scope2776

Somebody probably just made it up 100 years ago, and it was just grandfathered into all the textbooks and now it's regarded as LAW! Unfortunately, it probably requires a triple-blinded study to remove the myth b/c it's the "standard of care". Left lateral recumbent / right lateral recumbent doesn't matter! evaluate your pt's airway and determine the appropriate way to clear their airway. Typically in semi-conscious patients who will react to deep suction it will be on their side; on unresponsive pt's i will typically be able to clear the pt's airway w/ suction while i attempt to control it. Unfortunately, medicine has been boiled down into rigid algorithms in an attempt to teach the masses... it's easy to say and teach: "put all pt's on their L side who are vomiting" but hard to teach: "throughly evaluate your pt's airway and maintain it".

i lol'd

Well said, well said. Yeah that totally makes sense. I wholeheartedly agree. There certainly are substandard ambulance companies. And what our profession needs is less fragmentation. I just get so fired up when I read articles or hear news about a fire department taking over a successful or excellent ambulance organization and turning it into a mess. I just wish there was some way to counter all the propaganda coming from the IAFF and other organizations about fire based EMS.

How about "Advocates for Ambulance based EMS"? It could also be centered around improving professionalism and business development of ambulance based EMS services. Do you think there would be a lot of support for this kinda thing?

After a search of both the forums and the internet at large I was unable to find an advocacy group for keeping fire out of EMS. The topic of fire based EMS and its merits has been disscussed ad nausem on this forum. It is my belief fire based EMS is a method of delivering EMS care, but not the best or most efficient. And without dirverting into another flame war I was wondering if anyone is aware or knows of an advocay group or political action group that advocates for keeping fire out of EMS? The problem with NAEMT and associated organizations is that they won't take a stand against their fire department members because they comprise a large percentage of their membership (officers included) and the NAEMT depends on members for revenue. The fire departments have the "Fire Service-Based EMS Advocates" organization. This organization is frequently spreading false truths about EMS delivery models. Are there any candidates within the NAEMT or other organizations opposed to fire based EMS? I envision an organization that fights potential take-overs of EMS by political action.... any thoughts?

That's really cool. It would do wonders for your skill competency. Just imagine making runs on all the cadavers at night with a laryngoscope!

Always leave your ambulance running. Turn the heat on in the back before you get out to attend to the pt. Don't set your bags down in the snow, it will melt and cause the bottom of your bags to get soggy. Leave the cot in the ambulance until you are ready to use it or you see that you can take it inside, otherwise it gets icy cold and snowy. Getting IVs and clean 12 leads are hard if your pt is shivering. Steal loads of blankets from the hospital and hoard them. Wear your stethoscope on the inside of your jacket.

Today I had a typical call to the nursing home for a fall. Pt fell onto their R hip. My pt has 10/10 pn shooting down their leg from the R hip, external rotation and tenderness to palp over the hip/proximal femur and inability to make gross movement of the R leg, including lifting the R leg off the ground. The pt had fractured the R hip before, requiring surgery. My pt's pelvis is stable. This was a typical hip fracture based on my exam and confirmed with radiological exam upon arrival in the ER. My question is: would you apply a pelvic wrap or commercial pelvic girdle/splint to this patient? Particularity the SAM pelvic sling? It was my impression that pelvic splinting is for pelvic instability and may actually harm a broken or dislocated hip. I cannot find any literature or contraindications to pelvic splinting with a through search on Google. I ask because the FD was about to put this device on my pt before I said something, and, needless to say I was more concerned with pain management. FD was not mistaken about the hip either, they knew it was a hip issue and were going to apply the device anyway. So I thought maybe I was missing something....

We use the ResQPOD in our commercial urban system, if I remember correctly from the lecture I received on it the ResQPOD is the only class IIa CPR adjunct proven to improve survival rates... I haven't had a problem with them. If fact they are kinda handy, they have a red LED that flashes so whomever is bagging can bag when the light flashes and it reduces hyperventilation. From the ResQPOD® Impedance Threshold Device website: http://www.advancedcirculatory.com/resqpod...ct_overview.htm The ResQPOD is an impedance threshold device (ITD) that provides Perfusion on Demand (POD) by regulating pressures in the thorax during states of hypotension. Animal and clinical studies* have shown that during CPR, the ResQPOD: * Doubles blood flow to the heart * Increases blood flow to the brain by 50% * Doubles systolic blood pressure * Increases survival rates * Increases the likelihood of successful defibrillation * Provides benefit in all arrest rhythms * Circulates drugs more effectively

