firemedic37

The NREMT issues its own patches however I have never seen a uniform that uses them, most places use the state patch (if one exists) on one sleeve and the company patch and/or American flag on the other one.

We used to have national patches back in the day but have not had them for over a decade now since the new uniforms came out, I would love to return to a national qualification patch like the Police and Fire Service have now that there are standardised qualification titles once again.

When we had our uniform shirts we had the National Patch on the left shoulder unless you were an Iowa EMT-P then you had the State Paramedic Patch (Iowa EMT-P was the NREMT-I/99, Iowa EMT-I was the NREMT-I/85). Then we had our service patch on the other shoulder. Now we have plain polo shirts with name tags with our level on the. Guess the cost of the shirts were getting to be too much so we switched to polos to save money.

I kind of miss our uniform shirts since it did have the patches on them. Most of the services around here don't require you to maintain your NREMT so most people just dropped it. Our service still requires you to maintain it.

We don't carry either one on our trucks but they are readily available in our ER. Depending on the doctor working and the patient we will use one or the other when there are signs of herniation.

I have personally taken a few patients with the hypertonic solutions, really no neurological change in the time I had them. I have given Mannitol once in the ER and then they flew the patient out so I again didn't see any neurological changes.

I know that the University of Iowa Hospitals and Clinics prefer Mannitol over hypertonic fluids, they have said that they have seen improvements in patients when they were given Mannitol on scene of traumatic accidents with signs of herniation. I have not seen any studies published by them yet. The only ones I know that actually carry it pre-hospital is their own helicopter, haven't seen or heard about any others actually carrying it yet.

This is interesting . . .

The University of Iowa EMSLRC Critical Care Course recommends 2 years experience in "EMS". This can be interrupted many ways, I think it should say at the "NREMT-P Level" (Iowa now has three Paramedic Levels: EMT-Paramedic, Paramedic Specialist and the new PARAMEDIC).

Our medical director requires 3 years at the Paramedic level prior to recommending you for the course. You have to have letters of recommendation from your Service Director and Medical Director in order to attend the course.

Like mentioned above the course adds to your knowledge already, it won't make you a Paramedic.

EDITED TO ADD THE FOLLOWING:

In Iowa the Critical Care Paramedic is an endorsement with an expanded Scope of Practice. You have to be a Paramedic Specialist or PARAMEDIC (New Standards) to attend the course.

Relax and enjoy your break from all of your hard work from passing.

It seems that for me at least Phenergan is strictly dispensed by the Pharmacy and has to have a written physician order and has to be mixed in 50 ml of NS minimum and given over 30 mins. I believe this is a hospital policy since they had a lawsuit due to an infiltration. So needless to say they took it off of the truck and gave us Zofran. BTW we give a lot more Zofran than we ever gave of Phenergan, guess our staff didn't like the side effects of Phenergan.

We don't hardly ever give it anymore unless Zofran doesn't work or pt has an allergy to it. Haven't given Benadryl for N/V yet never really thought about it.

I have to agree that the iPad is a great device. I got one when they first came out and I still use it daily, well when my wife lets me have it. We used to have two windows laptops and a windows desktop and since getting the iPad we replaced them all with a MacBook Pro and have never looked back.

The battery life is insane, we charge it about every three or four days and we actually use it a lot. We always leave it on so it boots faster and we are just seconds away from reading/sending emails, looking at the news and browsing the web. I wouldn't say we surf for hours a day but we do use it daily.

If we can't do a certain task on the iPad then we use our MacBook Pro. I used to think Macs were not that great until I started using the iPad and seeing how easy it was to use, their computers are just as easy and work a lot faster. All I need now is an iPhone, however my cellular provider doesn't have it available and probably will never have it.

If you have an Electronics Store close I would just go in there and start looking at them and seeing what you like and don't like. Personally I like Best Buy the best since you can test out both Macs and PCs. I warn you that you might convert during a single trip there.

Good luck and let us know what you decide.

Etomidate and a long lasting paralytic? That is all?

