jwraider

Thanks guys. The hypoglycemic protocol calls for 3cc/kg of d10 for the neonate so you're right it won't be very much volume! The protocol actually has: 1cc/kg d50 for > 2y/o 2cc/kg d25 for < 2 y/o 3cc/kg d10 for neonates Isn't that basically the same amount of sugar just diluted 2 as 3 times respectively? Could I then just draw up some d50 and then either double or triple the volume with NS and have my correct concentration? Thanks agin!

Hi guys... hitting you with more exciting questions.... My protocols have 3 concentrations of dextrose for adults (d50), ped's(d25) and neonates (d10). My drug sheet states to make d25 just eject half the d50 ampule and refill it with NS (pretty obvious one). I want to be able to do d10 on the fly as well so just to check my math: Eject 80% of the d50 ampule and refill it which makes 50cc of 10% solution correct? Thanks for your time =)

Thanks guys. I think I have enough info to go on and make my own decision and build on it. I'm sure with experience I will be able to read the patient and incorporate treatments earlier and at the right time but for now I will do a full assessment first.

Thanks guys. Seems like the method around here is Nitro before IV but the IV is coming quickly after. I'll keep what you said in mind though when I'm on my own. I did some research thanks for pointing out the difference between anti-platelets and anti-coagulants (one limits platelet activity while the other stops the liver from producing coagulating factors if I have it right?) So just to double check, do you still give ASA if the PT is on some kind of anti-coagulant (coumadin) or anti-platelet (ASA, plavix) or something like heparin or Refludan? (they block thrombin)

My drug sheet lists other anti-coagulants as a "relative" contraindication for ASA. I'm wondering how you run a chest pain call and make the decision to give aspirin because the decision is made during a rapid sequence of events. My ideal method for a chest pain is as follows: Initial assessment + (place PT on 02) OPQRST while monitor goes on and EMT grabs a BP Complete a 12 lead while asking SAMPLE and giving ASA 324mg PO Admin Nitro and move to the ambulance... (In the ambulance IV, then possibly Morphine while booking to the cath lab) So if the PT has taken ASA already do you not give ASA yourself and assume the PT took it correctly? (I wouldn't) If you're able to determine the PT took say 81mg do you give the rest? (I would) if the PT is on say coumadin do you withold the ASA? (I'm not sure... I believe it also can inhibit some arterial constriction so it still sounds useful) Thanks !

the other night on a ride along an ambulance comes into the bay and they are bagging a concious woman. Apparently the fire engine (they carry the cpap units in that county) didn't have theirs when they showed up on the call. Such a stupid system for cpap. As for albuterol for CHF I think every patient is different. If the patient needs their lungs dilated to breath they should get it (I know thats hard to tell sometimes in this situation). but I think it's a good thing for someone who develops a reaction to the junk in their lungs and starts closing up. Do the CHF treatment first if possible. I've watched a medic who was ruling out COPD excaserbation vs CHF try o2,albulterol,cpap,nitro in that order. The PT lung sounds were very diminished and he was complaining of mild chest pain (BP 160 ish I think) and a history of COPD.

I'd think you see a narrowed pulse pressure if it was tamponade... Does palpation make it worse? (I'm not saying push on the bruise but anything else hurt in the area.. range of motion of arm??) I just see that nothing makes it better... Can we get a SAMPLE? Anything interesting in history or meds taken? Is she at risk for PE? Cardiovascular disease? Maybe the MVA just made something that already existed worse. Are the bruises in the knee from trauma for sure? Just a wild ass guess from if a AAA sent an emboli down... or up to the brain? Does she pass the stroke test? And finally pupils and blood sugar? ... also student question: should she really be fully immobolized if she's "not acting right"? Can you clear cspine by communicating with her especially considering shes been moving around for 2 hours since the accident? I'm not saying I wouldn't do it but I like hearing the thought process behind these decisions.

Thanks for the offer but I've got a family here so hopefully I'll be close by when I find one. My school actually is supposed to find me one... but twice now I've had a precptor agree to take me only to cancel at the last minute due no fault of my own. I've also been putting in work finding one myself.. I had a preceptor say they would take me then never answer my calls argh! Sorry it's a long story I'm just very anxious now that's it's been so long!

