jwraider

I was talking to someone recently (my preceptor) who said they would treat any rhythm over 150+ with adenosine. He was referring to atrial rhythms like Sinus tach, SVT, afib, and aflutter. I was somewhat perplexed because the mechanism of adenosine as I understand it is this: Adenosine slows conduction time through the A-V node, can interrupt the reentry pathways through the A-V node, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia (PSVT), including PSVT associated with Wolff-Parkinson-White Syndrome. Source Which to me means it will have no direct effect on the SA node (sinus tach) or the atrium in general (afib/flutter) and potentially converts rhythms that are "re-entering" the atrium through extra pathways or the AV node. I found a good web site that states "Adenosine is considered first line therapy for the investigation and termination of supraventricular tachycardias because of its efficacy and safety." and also goes onto explain the potential for creating new dysrhythmias with adenosine. Source My definition for PSVT or SVT is a rhythm over 150 bpm that you can't see a P wave that is also regular with a narrow QRS. And SVT is the only rhythm I thought adenosine was for. So I'm wondering if anyone can help me understand this further because my preceptor wants me to research the action of Adenosine further and come back to him. But I'm not finding anything that supports his methods and I don't feel it's a good idea to try and convince him I'm right. He is a great paramedic so either he's just off on this one issue or I don't fully understand the use of this drug clinically. So would you use adenosine on Sinus tach at say 160bpm in a patient who is symptomatic but not ALOC (so not a cardio version candidate) ?

Thanks guys. "I suppose it is possible that some individual school" ...... Not to name names but it begins with an N and ends with an I. I went somewhere else though. I think this was possible several years ago here in CA but isn't now. And when it did happen I don't think it took forging a completing date I think it was on the up and up.

I keep hearing you can take it in CA if you are atleast 250hours into your internship but I can't find anything official that verifys that. Does anyone know if this is true or false and are you able to point me towards the right info? The NREMT site wants the "initial course completion date" which sounds like you have to wait. Thanks!

I'm in a urban enviroment and have been on a similair call recently. I'm just going to assume that this patient was uncooperative and EMS could not work with him initially. If they could have most of that could have been avoided. Looks like both the officer and the EMT weren't really taking command of the situation and got caught off guard. They should have managed him where they found him and let the transporting ambulance come to the patient and take over. This guy cannot refuse treatment he should have been assessed in one spot and if he tried to leave the cop should have stopped him. He would have been placed on a 5150 here and possibly handcuffed by police then transferred to a gurney with restraints (with a backboard already placed if for some reason this all happened after the face plant). He's obviously a danger to himself and needs to be fully assessed.

Just drive through. It's something I ran into here and there doing long distance transports. I'd get to the toll plaza and just go through because it's not like I was about to shell out my own $$. The software/picture system looks up the license plate and either sends a "ticket" or they apply the charge to the appropriate account.

She's 26 and there is a 12 year old in the car? Do we need to contact parents ? (assuming these aren't all her kids). Any chance the left breast pain is from a broken implant? I'll let firedoc ask her that question for me =) BP the same in both arms? Any medical Hx of note? Does pushing on the abdomen make her back pain worse? She would get a code2 trauma activation in my system.

awesome thanks Doczilla that clears up epinephrine. All the other discrepencies I found can be answered by following the tape but stopping at the max listed in the protocol. Thanks again.

I have some conflicting dosage requirements in my protocols and I'm wondering what you guys would do if faced with a similair problem. It's fairly likely the protocol is just not clear so if that's the case please let me know! For example: Pediatric Bradycardia The protocol states to use the Broselow tape for medications that are underlined. Epinephrine is listed as 0.01mg/kg 1:10,000 q3-5 no max and underlined. On the Broselow tape for a 33KG child the dose would be 0.33mg. Now look at this other page in the protocol book supposedly listing drugs and dosages not covered in on the Broselow tape: Pediatric Dose Chart You'll notice there is a 0.1mg max listed for 1:10,000 Epi.... so how do I not go against one of the protocols? Valium has a similair issue where in the protocol it lists a max of 5mg Pediatric Seizure but the drug is underlined and reffering to the tape shows dosages exceeding 5mg (6.6mg for a 30-36kg kiddo). So do I stop at 5mg or follow the Broselow and give a 6.6 mg dose? Any ideas on what line of thought you would take to approach the contradictions? I'm really not sure where to place more weight. The protocols say to use the tape then don't specify exactly when not to if there is a conflict. My preceptor said he would document all dosages calculated per Broselow tape and go with what the tape says. I'd prefer to do a mix of following the valium max of 5mg but use the tape for epi because a 12 yeard old that ways 50kg probably needs more than 0.1mg. I don't think that's a good idea though it would be hard to defend myself if I didn't commit to one line of thinking. I'd really like to be able to follow protocol as a new medic and student! p.s. here is an example of a protocol with non underlined neds: Prediatric Respiratory Distress (lower) Thanks for reading and sorting through my mess =)

Thanks for all the helpful replies!! I appreciate your thoughts and advice.

I'm in a similair city so I hear you on the scene safety thing =) Thanks for the helpful replies everyone!