Just to play devil's advocate... Sometimes I think urban medicine is more difficult because you don't have the luxury of time. For example it's a challenge to deliver my patients to the ER with ABC's established, a through assessment performed, and treatment began. Sometimes the best medics can overcome this challenge, sometimes the weak ones do not. I believe that my assessment skills must be sharper, my clinical skills more precise, I often have to multitask, and I must always triage skills and diagnostic procedures. I have never worked in rural medicine, and I have a respect for those that do, but how nice would it be to have an abundant amount of time to explore differentials, perform multiple tests, have long amounts of time to consider and perform procedures? I take pride in keeping scene times low and beginning appropriate treatment even though the hospital is 10 minutes away. I'm not saying urban medicine is better, just different. Truthfully, short transports can be used as a crutch by weak urban medics; just as inappropriate helicopter transports can be used as a crutch by rural medics.

Would anyone consider adenosine for this patient? Or are you thinking more along the lines of an antidysrythmic? Our class has been told numerous different things from different instructors regarding adenosine to patients with WPW. Some belive adenosine will cause circus reentry by shutting down the AV node, abet momentarily, and force the impulse through the accessory fiber. Others say that adenosine is the treatment of choice for WPW, because it will break the circus reentry by effecting the entire heart. I know calcium channel blockers are contraindicated in WPW. Some claim because it forces the depolorization into the accessory fiber, and some claim adenosine is okay because of the short mechanism of action, but calcium channel blockers are contraindicated because they have a longer half-life.

Do you guys always secure with the over-the-shoulder straps? I know some people are really big on always using the shoulder straps, but it is rarely done around here. How about restraints for the attending in the back of the ambulance? How often do you buckle up in the back? I know our ambulances only have a lap belt for the capitan's chair.

Okay! Excellent responses! Thank you! He was in fact suffering from acute pericarditis. I didn't really come out and say it, but, he did have orthopnea, hence the pain got better after "getting up" to call 911. Tough call, I was wanting to see if anybody stuck their neck out either way, MI or pericarditis and your differential dx. From the website where I got the ECG: "Normal sinus rhythm at rate of 90. Diffuse ST segment elevations are noted especially in leads II, aVF, V2-V6, with concavity upwards. PR segment depressions are noted in several leads as well; very clearly in lead II. The above changes are classic for acute pericarditis. Only a scant majority of cases of pericarditis will have such a diagnostic tracing however. Differentiating the ST changes of pericarditis from those of ischemia and early repolarization may be problematic. The lack of reciprocal ST depressions helps with regard to ischemia. Early repolarization usually is not present in both the limb leads and the precordial leads. In V6 if the apex of the T wave is less than 4 times the height of the onset of the ST segment, this is a point against early repolarization. In this case, since the history is that of a 27 year old male with sharp pleuritic chest pain worse when lying supine, the diagnosis becomes somewhat less obscure! One last point: arrythmias appear to be relatively uncommon in these cases. " Thoughts?

The nurse is taken away in handcuffs by the police officer. You elect to synchronize cardiovert anywhere between 50 to 100 j (your preference). A 12 Lead immediately after the cardioversion shows: During transport you do another 12 lead, this is what you see: Vitals: P: 100 and regular, R:20 and a little more relaxed, BP: 108/70. Soon after you take the second 12 lead she complains of palpitations and you look over at the monitor and see this identical rhythm: Vitals remain unchanged, RR increases slightly. No other complaints/changes. You are 5 min away from the ED. What next? Would you have done anything differently looking back?

Yes, excellent questions, waiting for the answers, defiantly interested... In your opinion were the waves more like p-mitrale or two separate waves? How close were the waves to the QRS complex? (PR interval?) Was there a negative component to the wave? Did you check your lead placement and monitor settings? Just asking..... Maybe a second degree 2:1 block, or for some odd reason i'm thinking LGL if they were really close to the QRS.... Could also be the result of an accessory pathway... antedromic reentry? Really just stabs in the dark at this point.

Your pain control management should not be set up to deny access to people you think might be seekers. It should be set up to provide pts in pain with appropriate medication. Furthermore, people can have legitimate pain without the outward appearance of injury or deformity and/or a change in vitals. You system is flawed because your rationale for pain control relies solely upon your judgement of how bad you think the pts pain is. While the Paramedics impression should certainly weigh in on the use of pn meds, the pts impression should also have equal bearing; depending on severity (0-10). Using the 1-10 scale is a quantitative approach, while using your impression is a qualitative. Which method is more suitable for protocol? The communication of pt information you describe seems to be a violation of privacy? And remember that seekers can actually have real conditions that may require analgesia. It seems as if your pain management protocol is in need of a rehaul. I would rather medicate a 100 seekers with protocol doses of analgesia then let one old lady with abdominal pain suffer all the way to the hospital in my ambulance. And this is how your pain management should be approached.

i was thinking seizure too... what was the doc's rationale for not calling it a seizure? did she have repeat episodes in the ER? maybe something pysc/stress related? i dunno... a stab in the dark.... did she have a fever or feel warm? no cardiac history?

