and EM doesn't have a place at the table.


----------



## TLDR20 (Sep 6, 2016)

Devildoc said:


> Unfortunately for Duke it's the only show in town.



Except for that giant hospital less than 10 miles away, UNC.


----------



## Devildoc (Sep 6, 2016)

TLDR20 said:


> Except for that giant hospital less than 10 miles away, UNC.



Yeah, true.  I meant "town" literally.  Durham's only other hospital is a community hospital.  UNC does EM very, very well.  The former chief is Judy Tininalli (she wrote THE EM textbook), molded EM into its own department (vice "division"), and created a well-run, well-respected department. 

I was a paramedic when UNC started its EM residency, UNC was our medical control (same county).  All of the EM residents (and all new ED nurses) had to do EMS rotations, and we did a lot of the ED-specific teaching for ACLS, PALS, etc.


----------



## Muppet (Sep 7, 2016)

Devildoc said:


> Yeah, true.  I meant "town" literally.  Durham's only other hospital is a community hospital.  UNC does EM very, very well.  The former chief is Judy Tininalli (she wrote THE EM textbook), molded EM into its own department (vice "division"), and created a well-run, well-respected department.
> 
> I was a paramedic when UNC started its EM residency, UNC was our medical control (same county).  All of the EM residents (and all new ED nurses) had to do EMS rotations, and we did a lot of the ED-specific teaching for ACLS, PALS, etc.



In my opinion, we as paramedics had to do E.D., ICU, burn and so on, time. New nurses and residents should have to do EMS time to better understand EMS as a whole. I have been fortunate to have EMS residents and fellows doing EMS time for their EMS fellowship / medical directors course. I learned alot, they did also. Now, when we bring in a fucked up trauma not all packaged pretty but saved, they will know not to cry and bitch about how the line is taped, why they may not be intubated BUT were properly ventilated and that permissive hypotension SOP was preformed. 

M.


----------



## Devildoc (Sep 7, 2016)

Muppet said:


> In my opinion, we as paramedics had to do E.D., ICU, burn and so on, time. New nurses and residents should have to do EMS time to better understand EMS as a whole. I have been fortunate to have EMS residents and fellows doing EMS time for their EMS fellowship / medical directors course. I learned alot, they did also. Now, when we bring in a fucked up trauma not all packaged pretty but saved, they will know not to cry and bitch about how the line is taped, why they may not be intubated BUT were properly ventilated and that permissive hypotension SOP was preformed.
> 
> M.



I didn't know how good I had it.  I went through a paramedic certification program taught and sponsored by UNC Hospitals.  Every department in which we did clinicals pretty much welcomed us with open arms.  We did far more clinical time than the minimum required by the state or DOT curriculum, and the resulting relationships between EMS and that hospital, particularly the ED, thrived because of it.

I now know, many (MANY) years later that not all EMS agencies and hospitals have such a warm relationship.  So much the pity.

When I was in the ED at Duke I tried to get ED nurses to do ride-along time, but the hospital wouldn't allow it because of "liability."  Even though the two other, local Level 1 trauma centers did it fine.  I also tried to get local reserve and NG corpsmen and medics to come into the ED for clinical time or con ed; again, I could get MOAs with the military folks, but the hospital wouldn't hear of it. 

I had a love-hate relationship with that department.  We did (and it still does) provide excellent, excellent care in the face of many roadblocks.  The department really wants to be better, but for whatever reasons, it just won't be allowed.


----------



## policemedic (Sep 7, 2016)

As @Muppet said, we rotated through almost every department with a heavy emphasis on EM and critical-care areas.  To this day I STILL say if I ever did nursing school it would only be to practice in an ED or ICU. 

The only unit I didn't feel welcome in was L&D.  The nurses really didn't like us being there; the physicians were great but the nurses killed the experience.


----------



## Devildoc (Sep 7, 2016)

policemedic said:


> As @Muppet said, we rotated through almost every department with a heavy emphasis on EM and critical-care areas.  To this day I STILL say if I ever did nursing school it would only be to practice in an ED or ICU.
> 
> The only unit I didn't feel welcome in was L&D.  The nurses really didn't like us being there; the physicians were great but the nurses killed the experience.



I have spent the majority of my nurse time in the ED, after working in a surgery-trauma and neurosurg ICU.  Last couple years in radiology for a mental and emotional break.  I think the vast majority of former medics who go into nurses do ED or ICU.

Yeah, L&D nurses are cliquish.  Even to other nurses.  When I was in nursing school I had already delivered a handful of babies between EMS and the military, so I know my attitude did not endear myself to them.


----------



## TLDR20 (Sep 7, 2016)

Muppet said:


> In my opinion, we as paramedics had to do E.D., ICU, burn and so on, time. New nurses and residents should have to do EMS time to better understand EMS as a whole. I have been fortunate to have EMS residents and fellows doing EMS time for their EMS fellowship / medical directors course. I learned alot, they did also. Now, when we bring in a fucked up trauma not all packaged pretty but saved, they will know not to cry and bitch about how the line is taped, why they may not be intubated BUT were properly ventilated and that permissive hypotension SOP was preformed.
> 
> M.