Hello... A few nights ago during my internship I succussfully performed my first field intubation. It was a trauma arrest and a fairly messy scene. Multiple GSW victim in PEA with police performing CPR on arrival and alot of blood on the ground. My preceptor had told me that during our first code my only job would be airway. Due to this I had everything setup before everyone else was done packaging the patient. My preceptor said go ahead and after some initial issues with my view (I did not set myself up well just sitting there on the ground behind the supine patient) I got it. Normally you BLS a trauma victim to the ambulance unless you need to treat flail chest or tension pneumo or your BLS airway isn't good enough, correct? Someone on scene suggested next time that I intubate "at the back of the bus" or in othe words bringing the patient to the back like we are going to load them but stand there and intubate right before going in. What do you guys think about doing it at this time? It seems to make sense to me with the only draw back being a slight delay to transport time. It provides a good angle (just like an OR intubation in a sense) and if it doesn't work you can just hop in and go. What I don't like is it makes everyone else stop what they are doing to wait for you and delays transport time. Thanks for your thoughts!

actually thank you spenac for the reminder I have chronic acid reflux and I'm fairly skinny. I have been meaning to try a gluten free diet to see if celiac disease is a possible cause.

Here is a link: How Doctors Think by Jerome Groopman I'm about half way through this book and I'm wondering if anyone else has read it and been able to apply the material to their practice. I know alot of it really pertains to how doctors operate but it does talk about things like a providers own mental and emotional state and how that effects the diagnosis/differential. It also talks about "anchoring" or picking an easy diagnosis without considering what else the problem could be. I think there are some good tidbits in this book if you're looking for something to read.

Sorry if this is a repeat link but I found the article very educational: Capnography for Paramedics Some of the highlights I thought were: -Differentiating between obstructive disease and CHF -Measuring cardiac output during a code and signs of ROSC -Confirming tube placement with accuracy -Monitoring sedated patients LOC -Can show early signs of complications before a patient deteriotes or starts to wheeze for example If anyone knows this stuff well and can tell me if this is possible: A V/Q mismatch is when C02 is obstructed from leaving the lungs such as with a pulmonary embolism so that the monitor shows a low level of C02 but in reality a high level may exist in the blood. I get that as medics we cant go to an ABG but is there anything that can be looked at that proves this and that can help differentiate a PE? The article does mention there will be a low C02 reading with a PE due to both hyperventilation and obstruction but this is the case for several other conditions as well. Thanks! I hope this is helpful for some.

"How long should i be an EMT before i start Paramedic?" As long as it takes you to be comfortable operating in an ambulance, taking vitals and talking to patients. You can do that while starting medic school as well just make sure you do it and you'll have better success in your internship. Everyone is different though good luck!

Hey JW which agency did you ride with? I'm in the East Bay. As far as burnout vs complaining goes you may just have been experiencing EMS crews bitching and gossiping just for the sake of bitching and gossiping. Unfortunately that happens alot and you see it even more towards the end of a tour or long shift as people get tired. I think people start to burnout when they are doing the job but really don't want to be there. You see patient care suffer and it's immediately obvious with the "drunks" and regulars you'll see someone treat them very poorly because they don't enjoy their job anymore (or never did). Personally I take the job and role as an opporuntiy to provide service work to the community and it's a bonus that I can be paid and make a career of it. I don't agree with the "if you are doing just this to be a FF don't do it". I believe that what you need to do is be 110% into being a paramedic while you are being a paramedic no matter what. Even if you only do it for 3 years thats great. Unfortunately there are people out there who are just doing their time to become a FF and they end up being the ones providing poor care and bitching about their job. In order to succeed you must always be trying to be your best and I think that can be hard for people with short timer syndrome. You really need to like the job because school is tough and yes you could end up a career medic in a FD (I met a captain who was pushing d50 and explaining he had been a medic for 20+ years now the other day). Oh and more importantly because your patients deserve the best care possible. You don't want to be sitting in the back with someone wondering why you didn't focus more on your skills and if that could be reversing their sickness. Feel free to PM me if you need info on paramedic school or agencys in the area good luck.

As far as the skills portion goes you need to be able to run the assessment in order, efficiently and correctly. Don't worry about what the scenarios will be you apply the same approach to all of them with minor variables. But the point is they are testing you can run the assessment not to trick you so just focus on the assessment. (did I mention the assessment ?? hehe)

Unitek can be good if the right person goes through at the right time. One good thing is you stay in the hotel and focus 100% on the course (something like learning a foriegn language through immersion). But the material comes too fast though if you're not already familair with it (I know you are). You can't fall behind! They do lecture with frequent tests and quizzes from 8am to around 4pm. After dinner everyone divides up into groups and goes through skill stations. If I were you I'd look into other options because of the price of the course. Do you really need to be an EMT within 2 weeks? You might find other better optios (retaking the test) or better programs that take extra time to focus on weak points. Good luck!!

Thanks I agree. Dilution seems a good way to work around the possible head bleed.

Just curious how you got him on the board and fully cspined with two people. Thanks interested in case I'm in that situation someday.

Windshield was starred and a head injury was very possible. Would anyone withold the dextrose until a ctscan was performed?

Did they give you anything more specific than "IV setup"? You may be able to go into the process of starting the IV and how to have things ready to hand the medic. Know when they'll want the tape... the catheter etc. Good luck I'm sure they'll like you!

I think The only reason it would be controversial is if it's just given without suspecting or proving hypoglycemia. Maybe someone with a bit more experience can help me out but didn't we use to push bicarb in every arrest?

I'm another student so take this with a grain of salt. Refractory cardiac arrest I'm assuming means a code where ACLS drugs / interventions have not worked. So then going to d50 is considered "possibly" useful and controversial according to the card.

Feel free to call me on anything I don't want to be out there making stupid mistakes but yes I can sit down and calculate drip rates and concentrations etc. I was worried about running the actual call and being faced with a very sick kid and wanted to make sure my shortcuts weren't changing the dosage. My previous post was about recognizing that the protocol was calling for more dilution not less dextrose as the PT gets younger. Thanks again