What about Succ?

What if you miss the tube and cannot ventilate?

Painful like having a steel blade inserted into your vallecula, or directly onto your delicate epiglottis, applying 8lbs+ of pressure, then placing a rigid tube in your airway and "choking" you from the inside with a air filled cuff?

Cite?

You mean there are times when it is not necessary to keep them safe?

That is the poorest excuse not to paralyze a intubated patient I have ever heard. That is as bad as not treating abd pain so the Dr can assess.

Just how exactly do you check the neuro status on a patient sedated to the point of intubation and manual ventilation?

Are they just assessing reflex's? Isn't that something you can report?

Do you have to restrain these "neurologically intact" intubated patients?

Etomidate and Vecuronium are used since that is what our Medical Director has selected for us to use. No Succs in the field but we do have access to it in the hospital (we are hospital based). If we cannot get the tube and truly cannot ventilate (which has never happened to me) it should be very easy to ventilate a sedated and paralyzed patient I do it all the time. If you are worried about the patient aspirating then place a NG or OG tube and turn on the suction, not guaranteed to work but better than nothing. And in the event if the patient is aspirating we carry quick trachs and surgical airways to get an airway.

Proper sedation will take care of the gag reflex. Intubation should not be traumatic, if it is then you are doing it wrong. If you are creating pain with the cuff then you are over inflating the ballon. Remember it should seal the trachea not stretch it.

By all means my patients are always kept safe. Sometimes you cannot adequately sedate a patient so a paralytic is needed in order to ensure that they do not pull the tube/IVs out or come up off of the cot. There are usually very few patients that you can not adequately sedate with Versed/Propofol. Here is my question to you, how many patients in the ICU are given paralytics regularly during their hospital stay? Not very many, they are commonly placed on versed or propofol infusions. These patient are able to open their eyes and watch TV and interact with staff and family. Thus they are neurological intact patients that need ventilatory support.

You sedate a patient to the point where they are not fighting the ventilator, of course you set the ventilator where the patient can trigger it when they breath on their own so they feel that they can breath on their own and are not waiting for a breath.

You can report that a patient was neurologically intact prior to RSI, but guess what they want to see it for themselves. You must not routinely transport patients that require ventilatory support. I routinely am required to transport these patients to Level I Trauma Centers and Cardiovascular Centers for further care. They are not happy when you deliver a patient that they cannot assess thus taking up valuable time before they start their interventions.

When you RSI a patient we are required to place them into soft restraints. This is not to restrain them, every patient reacts differently to drugs, so you never really know how long your sedation is going to last. So you place them into soft restraints so that they do not pull on the tube or IVs. It is the same thing that they do in the hospital.

If EMS continues to over RSI our patients or mismanage them once we do they are going to take it away from us. RSI can save loves but unfortunately it also can have detrimental effect on the patient if done incorrectly.

By the way we do provide pain management to abdominal pain patients. Thats different then trying to access their neurological status. Their pain will come back, nowadays as long as you can describe their pain and location it is fine since they will always have an abdominal CT done to diagnose the patient.

Hope this helps.

If they are properly sedated there is no need for paralytics or heavy doses of pain meds. There is more than just simple reflexes that you can assess on a neuro exam when people are not paralyzed. Granted you will probably not need them in the field but in the ER and ICU they are helpful. Things such as corneal reflexes, ability to breathe on their own, cold calorics can help us to decide if they are salvageable or should be put on a terminal wean.

I agree that Vec isn't the best but some medical directors are not comfortable with Sux, so that is out of FM37's hands.

I knew there would be people that disagree with what I said, I felt that you answered it very well, thanks.

Removed duplicate quote.

I have to chime in on this one. We have a great RSI protocol in my opinion, we use Etomidate then Vecuronim and continue sedation with Versed or Valium depending on provider preference. We have the option to give Fentanyl for pain if it is a traumatic or painful injury, usually if it is a medical patient there is little need for pain management. As several have already stated I would not use Etomidate for continued sedation.

