rock_shoes

Documented history yes. Constant a-fib not necessarily. Some patients go in and out of a-fib based on any number of things. With this patient it was likely related to both low magnesium levels and a respiratory infection. I did qualify the consideration of CCBs with ensuring the rate was not in fact compensatory (respiratory infection in this case). All sounds perfectly reasonable to me. Interesting case. Any idea why her magnesium levels were in the toilet?

Ah, so it likely is compensatory. Scratch the CCB for the time being then. What's her dental history? Any recent trips to the dentist? Take a look in the mouth. Any sign of an abscess? It's amazing the s&s that rear their head with dental/jaw infection.

Alright then. First ensure the rate isn't compensatory. Any recent illnesses? Has she spiked a temp? Does anything lead you to believe this patient may be septic (skin infections, chronic respiratory infections, UTI's)? After that, provided she isn't allergic to it, verapamil 100mcg/kg SIVP is worth a go. Follow it up with verapamil 150mcg/kg SIVP 15-30 minutes later if the first dose doesn't do the trick. Anything under a 110 BPM for rate is going far enough in this case. No point putting that pacemaker safety net to use if you don't need to. Monitor closely for hypotension. A small fluid challenge is worth doing prior to the verapamil. It's amazing what a little fluid can do sometimes.

Agreed on the Ventolin/Atrovent. Anyone else thinking we should consider a beta blocker or a CCB with a 30 minute transport time? Worth giving the Doc a ring and having the discussion anyway. She's already paced so it's lower risk than most patients (a demand pacer considering the ECG findings being shared) and based on her history we're probably looking at an a-fib less than 48 hours old. I'm surprised her medications don't include coumadin or dabigatran. I'm leaning more toward a CCB over a beta blocker in this case with signs of bronchospasm also presenting (I know in Alberta it's metoprolol or metoprolol but a guy can dream).

I work targeted ALS in an area serving 2.5 million people with a total of 8 ALS units in the entire area (as in 3.2 ALS ambulances per 1 million population). Even working within a high exposure system, I typically only use the IO one out of every twelve shifts. If the numbers presented regarding IO usage within this particular system are correct this services IO usage policy and IV skill maintenance are in dire need of review. Are medics in this area simply using the IO because its easy and a fun toy? If they're using IO's so frequently are they at least pre-dosing some lidocaine through the IO before the initial rapid flush (excluding those placed in codes of course)?

I recall those particular monkeys. My recomendation, particularly for those likely to remain in spinal precautions for a prolonged period, would be to use a spinal rated scoop instead of a board. The curve of the scoop, and the space between the halves in line with the spine, make it dramatically more comfortable. If you have a couple of those polar fleece blankets I know a great procedure to use them to pad up a scoop for those interfacility transports when a patient can't be cleared by x-ray. The average SMR practice in Alberta gives me nightmares when I think of the ridiculous number of unduly caused pressure sores that result from it.

I remember those rural days when the only appropriate body removal vehicle was the local ambulance. It was a unique experience that truly harkened back to the origins of EMS in BC. I always felt it was an honor for a patient's family to entrust us with this final act.

Wow. This case blows my mind. It's one of the most glaring examples I've ever read of a drug most paramedics view as being "relatively benign" spiralling patient care out of control. Titrated low dose naloxone=self managed airway with short afternoon hospital stay (most likely). High dose naloxone=extreme pain/agitation/withdrawl, intubation, central line, chest tube, and an ICU stay. Out of my own curiosity, what is the typical naloxone dosage protocol for most people here on EMTCity? I work under a guideline system so I've used anywhere from 0.4-2.0 mg IM or IV depending on the patient and the desired effect. Usually I give just enough for the patient to maintain their airway and self ventilate. In the case presented the initial dose would probably have been 0.4mg IM. The only time I've ever pushed naloxone 2.0 mg IV is in a code where opiate overdose was a suspected cause (repeated as needed in the code situation).

Every new diesel engine sold in North America in a passenger vehicle will have some form of forced induction (either a turbo, supercharger, or both).

Having been in the usual range of chassis, I'll take a GM Duramax over any of the other options. Smooth reliable power without the jerky, uneven throttle response that seems to plague gas powered units. The problems regarding feeling inadequate power have nothing to do with diesel versus gas (at least in speaking about GM chassis). The duramax engine has actually been de-tuned to lower power output in van chassis to accomodate the less robust transmission that fits in a van chassis (to the tune of 100+ HP). I have a few conspiracy theories as to why GM hasn't beefed up the van tranny to handle the duramax at full power, the primary one being durability. Consider the realistic life expectancy of a gas unit versus a diesel unit. Realistic life expectancy for a gas unit is somewhere in the range of 200000 Km. Realistic life expectancy of a diesel unit is somewhere in the neighborhood of 350000 Km. To put that into a little better perspective, a diesel unit can expect to have a 75% longer service life than a similarly equiped gas unit. If GM took away the one percieved advantage to Gas (namely more available power) chassis they would end up selling fewer total chassis. The additional initial outlay of $8000-$10000 for a diesel unit (keeping in mind the total unit cost will likely exceed $100000 no matter what) doesn't seem so far fetched when you factor in a 75% increase in service life prior to replacement. Now from the driving perspective. An ambulance weighs anywhere from 12000-16000 lbs. That's a significant load to move at all times. What's the engine of choice for nearly every industrial internal combustion engine in existence when the primary function is moving heavy loads? Diesel! The laws of physics haven't changed. Proportionally heavy vehicles of any kind are better served by the low end torque provided by a diesel engine.

