BAYAMedic

Nope, they need only to remove them selves from the gene pool to qualify. Fireman1037

Wow Dwayne, we know you have firemonkey issues but what I find more concerning is your open invitation to "violate me".... Did you by chance mean find you in violation? Or were you wanting something else...... Weird pararescumen ninjas these days..... Fireman1037

Thanks kiwi, Our dosing is 2mg/kg and may be repeated to maintain sedation. So would this be a better adjunct to use than midazolam for cardioversion or pacing? Fireman1037

Ok so here I am echoing Croakers post from last month. Due to the drug shortages, we are unable to get Etomidate and are switching to Ketamine. What can you guys tell me about your experiences with Ketamine for sedation for RSI. Fireman1037

I think your just happy he got your name right on the first attempt. Fireman1037

I would encourage you to re-read my post RWN, The point I was making had nothing to do with your success or failures with IVs. It has to do with the simplification of Airway management, and not psyching yourself out. I have no idea how long you were a Basic before you started medic school, but I was for 7 Years, Not all of that time working with an ALS Provider. I had the skill of intubation so glorified in my own head, that when the medic popped his laryngoscope open, the clouds parted, the heavens opened up and the angels sang. Another life saved. I had created some XXL sized clown shoes to fill. Then came my OR rotation, (after like you having passed hundreds of mannequin tubes) and I realized that its a far more simple procedure than I had made it out to be. Take it slow, and make it smooth. Fireman1037

Well said Dwayne and I know I may get flamed for over simplifying it but think of it this way. Do you have the same kind of anxiety when you start an IV? Because that is putting a small plastic tube in a larger meat tube, all while not having visualization. Intubation is the same thing, all while having the direct view of where the tip of the tube is going. Everyone has two tubes to choose from, and the majority of patients dont desaturate in the time frame of Jeopardy theame music, so take your time. Take a deep breath, know you practiced your butt off, and go for it!

Hmm 'Zilla... Seems to me like that looks like a cut and paste off of a powerpoint I saw once.... Fireman1037

In clinical's we pushed it like water in the ER's, Only pushed Morphine once for pain control, and twice for cardiac, and didn't push Fentanyl until I made it out to the field. So my limited experience with this med is partially based on my personal experience as a patient. Dilaudid Seemed to work a bit better on orthopedic pain than Fenanyl. It seems to fall into the "Rule of tens of Opioids" as well IE. 10mg MS = 100mcg Fentanyl = 1mg Dilaudid, IVP. Maybe I am just one of the sensitive ones, but Nausea did come but was relatively fleeting and dependent on how fast the dose was pushed, So might not be a bad idea to pre-treat with some Zofran. I haven't used it in a RSI situation, so I cannot comment on its effect that way. If you have any voice in purchasing, I would ask for the 1mg/2mL Carpuject vs the 2mg/2mL for ease of dosing and a touch better control if you hit a bump in the road. Fireman1037

ERDOC, are you Practicing in Washington state now? If so I'd love to meet up sometime. Yes, the brilliance of my home state... What its doesn't mention is that the Community Health Clinics have taken a HUGE hit in their budgets as well, over the last 18 months. The Clinic my Wife used to work for had to show a reduction in services, to include dental, Suboxone, and Pain management and face staffing reductions and reorganization in leadership structure. Receptionists were required to change to all 15 minute appointments and had to go to the supervisor for authorization for extended appointments (with some exceptions). So if the ease of access to primary health care management is reduced, the Emergency room usage is going to spike. With every discharge from the ED a referral is given to the patient to follow up in the next 72 hours with GP. The Clinic still doesn’t have any appointments for the next month..... Vicious cycle continues. So how is this currently being dealt with? From a semi reliable source, Deliberate miscoding on the physicians part. If you use a DX code that is correlated with "Emergent acceptance" and increase the number of tests you run to make it look like a difficult case, from a billing standpoint, the likelihood of rejection is lower. So this case of esophageal reflux is esophageal spasm, and had to be ruled out it wasn’t a cardiac event, so 4 set of enzymes are performed, on a nitro drip for a couple hours then after all cardiac markers come back negative, chest x-ray negative and echo negative, give a GI Cocktail and release with an RX for omezaprole. Am I being a touch excessive and cynical for the case of making a point, Yes. So how do we deal with this in EMS? I LOVE the idea of paramedics having a Medicare- debit card, and a different mode of transfer form. Right elbow pain times three months and has been taken by EMS twice. The pt. requested hospital happens to be next to the Mall. So rather than driving by 2 hospitals to get to said hospital, get a modified refusal form and release of liability form, and a cab to requested hospital ABC, with a Remote check-in patch called to ABC by Paramedic to get them in line for triage. Or better yet, have contracts with the doc-in-the-box urgent cares and tell the patient that they will be able to handle the complaint just as effectively. Cost to tax payers $30 bucks for a cab vs $600 minimum ambulance transfer fee. $200 dollar Urgent care vs $1200 ER. Fireman1037

