jwraider

Sonoma and Solano county in CA although I'm still in the hiring process in Solano. I hear you that they are usually similair but I'm finding some differences. The trauma triage schemes are fairly different as one county seems to prefer over triage while the other wants to avoid it discounting co morbid and mechanism (the same county also requires base contact for non obvious activations) One county treats a BS under 80 the other under 60 One county also defines 3 different pt presentations for narrow tach with a different set of cardio version energy settings. I'm just going toget to know both verbatim and then sort out the key differences so I'm acutely aware of them. I'm sure this works out fine usually just so dering if anyone has suggestions. Thanks again!

Hi guys, Anyone have suggestions on memorizing and operating with 2 or more protocol sets? I'm a medic and it looks like I'll be working in 2 different counties ( ems systems ). Do you memorize one and then note the differences in the other? Any pitfalls to watch out for? Thanks for the advice!

Anthony - Duh right? If the heart isn't beating giving Epi isn't going to make it beat faster. Some peripheral vasoconstriction could be a good thing too. Thanks that was the point that was missing. In the case we were discussing the PTs blood was left on scene and nothing we could have done would have helped. Blood replacement hopefully is in the future because that is the fix that is needed. Fiznat - Nice article thank you. The one part that is specific to my question says Epi is not effective but it does not say contraindicated.

Anthony he was actually in conversation with the fire medic and they both agreed with each other. The idea being the faster you send the blood around the system the faster it spills out the hole(s).

Hello, I'm wondering what your thoughts might be on this subject. The reason I've started this discussion is I am a new medic and I've now had two very strong opposing opinions given to me by those who are more experienced. (For arguments sake we are talking about patients who are not being pronounced for whatever reason or due to protocol) When dealing with a traumatic arrest you want to focus on treating the underlying cause if possible. For example fixing a pneumo or airway obstruction. There are a bunch of airway breathing problems we can fix. We can also stop bleeding and replace volume. Where my two mentors disagreed was in the treatment of a hemorrhagic patient. One person says "ACLS drugs are just going to make him bleed faster" while the other says "treat with ACLS anyway". These are blanket statements of course. So what do you do? Are there situations where you withold ACLS (let's say NSR / PEA with a ton of blood loss) ? My opinion is blanket statements like these suck and special care must be given to these situations. So I'm curious what everyone's line of thinking is they use to make their treatment decisions. Thanks!

I was just thinking about this. I find it weird that there is no official list that we work from. I'm not sure if it should be at the national level or the county level but why not a repository of med sheets that we work from with consistency?

I thought I'd add our county protocol for this. First it states an IO is for an emergency (a real one!) with a GCS of 8 or under. For concius PTs or a PT who regains concioussness admin Lidocaine 2% 0.5mg/kg max 50mg slowly. After 30-60 seconds flush with NS. It explains for the PT regains consciousness and complains of severe pain at the IV site to stop the infusion and admin lidocaine just like above. (Notice it says stop the infusion inferring that is what is causing the pain).

I haven't had to do an IO on someone yet on someone who would feel anything. I know some counties have lido in their protocol to flush with as that is when the most pain is felt. My guess would be the pain is felt as long as you are pushing anything through the IO. I've used the standard size on a larger patient and the fat tissue just seemed to compress under the plastic and the catheter ended up in the right place. I wasn't on the call of course but do you guys have protocols for Valium to go other routes besides IO/IV ? Seems like this guy would have had good perfusion if he was faking an IM injection of Valium or Versed would have worked. Some systems now have intranasal versed which is great for seizures in my opinion. I'm not trying to second guess you as much as I'm pointing out painful IOs can be avoided. I think it would be interesting to discuss situations where an IO is needed for a concious PT and how we would handle it.

Thanks for the videos they were both educational and entertaining. I know how much of a pain in the butt it can be to format the files correctly so thanks. So are the ambulances staffed with basics and intermediates? Or is advanced care paramedic really advanced and there are basic paramedics?

Thanks everyone for your thoughts and experiences. I shared most of the same views you expressed before posting this and it's very helpful to let her know that the vast majority of us know how to handle this situation the right way.