Speaking strictly from a technical sense the caption used is appropriate. Someone of this woman's size is a "wide load" for a wheelchair. Regarding the lack of professionalism displayed by any individual who posts pictures of their patients to social media, that's just plain unacceptable. He should have been fired. The grounds for a law suit on the other hand are questionable.

True. A CT scan hastened by the meager amount of time saved running L&S with no current neuro deficits (outside of the patient's norm) however...

Welcome aboard. I work out of Vancouver but did my EMT-P through SAIT in Calgary. Fire away with any questions you have.

Every response deserves a full risk/benefit analysis. If the risk to you, your partner, and the public outweighs potential benefit to the patient, what AMPDS spits out is completely irrelevant. Remember you are expected to be a professional driver in this event.

Welcome. As others have mentioned the process is quite different from one country to the next so your journey could take any number of forms in the next little while. These are the two canadian paramedic regulators I deal with being registered in two provinces. http://www.collegeofparamedics.org/ http://www.health.gov.bc.ca/ema/ Both are very different to deal with and have different scope of practice requirements. I did my ACP/EMT-P training in Alberta because of this. These differences are also why I maintain an Alberta registration even though I currently work in BC.

My interpretation of that evidence is a little different. What that evidence tells me is that the indications for use need to be tailored such that only sufficiently high risk trauma patients are treated with it. The evidence with regard to benefit is crystal clear in that the sooner a high risk trauma patient receives TXA the lower their risk of bleeding related death. The current evidence screams that pre-hospital is exactly the place for TXA provided it's being administered to the correct patient population.

Just curious CheekyEMT, why dispatch as a fall back? You strike me as someone with a passion for patient care. The current AMPDS system (I'm assuming that's the system you're dispatched under in Ontario) is de-humanizing. Technically the determinants make sense but the question process to arrive at those determinants is tragically flawed (I do realise the answers are only as good as the person answering the questions). This process results in incorrect call assignment more often than not (ie. the crew is sent lights and sirens for SOB when in reality the patient has kidney stones). The renal calculus patient deserves proper pain management by all means, but a lights and sirens response is putting crews and the public at risk for an issue that is not sufficiently time sensitive to justify the risk. I've known a number of paramedics who have spent time in dispatch and the reality of how tragically flawed the current call-taking model is places them under more stress than working on car ever did. Education is the ticket for those no longer able to work on a regular duty car; either as an instructor helping develop the next generation, or as a student helping to redefine the future of paramedicine (physician assistant, community care, critical care transport).

Without seeing your step down environment my best guess would be that your post-procedure monitoring area provides too much stimulation. As you've seen emergence is a very real issue requiring careful management to avoid. Think of the type of environment people who suffer from migraines sequester themselves in during an episode. That's the perfect emergence environment for a patient coming off of ketamine. If your facility can't provide that type of environment for whatever reason a different agent would likely serve them better.

What type of emergence protocol does your unit use? Patient's coming off of ketamine need a quiet, relaxed, dark environment with as little external stimulus as possible. Failing that some benzo's usually help tremendously.

When it comes to investigating a patient complaint give her a system to follow. LOTARP or OPQRST work particularly well for pain complaints. L--Location O--Onset T--Type A--Associated symptoms/Aggravate R--Radiate/Relieve/Remote P--Past medical history (including medications and allergies) O--Onset P--Position/Provoke Q--Quality R--Radiate/Relieve/Remote S--Severity T--Time (Seems redundant but such is life) Personally I prefer LOTARP, but to each their own. Also consider adding some high yield questions to her repertoire. Have you had this (insert complaint) before? If so what was the physician's diagnosis? If something is a chronic condition or has been ongoing for some time. What changed today prompting you to call EMS?

You've already had all the standard "hang in there" and "you can do it" type answers so I won't waste your time with another one of those. The truth is you have had a potentially career ending injury/re-construction. By all means power on and fight to get back to work, but please continue to recognize that may not be a possibility. With 13 years on the ambulance that doesn't mean you need to retire from healthcare. It means you might have to seek another avenue. Top suggestions include, transitioning to your services clinical education department, becoming a college instructor, and becoming a PA (Physicians Assistant). Ontario is one of the first provinces to run a civillian PA program and the majority of people selected thus far have come from ACP and RN backgrounds. If this becomes the end of your "on ambulance" career it could also become an opportunity for you to become a true clinical leader in EMS. http://www.facmed.utoronto.ca/programs/healthscience/PAEducation.htm

Sorry mobey but my reference material indicates 400-800mg 3-4 times daily (not to exceed 3200mg/day) ibuprofen for adults. I use an electronic version of Davis drug guide for physicians. The dosing you have is PO dosing for infants and children.

Based on what evidence? You have no visible or palpable trauma without any discernable traumatic mechanism. The damage we do in EMS by putting patients in non-required spinal precautions is obscene.

AIME: Airway Intervention and Management in Emergencies http://caep.ca/cpdcme/roadshows-current-cme/aime BCAS runs this program as one of its cornerstone clinical education pieces. It's an excellent course for anyone expected to make evidence based/staged airway management decisions.

Both fair points. My current long term girlfriend is also in EMS. I can honestly say the benefits outweigh the negatives for me. Having a knowing sounding board is invaluable for both of us. At times EMS does try to take over, but that's where the rule comes into play (either one of us can institute it at any time). Every so often we invoke the "NO EMS RULE" where neither one of us is to talk about EMS for that entire day. It forces us to back away and focus on other more important things between the two of us. As for your second point, it's impossible for us to work for different services. There is one public EMS provider in the entire province of BC. That being the case it is however possible for us to work for the same service and never see each other again should things ever go awry.