Here, here!

A single police officer arrives and is available as needed.

As your partner begins to start an IV, you ask the pt some very pointed questions about drug use and specifically the use of cocaine tonight, to which he denies. After speaking another minute about the possibility of cocaine use, you have no reason to believe your pt has taken any illegal substances. After confirming that he does in fact have no allergies you give 324 mg ASA PO. The IV (18 G angio) is patent and running at TKO/KVO. The patient does not appear dehydrated, skin turgor is good and he tells you he voided a quantity of "clear" urine before bed. Your ambulance is not yet equipped with a phlebotomy lab. He does not have a Rx for nitro and is not diabetic. Other than his father having a hx of hypertension, he has no family history. BS has not changed (90). VS are: P: 96, BP: 100/94, R: 26/labored and SpO2: fluctuates between 90/89%. You explain the seriousness of the situation and the need to be transported to the local ER. He agrees. He has no problem standing up with your help, though it does cause a slight increase in respirations, and rotating to the cot. He is strapped in and placed in Semi-Fowler's. You move the pt to your waiting ambulance. The one ER in your county is 20 min away code 3. He reports that while the CP was getting better; it now seems to be returning. His breathing rate/quality remains the same. You observe Levine's sign. And now that he's sitting in Semi-Fowler's you can make out JVD. A few questions for consensus before we continue this scenario. What transport priority? Do you want to treat for hyperkalemia, and if so how? Would you give this pt nitro and at what dose? What else are you thinking?

A focused exam reveals no signs of pregnancy and you have no reason to believe she is pregnant, other than the fact she is on birth-control. The patient seems to be slowing her breathing and is now somewhat diaphoretic. She is also becoming increasingly drowsy, you have to repeat some of your questions twice and speak a little louder. You ask is she has thrown up or had a fever recently, she replies "no". Skin turgor is normal. You ask her if she has ever had difficulty breathing or palpitations before to which she replies, "no". You listen to lung sounds as your EMT partner gets the new ETCO2 detector out. Lungs are clear, bi-lat and labored from what you can tell; with such diminished tidal volume. No adventitious sounds. You work to calm down the girl's breathing with therapeutic communications. Your attempts at vagal maneuvers, such as bearing down or blowing on a syringe, are worthless because the patient cannot hold her breath or work at anything other than breathing for more than a couple of seconds. The capnography nasal cannula is placed under the NRB mask and reads 45. The waveform is tall but does not show a "shark-fin". The nurse asks, "what's all this fuss about! She's just hyperventilating!" The young woman seems to become more agitated while you perform your interventions. You ask your partner to start an IV (18G angio) of NS at TKO/KVO. As he begins this you place the patient on a 3-Lead. You see a wide complex tachycardia at roughly 300 BPM. You then decide to do a 12-Lead: VS are as follows: P: roughly 250-300, BP: 86/56, R: 26, SpO2: 87%, ETCO2: 45. Using your Paramedic super-power you guess her weight to be about 40 kg. Treatments? Working diagnosis? Do you want to "load and go" or "stay and play"?

DIB is in fact "Difficulty in Breathing" sorry for any confusion.... You immediately take the paper bag off the girl's face, to which the "nurse" replies, "Why did you do that? It was making her better!" In fact, in the time since you have arrived the child breathing seemed to be slowing down and the girl seemed to be relaxing, becoming almost drowsy. Your EMT partner places the pt on 15 LPM NRB and takes some vitals as you instruct the nurse to gather any medical information about the girl. VS are: R: 30, BP: 90/60, and pulse is "too fast to feel" maybe 200 or 250 "I can't tell". The girl is still awake, and the slightest bit drowsy, and still breathing fast with the NRB. No signs of cyanosis or retractions, though the girls is obviously working hard to breath. A little sweat is starting to form on the girls forehead, other than that skin is unremarkable. Your EMT has a look at the pupils as you put on the pulse oximeter. Pupils are PPEARL and pulse ox reads 88%. The nurse returns with a few copied papers and hands them to you. One is a consent to treat for emergencies, signed by the pt's parents, another is a history sheet that reads, "NKDA" and states no prior medical history. The "nurse" asks, "why don't you just take her to the hospital already? Teach her a lesson." The principal asks why you aren't listening to his "nurse". Your squad has recently ungraded their LP 12's to the capnography function. Your partner asks if you'd like him to apply the detector under the NRB? You ask the girl if she is allergic to anything to which she replies, "no". You ask if she has been stung by a bee or been outside, she says, "no". You ask if she has asthma, she says, "yes"........... "only"........... "when"............... "I play"................. "sports"............... After working so hard to speak, she concentrates solely on breathing, almost having to gulp for air. You ask about an inhaler and she says after a minute or so, " at home". You ask if she is on other medications and after another minute of breathing she states, "yes".................... "birth".......................... "control". You ask, "Do you smoke?" She says, "no". The nurse says the girls was complaining of her "heart beating fast" after she heard of her failing grade. You look at the young woman and she nods her head in agreement. You ask about chest pain and she also nods "yes". And after instruction holds up 1 finger to quantify. Physical exam reveals no DCAP-BTLS. What next?