Most importantly watch the patient and that will tell you if you need to provide more sedation or pain management for them. We rarely keep them paralyzed due to the fact the receiving hospitals don't want them to be since they can't check neurological status on arrival, however there are times when it is necessary to keep them safe.

As far as reversal agents, Narcan is safe to give however I caution the use of Romazicon. Even though we carry it, it is strictly a Medical Control ONLY medication due to the risks associated with it.

Hope this helps.

The transition course are not that difficult. They are going to be implemented into your 24 and 48 hour refreshers. Instead of the old standard refreshers we all have had to set through numerous times this will be a title different. They may bring you some new skills or medications but mostly for me at least very little is going to change. It will be easy for EMT-Basics and Paramedics. But the EMT-Intermediates out there, now its going to be more work and more testing for them.

I would think that the ablation was not done correctly, it's still causing an abnormal arrhythmia. An ablation is 90% effective, your son might be in the 10%. The good news is that there is still more that they can do. Some times WPW syndrome has multiple electrical pathways and ablation might not get them all. Surgery might be the next thing, this is close to 100% effective.

The 12-lead is probably showing ST segment elevation de to the ablation, it is difficult to know how the electrical impulses are traveling and may not be following the correct pathway thus causing the ST elevation. I would definitely insist on electrophysiologic testing. This will tell you if your son has multiple pathways or not.

It is best to take it easy and see what is causing this problem before it does become a bigger problem.

It is interesting that you gave a 650 mL bolus to a pt with stable vitals, yes it could cause the HR to increase some or cause CHF because the heart is failing to pump effectively due to the slow rate. The rhythm? I can't tell due to the "artifact" and that it is a very large file size.

What would I have done? I would of done a complete medical assessment to include BGL and stroke test due to chief complaint. EKG, 12-lead, IV of NS at TKO since the B/P was stable and pacer pads just in case. Even if this was a complete block with "artifact" then the pt could of been a candidate for Atropine, I know, I know we don't give it to complete heart blocks unless medical control orders it, and in my system they usually do. Sometimes it works but mostly not.

I understand that the pt was confused and not acting right and that is a serious sign/symptom and should be evaluated and treated as such. Even if it was caused by the bradycardia would not pacing be the better answer since the pt was compromised? I really would like to know what the BGL was and if the pt was on any blockers or anything that could of caused this abnormal bradycardia rhythm.

I had a pt once that had a BGL that was extremely low and it was causing V-Fib and his defibrillator kept shocking him until we gave him D50 and then the pt became alert and orientated times four complaining of severe chest pain. An electrolyte imbalance could of caused this to of happened.

Having an IV in a "fold" (for lack of a better term, hey, I just got up) can interfere with the flow of fluids sometimes due to the position some pt.'s must be placed.

This in fact is a huge problem during transport, most trauma pt's just don't lay still and not move their arms when they are in pain or having problems breathing. I rarely start them in the AC, they are a pain. They stop flowing when they bend their arm and if you have them on an IV pump then it beeps at you the entire time.

Think about the majority of the life threatening trauma pt's that we have, they mostly are younger people experimenting with something. They are some of the easiest pt's to start an IV on and you can very easily establish a 16/18 G in the hand or inner forearm. I start most of my IV's inner forearm, pt's tend to pick at them less too.

The only reason that they may of started new lines were to ensure that they did not become clamped off during surgery since they needed infusions and fluids to maintain life.

but never tried that trick with the i.v.'s.

This was developed out of necessity; I regularly take transfers with four or more infusion going plus a NS or two at TKO. We have two IV pulls on our Stryker cot. However the IV hooks are small, we had to bend them at first to fit multiple IV's on however we still needed more room to hang more, with two pulls and two carabiners I can take a total of 8 infusions easily and more if need be. Now IV pumps are a different story especially with a ventilator on the cot. So we go these new B Braun Space Infusion Pump (http://www.bbraunusa.com/images/bbraun_usa/space_hand.jpg). These are really nice. Sorry to get off topic.