I disagree. Maybe new ED nurses need that, but there is no reason for an ICU nurse to ride a rig.


----------



## TLDR20 (Sep 7, 2016)

policemedic said:


> As @Muppet said, we rotated through almost every department with a heavy emphasis on EM and critical-care areas.  To this day I STILL say if I ever did nursing school it would only be to practice in an ED or ICU.
> 
> The only unit I didn't feel welcome in was L&D.  The nurses really didn't like us being there; the physicians were great but the nurses killed the experience.



As a student nurse my best experience was in L&D, as a paramedic that shit sucked. Even female paramedics and critical care transport people get the cold shoulder. A lot has to do with the fact that L&D nurses are fiercely protective, like mama bear protective. L&D is also a place where nurses truly work to the top of their license. If I wasn't a guy I would go down that path.


----------



## Devildoc (Sep 7, 2016)

TLDR20 said:


> I disagree. Maybe new ED nurses need that, but there is no reason for an ICU nurse to ride a rig.



I agree, unless an ICU nurse is trying to get into critical care transport, if that transport does scene runs.  Then it would be beneficial.  But outside of that, I don't know how beneficial it would be.


----------



## Muppet (Sep 7, 2016)

TLDR20 said:


> I disagree. Maybe new ED nurses need that, but there is no reason for an ICU nurse to ride a rig.



OK. Agree on that point.

M.


----------



## Red Flag 1 (Sep 8, 2016)

TLDR20 said:


> I disagree. Maybe new ED nurses need that, but there is no reason for an ICU nurse to ride a rig.


----------



## policemedic (Sep 8, 2016)

Red Flag 1 said:


> Yup, I can agree with that.
> 
> I do think undergrad nurses could benefit from a few weeks running calls with a busy EMS squad. It will be eye opening, and they will have a much better prespective regarding front line medicine, in the field. I' d go so far as to suggest ER nurses run a few EMS calls too.



I've encountered a number of nurses, who through no fault of their own, are blissfully clueless about paramedics.  A wee bit of ride time would fix that.  I actually blame some of this on the idiots some companies choose to put on trucks (the old transport vs. 911 argument).

ICU nurses may benefit from riding critical care trucks a time or two. I've had a few disagreements with nurses about why I needed to see/know the pt's labs or other values, why I refused to take them until the staff did a 12-lead (yes, I can do and read one but then he's mine...), invasive monitoring numbers etc.   Perhaps riding with us might solve that issue.

ED nurses are a bit more in tune with us, but ride time would help them understand the challenges we encounter.   It would also help them understand the care we can provide.


----------



## Red Flag 1 (Sep 8, 2016)

policemedic said:


> I've encountered a number of nurses, who through no fault of their own, are blissfully clueless about paramedics.  A wee bit of ride time would fix that.  I actually blame some of this on the idiots some companies choose to put on trucks (the old transport vs. 911 argument).
> 
> ICU nurses may benefit from riding critical care trucks a time or two. I've had a few disagreements with nurses about why I needed to see/know the pt's labs or other values, why I refused to take them until the staff did a 12-lead (yes, I can do and read one but then he's mine...), invasive monitoring numbers etc.   Perhaps riding with us might solve that issue.


----------



## Red Flag 1 (Sep 8, 2016)

policemedic said:


> I've encountered a number of nurses, who through no fault of their own, are blissfully clueless about paramedics.  A wee bit of ride time would fix that.  I actually blame some of this on the idiots some companies choose to put on trucks (the old transport vs. 911 argument).
> 
> ICU nurses may benefit from riding critical care trucks a time or two. I've had a few disagreements with nurses about why I needed to see/know the pt's labs or other values, why I refused to take them until the staff did a 12-lead (yes, I can do and read one but then he's mine...), invasive monitoring numbers etc.   Perhaps riding with us might solve that issue.
> 
> ED nurses are a bit more in tune with us, but ride time would help them understand the challenges we encounter.   It would also help them understand the care we can provide.


.


----------



## policemedic (Sep 8, 2016)

Red Flag 1 said:


> I think your practice of holding out for labs and a 12 lead is good practice. It is smart and logical to check how you did in he field. I can see that the hand over of the patient to the ER ends your part in the continuim of care. That is how the ED people will look at things. I believe you are spot on to await the information about your patient.



Doc,

I probably wasn't clear.

When I bring in patients from a 911 run--pure prehospital medicine--I have the capability to run 12- and 15-lead EKGs and interpret them myself.  I always do pre- and post-treatment EKGs when indicated.  Labs are a different story; 911 trucks generally don't have iStats or the capability to do labs apart from glucose testing.  In our area, taking the time to obtain, measure and interpret a CBC, cardiac enzymes, or 'lytes would delay us too much due to short transport times.  By the time we got results, we'd probably be pulling into the ED.  In other areas, obtaining this information may be vital and may be the basis of a flight vs ground decision.

However, when I did critical care transports, I would never accept responsibility for a patient from the unit until I had read the entire chart, interpreted lab values/ABGs, Swan-Ganz, etc.  If the chart didn't include a recent 12-lead I made the staff do one.  This caused some consternation but I wasn't willing to accept an ICU level patient without knowing all the facts.