Welcome to the City! Don't get down man, you are doing the best thing you can to advance yourself in your career currently. You have recognized the need to be a legitimate medical provider. Now it sounds like you are lumping two separate things together. Private and IFT/CCT are two very separate things. If all you have done has been IFT with a prepackaged patient, you have seen some complex cases. But you also haven't had to stabilize them, and generally the transports so very smoothly. You haven't had to assess, diagnose, and treat them so I see how they may question your "street cred" if you will. Not all Firemen's knuckles still drag the ground despite what Dwayne might tell you, but they sound like jerks. Hold your head high, know you are doing whats best for your self and for your patients. EMT "experience" prior to medic school is a point of contention around here that has been done to death, so I won't re hash that aspect. The thing here is know that you are doing the best, to make yourself a better provider. Lastly, I would encourage you to proof your post before you hit that button. I myself have issues in that area, Dwayne nailed me the other day even. But it will make you look a whole lot more professional and more educated with some simple capitalization. Fireman1037

Seems like a very expensive pair of Adspecs. A similar principal of variable lenses to be able to be used in poor populations of Africa. http://blog.arenasolutions.com/adspecs-oil-filled-eyeglasses-a-vision-for-the-emerging-world/ Fireman1037

Central Washington University has offered a BS for many years. Pre-reqs plus year of program land you with your certificate. They now have the 3rd year (3 year BS) designed to be your first year in the field, and is available all online. It focuses on management, finance and research rather than the CC-P side however. They are now accepting anyone with the 2 year EMS degree to take the 3rd year online and get your bachelors. http://www.cwu.edu/~nehs/paramedics/Advanced_Paramedic.php Fireman1037 Edited to add program URL

It was a combination of experiences that lead me this direction. Grandpa was a volunteer fireman and one of the first EMT's in the state of Washington. Uncle was a Volly FF/EMT, another Uncle was a career Captain/Medic on a Metro Dept. I wanted to fill the family tree out and be a fireman too. Then it happened... I out grew the toy trucks, the cute bunker gear onesie, the firetruck shoes and went on to so many other childhood fantasies. I wanted to be a pilot. That was in my freshman year of high school, and the school had a school to work job shadow. So they sent me out to the rural airport... to hang out with airplane mechanics. So I sat there all day bored out of my mind when it happened. A real pilot showed up, a fixed wing medical transport pilot. He proceeded to tell me the really cool job is in the back of his aircraft. Fast forward six months to my 16th birthday. Working at a road side bakery/fruit stand we just sat down to eat cake when a car pulled up and honked. We kinda dismissed it. Then it honked again. I went out there and found a 60's age 300+ lb male red in face, diaphoretic, clutching his chest. "Help, Ambulance" I called 911, and gave him Aspirin out of the first aid kit ( those damn Bayer commercials work) 16 minutes later the ambulance shows up, loads him up, and hauls him away. The local paper wrote up about the birthday hero and the family sent me a thank you card, but I had felt so helpless. Why did it take so long? I wanna be able to help, to not feel useless and so since I was 16, I joined the Volunteer Fire Dept. no ems out of that station. EMS was up the road 8 miles. But that got me started. National Ski Patrol that winter. The MD Director of the ski patrol let me work with him down at the hospital in the ER. That was cool but the ones that impressed me were the Paramedics who would bring in the patient well on there way to recovery. I mean they had to have been really sick when they called 911, but the paramedics had to have fixed them, as they were doing well now. So I started riding third with this ALS agency. That next summer (17) I took my First Responder class so I could use the training with the fire dept on car wrecks. I did a lot of volunteering that year and spent a ton of shifts in the ER. in march of 03 Then I got sick. Two weeks in a level 4 Hospital, One Medstar flight to a children's hospital, a week more there, then outpatient IV med visits. DX: Nisseria Meningitis. I learned the importance of bedside manner, during this time. 6 months later I was back and healthy, Starting my Sr. year. I had all of my graduation requirements filled, I just needed elective credits. So I enrolled in school to work internship. 9-5 M-F, I was at the ALS agency 38 miles from my house. 3 months after I Turned 18 I started my EMT class and got my card, but there were no jobs, or shifts I could take, because I had to be 21 to drive. I graduated, Got the "presidential scholarship for volunteerism" and then Was going to go to school to start paramedic Pre-Reqs. Got sick again, recurrant debilitating headaches. Lost about a year because I was dealing with appointments, and Pain management zoned out adjustments. Then got off all of it and everything resolved DX: rebound headaches. Moved to North Dakota to work in the oilfields (bad idea, Its cold!) and then got a job back in Washington state as " Industrial EMT/ Mine Medic" Another volunteer gig with an ALS Service, Had a really emotional call (first pedi code) and stepped back for a bit. A few years later I realized how much I missed it, Got on with a Volly IFT Service and re took EMT-B. Re-certed and started Paramedic School. So I have worked for 8+ agencies over 9 years got in and out of it in varying levels, Private, public, non profit, for profit, remote non transport, hyper urban. I have ran the gambit. I like to think I am a proof that despite what life throws at you, you can always go back. Sorry for the Long Bio, but like AK I started writing and couldn't stop. Fireman1037