Hi everyone, My spouse and I have recently been dealing with this issue and I was wondering how it worked for other people? I've been in the position recently where I've been paired up with a female partner (I'm a male) for a 24 hour shift that is somewhat secluded from other people. The station is near an airport and there is a sleeping room and a general room with a TV and a fridge. My spouse doesn't like this arrangement and thinks that it is an opportunity for relationships to form or someone to make an accusation of some kind of harassment or assault. Has anyone else had to deal with this or if not do you have an opinion? She's said I do all the right things to be a good guy and handle the situation with integrity but it's still something she is uncomfortable with. (I sleep in the TV room and my spouse has full access to me via phone, camera phone, she knows where I am at all times) I'd like to avoid the situation as much as possible but I've just become a paramedic and for many reasons I'm not in the driving seat as far as the shifts that are available to me. Even with that I know it's a fairly common scenario for men and women to work together alone in this industry and it's not completely avoidable if this is an issue for someone. Thank you! I'm sure this has been discussed before but I think it's a relevant topic to discuss further I hope you agree! =)

It a Pt that small why pressure infuse? Just push it through a syringe you have better control over the dose and rate that way (imo).

possibly a few scenarios with skills wrapped up in them. -CPR, assessment and backboard for sure (just go over all your skill sheets and know them). They won't fudge on any mistakes. Good luck you may be applying to the same service as me , see you out there!

I think the "don't call an ambulance" comes from the line of thinking of "she's going to have them and they will stop on their own". If you think sugar need and 02 levels need to be checked call the ambulance (and we always do with seizures so it's a tough call to deal with).

Patients pulse was in the 160-180 range. -That's pretty quick and might lend to the cocaine differential Normal QRS. Had ST elevation with Reciprical ST depression. - Just wondering which leads?

If he's unreliable he gets a backboard as much as that might suck for him and the FD on scene. In my county a +LOC buys a code2 trauma activation (a few less MDs show up in the room) and it would be fairly awkward to show up and not have the PT cspined. I'm not saying that's always a good reason to use a treatment but that's how it would go here. I wonder if raising his sugar would change things? Would anyone give him d50 on scene? If he suddenly recollected everything and became more reliable could you base treatment on the new story? If he was altered due to sugar at the time of the accident who knows what he missed.

nice link thanks

The poster above who asked about the relationship you have with your preceptor is right on in my opinion. Start by making sure you two are on the same page and they are able to constructively criticize you. Even in a busy system during an internship there are only going to be so many "tough" decisions to make. It's more about your thought process and your ability to use common sense and think critically. Your preceptor should be helping you develop this while you are learning to run calls. 1) Make sure you are establishing a detailed order of events (got dizzy then fell and hit head versus fell and hit head and is now dizzy). This will help you feel confident you know what is going on. 2) Also I'm sure you do but know your protocols and what is common practice in your area. These guidelines help alot with tough decisions. 3) Use medical control when you really don't know what to do. This should be "OK" but I imagine your preceptor will step in and help you with the answer. During my internship I had a PT complaining of chest pain but who was definitely altered (confirmed by family) with possible facial droop (was debatable). I couldn't decide CVA versus MI or both and was stuck in making a treatment decision. My preceptor had me go back through the order of events which I used to establish a differential and rule certain things in and out. Sometimes you just need to slow things down and make sure you know what is going on. It's probably very apparent to you if you can take a step back. Good luck! Be confident! You've made it this far.

First of all best of luck to you. I took them and passed this past December in CA. The testing center I used offered a pre-test day where we got to practice with the instructors which was very helpful of course. If you don't have that option I'll try and recount the things they said to remember about the oral station: 1) Do a good job of describing what you would do and check for with the scene size up especially on a trauma call. Be thorough about determining the mechanism and scene management. Some examples would be either dealing with downed power lines or dealing with stairs and other access problems a house might have. Their point was they wanted to be sure you could perform scene management well, not just recite a skill sheet. 2) It will be 2 scenarios and take you about 20-30 minutes. One will definetely be a medical and the 2nd might be as well (you do a trauma assessment at another station so the oral scenarios might be two medicals or one of each) I think I had a CVA and a hypothermia call. Very straight forward they aren't trying to trick you. I believe you are allowed to take notes so do that so you don't get lost and lose track of what you've already done.