Sorry if this post is not appropriate for this forum but if anyone can lend me a hand I would appreciate it. I'm in CA in the bay area looking for a preceptor and need one soon! I'm 3 months out of clinicals after having 3 internships fall through due to preceptors being promoted or other random things that keep them from taking a student. I'm on the AMR list but I didn't go to NCTI so it could be a long wait. I know 3 months doesn't sound overly long to some people but if I get to 4 months my school will try and drop me from the program even though they refer to me as a "strong student". If anyone has suggestions on how to find a preceptor or happens to know or be one in my area I would really appreciate it =)

Hey EMSgeek . I just went through cardiology so in case this helps... Our instructor taught us to approach ecg's with whatever comes natural. Some people for example when they first see a strip see what is wrong with it and figure it out (I do). Others take the same approach to every strip like finding P waves then regularity etc. Either way we are instructed to take a common/methodical approach everytime. For heart blocks in simple terms to decide which type it is I take 3 steps: 1) P waves...(too many? 2) PRI... (too long? varies? constant? grows?) 3) QRS... (size?) For me the kicker is the PRI which tells you what type of block you have. If it grows it's wenkebach or if it varies it should be some kind of 3rd degree block and finally a constant would either be 1st degree or 2nd degree type II. Focusing on the PRI made them easy to remember for me. Hope this helps.

Diltiazem =) Took 3 rounds to get his rate back to normal... We don't have any calcium channel blockers in our protocols here so electrical cardioversion would have been the only option (amiodarone is in some protocols around here for afib but only after electrical cardioversion fails). Thanks for the responses... While watching this patient get his treatment in the ED I just had to wonder how I wold handle him prehosital with a different set of options.

Sorry I couldn't take a copy of the EKG. The complex was a short R wave going down into a W with the left side being bigger than the right. Prior EKG showed NSR with the same BBB in most leads but v3-4 still look different now. The chest xray will show the fluid in the ® base I didn't get a chance to see the labs (sorry for the incomplete case presentation!) I can give all the answers to how this PT ends up but I'm really interested in how you guys would treat him in the field initially. He presents in obvious distress and just looking at him you'd want to do something. I have my own treatment and then what I saw the MD do (totally different damnit!) so thats why I thought this was an interesting case. Do you treat for chest pain? Do you treat for pulmonary edema (or both)? Do you try and convert the rhythm? (adeonisine,amiodarone,cardioversion are available here but this is afib so only.. cardioversion for me to use..) I told my preceptor (if this had been my patient) I would treat with nitro and ASA (the guy wouldn't tolerate a NRB much less cpap although I probably would have given him a harder time over the NRB issue than the MD did) and transport. My dillema was I also wanted to control the rhythm but I didn't want to sedate and cardiovert.

So this is a patient I saw last night in the ED (I'm finishing up medic school clinicals). He's not neccessarily a fascinating case but I'm interested in what your guys treatment would be based on what I saw in the ED. -70 y/o male -AOx4 -Acute onset of chest pain and shortness of breath (pain is 3/10, "kind of like pressure but -just uncomfortable", no relief, no movement "seems to bet getting worse (the symptoms in general)" -Airway patent, RR 34 (shallow due to speed?) with crackles in R base SP02 88% -Radial pulse present but irregular and 150 BPM -BP 150/96 -Skin Pale (and pardon my poor interpreation he was caucasian and just looked musky or dark in the upper body) -EKG: Uncontrolled A-fib with a RBBB no ST elevation or depression although leads V3 and V4 have mostly negative triphasic QRS complexes and the machine suggests "consider anterior infarct" PT seems calm but wont tolerate a NRB. on NC @ 6lpm SP02 92% Hx: No allergies, takes plavix "I've had an irregular heart beat before but this is worse" (Pt was seen in an ED 2 months prior but denies cardioversion, MI and the visit he says was "unconclusive". "I just had some blood work last week I'm waiting to hear back from my MD" -The current symptons came on suddenly while watching TV and his wife drove him in to the ER. -Denies Hx of MI, CHF, HTN, Renal disease Physical: Skin signs and lung sounds above... Pt wants to be sitting up.. MD thought there might be some edema around shins but patient stated they looked normal to him. -No JVD, no pain (other than chest) So would you guys treat for chest pain? pulmonary edema? try and convert the rhythm?

I just took PALS also... The protocols I will use during my internship echo what was taught which is "do not intubate if a BLS airway is adequate" I wish there was more info on why pediatric intubations were discouraged or harmful that would help with understanding when to be aggressive or not. Is it due to provider lack of experience with the procedure? Poor application of the procedure leading to trauma or hypoxia? Or is there a longterm problem?

Yeah that's a bunch more we do have it pretty good in CA. I went into the year thinking I could go without funding I was honestly fortunate to get the help I got... it's just not very much when you consider how intensive a paramedic program is and that most of the time the students aren't fresh high school grads living at home. Hopefully there will be more scholarships and funding for future paramedic students =)

I live in CA. I was given $2,200 + school loans as financial aid to assist me while attending my paramedic program this year (or 1 semester worth of aid). My program is technically 2 semesters (although it will take me 13 months) and I'm gonna go out on a limb and say it was slightly harder than 2 semesters of general education which would have netted twice the amount of aid. They said because It's a continuing program they cannot "pay me twice" everything counts as the fall semester. I'm hoping someday to have an effect on the system to increase the level of education for paramedics along with assistance to get through school because it really is ridiculous right now. It's all about nursing here unfortunately.