I have seen two Hemothoraxs in my career of five years, they were both in the hospital setting and one was a car vs. pedestrian and the other was a gunshot. Neither lived, both had their chest opened in the ED.

Pneumothoraxs on the other hand are much more common at least for me, I had one while I was doing ride time and the lead paramedic refused to decompress it since he has never done or seen one in his 25 years of being a paramedic, but don't worry the flight crew didn't do it either. They let the ED doc put a chest tube in. I have had three in the field all successfully decompressed before getting to the hospital, two developed (or at least discovered) en route and the other was found on initial assessment.

This one is not one of great valor but it was a good call since it made the pt happy.

We were called for a child fallen, I responded with the Fire Department on the Rescue Truck. We got on scene and found a 5 y/o boy that was complaining of his cat stuck in the tree and when he tried to climb the tree he fell. Pt had no complaints and was checked out and his only complaint was to that "Thomas" was stuck in the tree. We had our engine respond and use the ladder to get "Thomas" down without any further injuries or falls. That truly did make the pt happy, it even made the newspaper. The pt's family was speechless that we actually did get the cat down. Only if dispatch knew what was going on in the first place.

I would have to add the following things:

A good stethoscope, not many employers provide you with a good stethoscope.

Tarascon Pocket Pharmacopoeia, a quick and very effective guide to medications, provides doses and what that dose is used for.

Hemostat, unlikely you will see an arterial bleed and yet well enough to clamp it. I use it to clip blankets together when its windy, open bottles of Nitro or when I need to hold something tightly. You never know when you will need one.

Carabiner, I clip a couple to my belt to use when I take multiple IV infusion. I hang the bags together so it is easier to transfer all the IV's.

And that's about all I carry besides some gloves, pocket knife, flashlight, trauma shears and my cell phone. I don't feel weighted down and have never needed anything else when working 911 and transfers. Hope this helps.

I work for a company that does Critical Care Transfers. We are staffed with one Critical Care Paramedic in the back and one EMT-B to drive. On occasion we have had to have another person in the back, usually a Paramedic. We don't take a nurse, respiratory therapist or physician. We have our own protocols for ventilator settings, medications, RSI, surgical airways and everything else related to critical care transfers. And of course when all else fails we have on-line medical control. We do everything a flight crew can but in the back of a ambulance.

In our state a RN working in the pre-hospital setting operates at the EMS level the Medical Director approves usually a REMT-I or REMT-P level.

Our polo uniform is embroidered with our company name and logo, our button up uniform have our company patch and our EMS Level Patch (National Level except for NREMT-I/99 we have a State Paramedic Patch) sown to the shoulders. Then we are required to wear our badge with our photo, first/nickname and EMS level credentials. Our last names are not allowed on our badges.

If you are using this for a Paramedic Course they have a very nice Skills Tracker and Clinical/Shift Scheduler. It allows you the instructor to view in live time the progress of your students, both skills and hours completed. It allows the students to see the progress of fellow classmates to see where they stand in their class.

It is also recommended for people that want to challenge the NREMT exam for re-certification since it will test your knowledge and let you know what you forgot since leaving the class room.

It makes everything easier, the students even like it since PCR are now almost all electronic. It really prepares them for the real world.

First off congrats on passing!

Yes you will need a certification or licensing for the State of New York, here is the Reciprocity Process: http://www.health.ny.gov/nysdoh/ems/pdf/reciprocity_packet.pdf

Here is more information about them: http://www.nycremsco.org/

Hope this helps! Also it would be nice to have knowledge of the streets and how their system works, but I don't see that as a requirement for employment. I am sure that will have a street and road map test for you to complete after working for awhile. Good luck!

I have not, the website looks a little dated in design. Are you looking for a Study Guide or practice exams? If you are looking for practice exams I highly recommend FISDAP. (https://www.fisdap.net/) It is very similar to the NREMT-P testing and tells you what you need to study after you test. It is not an easy test and you will most certainly have to take your time and think.