OK get more info about the shortness of breath. Progression? cough? Sputum? Severity? Any recent changes in diet or medications? Does the pain in her right leg feel different (location, quality) than usual or is it just worse? How swollen does each leg look and compare that to normal? Also is one bigger than the other? "synthroid" Does she have hypothyroidism? Did it start after the radiation or before? How do heart tones sound (lol magical question there coming from me)... Any history of "fluid around her heart" ? I'm going to guess she is suffering a complication from secondary hypothyroidism since her pituitary is not working right. She has the following symptoms of hypothyroidism: Poor muscle tone Fatigue Muscle cramps and joint pain Arthritis Weight gain and water retention. Any chance she has a goiter or issues with feeling cold? Complications that I found that result in the severe symptoms she is having (chest pain, shortness of breath, cardiac output) Pericardial effusions (I had to look this up during my internship, it's due to myxedema or leathery tissue) Anemia (HR speeds up to compensate now she's having an MI) Even if I'm right I can't completely rule out a PE

I know it wasn't on your list but you should consider Santa Rosa JC up in Sonoma county. Click here for their site It's the school I went to and during my internship I felt better prepared than NCTI students which there are a ton of in this area (NCTI has several courses a year). Foothill and city college get some respect too. Anyway SRJC is $2,000 and about 10-12 months long. They have excellent clinical and internship relationships. They require anatomy and a ECG course as pre-reqs (besides the obvious stuff). As you can see from the photos with the uniforms and such they are serious about what they do and I really feel lucky to have attended the program. You should consider moving there and finding a volunteer department since you appear to be going for a fire job.

Thank you. I was also wondering if anyone thought the NPA and/or lubricant jelly would mess with the absorption of the IN med.

I'll put in my try, I'm also a new medic. I will make my answer true to what I would be likely to do even though it may not seem perfect or the right answer because I'm new. This guy is presenting with respiratory distress. As he presents I would get his chief complaint (dyspnea) listen to his lungs (wheezing) and then ask PASTMED (progression, associated cp, sputum, talking words per sentance,medications, exertion, diagnosis?). He would give the above answers which to me these answers stick out: I don't see a doctor (possible untreated HTN or COPD) It started while I was asleep (cardiac?) I'm not diagnosed with anything (thanks for nothing) It's hard to breath and I don't have chest pain or sputum Using the equipment in my county I would turn on the monitor, attach the Sp02 (88%). Setup an Albuterol (5mg) Atrovent (0.5mg) treatment and place him on a nasal cannula with capnography. (I would look for a shark fin wave form although I imagine you do not have access to that info in this scenario. Shark fin = probable for bronchospasm http://emscapnography.blogspot.com ). Then I would get a BP (210/90 hmmmmm....) while placing the ECG leads on and get an IV (maybe check blood sugar off the IV) I would then move to transport and re-assess and go in depth with questioning. Recent illness? SAMPLE Order of events should be clarified Hx of heart problems? Lung problems? (smoker) Diabetes? HTN ? (I tend to go over those with patients here becaus emost have 1-4 of them! often untreated) When did you last smoke? My treatment plan is to see how the patient progresses both based on whatever is actually going wrong and if my interventions work or don't work. This is the progression as needed: 02 Neb CPAP with neb (we have those) No epi due to BP, age and probable Hx of HTN if CP develops treat with ASA and Nitro I would do a physical exam on his chest initially (accessory muscles) and do a detailed physical as time allows mixed in with my other actions. So my diagnosis would be respiratory distress secondary to smoking unless something else develops during the call (rhales, CP, EKG changes). By the way is there any other abnormalities on the EKG? like LVH?

Why has she been sitting in the chair for 2 days? What came first the chest pain or headache? Do a physical exam of her chest and legs. Do her legs have tenderness that suggest a DVT? Did the chest pain change in any other way besides severity? (quality, radiation, constant?) Does it look like a stroke AT ALL? Grips equal? Face equal? arm drift? Speech ok? She denies shortness of breath? Without being an MD and without access to better information provided by in hospital tests I can't see a reason not to treat for the chest pain. Also assuming nothing pertinent came from the above assessments. So: 02 NRB (assuming she looks like an 8/10) ASA 342mg Monitor + EKG BP (140/90) Organize and review PT meds IV access + Nitro SL 0.4mg Transport Blood sugar check Repeat assessments Continue 02 and Nitro, consider morphine.

fire_911medic since you said you use NPA's often how to you manage the airway when you are using versed IN? Do you drop the NPA after giving the versed?