----------



## Red Flag 1 (Sep 8, 2016)

policemedic said:


> Doc,
> 
> I probably wasn't clear.
> 
> ...


s.


----------



## TLDR20 (Sep 8, 2016)

As a soon to be full time ICU nurse, with considerable pre-hospital time under my belt, I can honestly say there is almost no reason for a new/student nurse to have any time on a rig. First off licensing would be a huge pain in the ass, so much so that it is a hindrance to any possible benefit. For a new hire ED nurse however I think it would be beneficial. It is easy to sit in the ED and criticize a paramedic for shotty care when you have never picked up a violent drunk who was just in an accident who you literally have to hold down to keep him from further injuring his C-spine. As a CVSIVU nurse I will never be receiving patients from point of  injury/illness. At the level I will be at(highest acuity level) I will also never hand them off to a CC transport team. I have an interesting perspective having seen it from both ends of the spectrum though.


----------



## Devildoc (Sep 8, 2016)

TLDR20 said:


> As a soon to be full time ICU nurse, with considerable pre-hospital time under my belt, I can honestly say there is almost no reason for a new/student nurse to have any time on a rig. First off licensing would be a huge pain in the ass, so much so that it is a hindrance to any possible benefit. For a new hire ED nurse however I think it would be beneficial. It is easy to sit in the ED and criticize a paramedic for shotty care when you have never picked up a violent drunk who was just in an accident who you literally have to hold down to keep him from further injuring his C-spine. As a CVSIVU nurse I will never be receiving patients from point of  injury/illness. At the level I will be at(highest acuity level) I will also never hand them off to a CC transport team. I have an interesting perspective having seen it from both ends of the spectrum though.



My first nursing gig was in the surg-trauma ICU at Chapel Hill.  When I started I had 13 years of EMS experience, with some of that critical care transport (air and ground).  Once, one time, we did hand off to CC transport who was being transported to a hospital closer to the patient's home (Emory if I recall).  I will be interested to hear your observations after working for a bit, having seen it from both ends of the spectrum.


----------



## Red Flag 1 (Sep 9, 2016)

TLDR20 said:


> As a soon to be full time ICU nurse, with considerable pre-hospital time under my belt, I can honestly say there is almost no reason for a new/student nurse to have any time on a rig. First off licensing would be a huge pain in the ass, so much so that it is a hindrance to any possible benefit. For a new hire ED nurse however I think it would be beneficial. It is easy to sit in the ED and criticize a paramedic for shotty care when you have never picked up a violent drunk who was just in an accident who you literally have to hold down to keephim from further injuring his C-spine. As a CVSIVU nurse I will never be receiving patients from point of  injury/illness. At the level I will be at(highest acuity level) I will also never hand them off to a CC transport team. I have an interesting perspective having seen it from both ends of the spectrum though.


----------



## Devildoc (Sep 9, 2016)

Red Flag 1 said:


> I think your observations about student status on rides is a valid point. The real life example you sited is perfect, and all too common.* Not many hospital based providers have had to intubate a patient with kneeling on blacktop as your only option*.



Sir, have you seen the literature?  ETI is no longer _en vogue, _I don't know too many pre-hospital providers who do this any more.


----------



## Red Flag 1 (Sep 9, 2016)

[Q


----------



## Devildoc (Sep 9, 2016)

Red Flag 1 said:


> Airway access beyond Miller and Mac rigid blades has been around for a long time. Fiberoptic endoscopes , and other methods of securing a protected airway were standard for in hospital use even when I stepped away.  Just how far into the field that has evolved, I was not aware. My point was to illustrate some of the extremes between in house, and pre hospital challenges. The one that always pops into my head was more than a few years ago.
> 
> Generally I was called to the hospital ER/ICU/Patient care floor. While at Base "X" in Ca., I was called to a mile post marker on a highway. Single car mishap with the driver face down in a four foot deep culvert. Those who never get out much, need to know what squads face everyday before passing judgement on how the patient appears coming through the ER doors.



Yes, sir, I was talking mostly tongue-in-cheek, which rarely comes across on the interwebs.  In EMS the pendulum swung from intubating everyone with a GCS less than 8, to intubating almost never.  I have seen prospective paramedic curricula suggesting ETI be taken out.  Which is weird because they still advocate crichs. 

At the pinnacle we could do RSI, retrograde, fiberoptic laryngoscopy, nasal intubation (my personal fave) along with needle and surgical crichs.  We weren't there long before one-by-one those skills were being abandoned.  Now largely the protocol is blind insertion airway device and proper ventilation with BVM.


----------



## Red Flag 1 (Sep 9, 2016)

Devildoc said:


> Yes, sir, I was talking mostly tongue-in-cheek, which rarely comes across on the interwebs.  In EMS the pendulum swung from intubating everyone with a GCS less than 8, to intubating almost never.  I have seen prospective paramedic curricula suggesting ETI be taken out.  Which is weird because they still advocate crichs.


----------