The biggest difference between it and other tests that I have seen is that it breaks it down into what you need to study and what you are already knowledgeable in. It is very detailed on what you need to study in order to have you pass your National test.

Do not be surprised if you do not pass it the first time, in my Paramedic Course only three of the students passed the first time and their were 22 students. After the others studied what it told them to, they passed the second time without any difficulty. It prepares you for the National Registry without a doubt in my mine. We now require our Paramedic students to pass this test as their final for the Paramedic Course. After implementing this our first time pass rate for the National Registry as increased significantly! We went from only one or two to passing on first attempt to six or seven. Its well worth the money, for the Practice Tests and the Study Guide is only $50.

Hope this helps!

My Fire Department had two Chaplains, one was very active and went on calls and the other one I have never met. The one that was active has left due to moving away to service a congregation elsewhere.

We really never knew what to expect from one, until we had the young chaplain that wanted to be active and was given membership on our department as well as our lead chaplain. It was extremely helpful to have him on calls where there was a death, it made it much easier on the family and you could tell that peace was with them. Other times it was nice to have one to talk to someone that had just lost everything they had, again you could see the peace that the individuals got. We have tried to recruit another chaplain to be as active as our last one, however not many want to. We expect our chaplains now to be an active member and get to know everyone and understand our aspect of the job. It makes it much easier for any member to approach them and talk to them about life and spiritual issues.

I am an individual that is very spiritual, I once was a minister myself however I was called away to my to my new "calling". I help out on calls and talk with other members and families when problems arise, however it was nice to be able to go to church and see a man that you knew give a good sermon.

Be sure to invite all of the departments members to your congregation and any events that you are hosting, this makes them more likely to attend your services.

Why buy two $200,000 ambulances when brand new, serviceable trucks are available for half that?

Medium duty trucks are overkill in all but a very cases.

Clarify they are not medium duty rigs, they are the Chevy Express 4500 and they are $190,000 for two rigs.

Last month was an expensive month for repairs we average around $1,000 a month.

These rigs are your "basic" rigs when it comes to safety standards, there is really nothing that we can cut out that would decrease the cost yet keep the safety aspect there. These rigs were designed for safety and functionality for our tasks, they may not make the ideal 911 rig but will definitely be safer than 99% of the rigs on the road. The biggest thing we did was remove the famous "CPR" seat due to numerous studies showing that it was the most dangerous seat in the back and add five-point harnesses in place of the standard bench seat and captains chair for the airway seat. This did add several thousand but I believe that it is well worth it.

Financing the new rigs will not be a problem, we have the money in a account that is not generating any interest so we are losing a lot more than just the inflation. These rigs will be paid in full before delivery.

When a pt is in cardiac and respiratory arrest it is nice to notice the bleeding but it does not prevent you from starting effective CPR. Sounds like you did a very good job by telling the husband to call 911 and get an AED, this is the step most EMS providers forget when they are not on the job because they are used to being the ones responding. They eventually remember it when they go to hook the AED/cardiac monitor up and they are asked where they got it from.

When we interview prospective employees (in your case students) we have a written, skills and a face-to-face interview. This gives us the prospective employer a good understanding of their weaknesses and strengths. You don't have to score perfectly to get hired (or picked), we look for certain thins in a prospective employee to ensure they will be a good fit. Since we stopped hiring the "smart" ones we have had much less (< 10%) turnover, our one turnover in 5 years was due to a non-work injury. Before if you scored perfectly on both the written and skills you were hired, regardless of your personality. Now we hire people that will fit in with us and if they need a little help improving on their skills or knowledge then we help them out.

Sorry I got off of subject there. Just saying that you shouldn't of had to get a perfect, little mistakes are understandable, after all you want to learn more and become a paramedic. If your heart is in it and they could see that it is then you will most likely get selected.

I would like to see more Paramedic Programs require an interview before being selected for the program. In the Paramedic Program that I help with there are a lot of students taking it because "It's different" and they really have no desire to be in EMS. It seems like this should be a good program if they require an interview for it. Is there a lot of competition to get into this program?

Good luck and keep us posted.