*student alert* *student alert* *student alert* Hey guys that was a cool video for me to see. I've performed CPR 3 times in a clinical setting so not much experience with a code. In school we were taught to continue CPR immediately after a shock without looking at the monitor (or patient I guess) per AHA guidelines. Watching this video the first shock obviously had an effect.. With the patient acting like this one was would you have immediately resumed CPR? And if so during that cycle you intubate (+ an IV) how do you think that would have played out? I think I know the answer (yes keep going) but after seeing that video it raised the question again. How about administering epi or amiodarone (bolus) after a 2nd or 3rd shock where the patient has converted you just don't know because of CPR and no monitor/pulse check. Just wondering what your experience is on it versus what the book says. I get the need to continue compressions because the heart still may not be up to the task but it seems so weird to be pushing on a chest with a beating heart! Looked like he just needed more 02.. If he had earlier CPR and high flow 02 in that BVM with an OPA I wonder how that would have changed things. Thank you

Hello, I'm preparing for my internship and I'm not able to ask my preceptor for help on this yet. I'm trying to show up with protocols memorized and understood. Hopefully you can help! Sorry I cannot link to the specific protocols but here is the main page with each listed: http://www.acgov.org/ems/ems_field_manual.htm The two protocols are 'chest pain' and 'shock' ..... Our county protocol for chest pain is pretty standard... monitor.. 02... ASA.. NTG and Morphine. It eventually specifies if there is no STEMI then go to "Cardiogenic shock protocol or other dysrhythmia" It also has a sidebar that states if the "BP drops below 90 or HR below 50 or above 100 to contact the base MD before continuing MS and NTG." So the confusing part for me is the Cardiogenic shock protocol defined as: "Ischemic chest pain with signs and symptoms of shock" (further defined as 2 of the following: Pulse >120 , ALOC, BP < 90 , Pale cool and or diaphoretic skin signs) Treatment being a fluid bolus and then dopamine (@2-20mcg/kg/min) if needed (if no dysrhythmia present). Won't that usually fall under the chest pain guidelines to contact the MD???? I'm sure I'm missing something... ! ..... It's almost like you are given options to treat a right sided MI (only if it isn't showing as a STEMI!) but the protocols are handcuffing themselves. Can anyone help me understand the thinking behind this protocol and what they want me to do?

I don't think I saw this mentioned but one option is to take a SAMPLE Hx... That way if the patients LOC drops by the time EMS crews arrive you can give them information they wouldn't be able top get.

Our protocols have TCP first but say "consider atropine while waiting for TCP". I'm still a student so forgive me but wouldn't setting up pacing be faster than starting an IV and drawing up the med etc? Here in Alameda county, CA it's 0.5mg repeatable to max 3mg (no different 2nd dose but I have seen that in a different county).

What about the HPI (history of present illness) When did it start? If the MD thinks it was PNA there is probably more of a story behind this guy than he suddenly couldn't breath. I'm not sure what you're looking for feedback on how did you feel about your assessment? What questions did you ask to find out what was going on? Thanks for the case presentation!

Dustdevil thanks for bringing this back on topic and thanks to those of you who gave me tips I appreciate it! Any advice though on how I shold handle myself? Seems like you're saying to rely on what I learned in school but is there any common rookie mistakes I can avoid? One tip I've been given is that I shouldn't always match the deamenor and energy level of the experienced people around me. For example they will be able to look calm and cool even when the situation is critical (due to their experience). I was told to always be on my toes and work fast without going overboard.

I have a few questions because it's what I'm doing (somewhat). I became an EMT in Jan of last year (Jan 2007). I then worked full time for a very busy (1 call per hour avg) interfacility company until school started last August (2007).I completed a 100 hour "911 experience" internship during medic didactic/clinicals on a 911 ambulance where I performed BLS skills and discussed calls and patients from a medic standpoint with my preceptor. I'm about to begin my internship and I'm wondering what pitfalls or problems I am prone to making due to my lack of 911 experience? I know this is can be specific to the individual just wondering if there are common mistakes. Things that scare me are.. I've never actually seen someone having a seizure... I've done several intubations but never actually placed an OPA (done in the OR during clinicals)... I haven't been on any calls with extrication assignments (which I'm guessing change the flow of a call)... My school director feels my strengths will be my age (29), common sense, communication ability. Thank you!

Thanks guys =) Lot's of helpful info and it's good to hear people have good experiences with multiple preceptors. My internship is expected to last 500 hours but can be extended to 700 ( they really don't like to do that). I'm mostly worried about getting mixed messages or having one fo the preceptors be not as good (in whatever way) as the other.

Anyone have experience/opinions with having 2 preceptors for a paramedic internship? I'm potentially doing my internship with a FD that is very dedicated to EMS (transports, long history of providing service). The fire medics rotate tours on the engine and the ambulance resulting me having 2 preceptors. Interested in anyone who's had experience and any advice about what it would be like.