My apologies about the use of DIB or "Difficulty in Breathing". It's fairly commonly used here and I thought it was a universal thing, again sorry of any confusion. Your EMT partner places the young man on 4 LPM NC and sits him down on a large armchair as you continue the physical assessment. His skin is slightly warm to the touch. He states he has been slightly warm since yesterday, but didn't think anything about it until you asked. Other than that skin is unremarkable. You ask him if anything makes his chest pain better or worse, to which he replies, " it was really painful and hard to breath while I was lying in bed, then I decided to get up and go to the phone, after I called the pain seemed to be going away, and it was easier to breath." You ask him how the CP is now, to which he replies "better than before". You ask him if he has pain anywhere else, he states "no". You ask him if he has any heart, lung or kidney problems, he says "no". No recent surgeries or hospitalizations, excepting a brief visit for a broken rib 3 years ago. His father has had controlled hypertension for 5 years. He is not a smoker and lives alone. He is a software engineer. He is fit and works out at "World Gym" three times a week in addition to pick up basketball games with coworkers on weekends. His basketball team is doing quite well. He is not coughing. Your EMT listens to his lungs and reports they sound "clear". Physical exam revels no signs of edema, JVD or DCAP-BTLS. EMT reports blood sugar is 90. VS after 5 min are as follows: P: 94, R: 26 and labored, BP: 100/92 and SpO2: fluctuates between 89 and 90%. You place him on the monitor and see ST elevation in lead II and III. You decide to do a 12 Lead: Treatments? Transport? Working Dx?

Dispatched to 16 y/o F unknown CC at 0900. Dispatch advises that the address is for the local high school and PD is enroute. No further information. You arrive at the school on a sunny day w/ no severe weather. The scene is safe. The principal meets you outside and instructs you to follow him. The school is fairly new, well kept, in the suburbs and serves mainly middle-class children from what you can tell. The principal leads you through the halls and past classrooms in session to a small first aid room next to the main office. Your general impression is a 16 y/o F in respiratory distress. She doesn't appear traumatic and is well dressed. The school nurse reports to you that this particular child had failed a final exam earlier this morning and has since complained of DIB. The "nurse" has the patient breathing into a brown paper sack, because she believes the child is suffering from "Hyperventilation Syndrome". She called 911 because this is the standard operating procedure for school emergencies. The child is in one-word-dyspnea. You ask her whats wrong and she responds, "can't"..... "breath".... What next? Complete the physical exam and treatments.

You are dispatched to 28 y/o M DIB at 0100. No further information from dispatch. You respond to reasonably priced and affordable condominiums recently built by a large contractor. The scene is safe. Weather is slightly overcast with sporadic showers. A well built 28 y/o M greats you at the door. Your general impression is a young adult male who appears to be in a little respiratory distress. Your EMT partner gets you a set of vitals: P: 90 and regular, R: 26 and labored, BP: 108/90, RA SpO2: 90%. The pt states he has had increasing DIB since he tried to go to bed at about 2300. Since he has gotten up and called 911, the pain seems to have gotten better. He also reports "stabbing" chest pain 4/10 that comes and goes, but has also gotten better in the few minutes before you have arrived. The patient believes the CP started after lunch as a result of the new "hotter than hell" boneless wings at the local bar. Thinking he was suffering from heartburn the pt eat a light dinner; a chef salad. Even still the CP increased throughout the evening and now he has difficulty catching his breath. Throughout this history the patient has to take breaks to breath, before continuing to speak. No PMx and NKDA. Besides the Zantac he took after lunch the patient has taken no medications. Continue the assessment and treatment from here!