That being said, the best crew I have worked with in the field in regards to orthopedics is my former Ski Patrol crew. When packaging up 3-4 "snowboarders wrist", or Skiiers knee, or ulnar boot top Fx per weekend, you got the practice to do it well. When the only pain control you have is your soothing voice, well timed distraction and a shredded wool GI surplus blanket for padding. You learn to play with what your dealt. Fireman1037

I have, and I do on occation. But there are times that that is far from convieniant. The point I was trying to make is train like you fight. As a poor example, it like the athleates who trin in a weight vest. Its harder now, to make the actual task at hand seem easier. Fireman1037

As all the good answers have already been taken, I will go down a slightly diffrent route. How comfortable are you with your skills? Have you had the chance to start difficult lines in a moving ambulance yet? I had the bad experiance of having perfect classroom starts, followed by nicely lit, no rush ER IV starts, To having my first few "real" field patients be really sick and needed a line ASAP. If you get the chance and have access etc. have a coworker drive down a particularly bad patch of road, while you try to stick a fellow student in the back of your rig. I have found 24ga to finger viens mimic baby foot veins nicely. And that being said, are you comfortable with multiple different IV cath styles? How about Lab draws? Remember your Color order Draw de jour? Are you equally comfortable with a syringe draw and a vaccutainer draw? Practice improvisation skills, expecially when it comes to airway managment. Use a Bougie as an ETT Introducer. Use a lighted stylet for transtracheal illumination for confirmation. Actually hook up the wires to your monitor for the ETCO2 detector. Which Blade do you use. Why dont you try the other for a while? If your comfort blade is the goto, why are you using the blade your less comfortable as your "rescue" blade? Are you comfortable running a BVM and maintaining a great seal and head position? How about CPAP? We never put it on in school and had trial by fire. How do you feel about your Cardiology? 12 lead interperatation is one thing that got beat into us in school, but how many times did we go over pad placement on actual humans vs just the mannequin. Realizing sometimes the pads don't stick well, and to towel wipe or razor a hairy chest are things not covered in my classroom experiance. What point are you going to place the Combipads on a bradicardic patient? are you thinking far enough down the line to have them placed pre-crump? Protocols. Not knowing your school or internship locations, I don't know if this is an issue. But if you work in more than one agency/county, you may have varying protocols dependant on where you are that day. Yes subtle crap but important if you want to impress that preceptor. Lastly the drug box. I spend alot of time in the drug box while studying. I work with two separate agencys, with two diffrent styles of drug boxes, and totally diffrent layouts. Can you be so confident, if asked to draw a diagram of your box you can remember what is supposed to be in each compartment and quantities? Hopefully Amongst my ramblings there is something you might consider useful or thought provoking, if not chalk it up to someone who is just a few months ahead of you into this curve Fireman1037

Several agencies, in several counties. Most of them were riding third or student so I wasn't making the money to eat out every meal. I learned to improvise Fireman1037

OK, here are a few of the tricks I have picked up. Cooked chicken breast, shredded with taco seasoning, green chilis, sour cream, cheese, and black beans. Roll the mixture in a soft taco shell, triple wrap in foil and freeze individually. Place on dashboard with defroster running when you get on shift. Nice hot lunch. If anyone wants it, I can get the recipe from my amazing wife, She usually makes about 2 dozen at a time and I have plenty for a month. MRE's are good but very high in calories, and always remember to have two water bottles that day for hydrating the warmer, and the drink mix. Foil wrapped pizza boxes sit nicely in the engine compartment of Type one ambulances and Type 6 wildland engines. There are 12v plug in coffee commuter cups that will keep soup warm, but take forever to heat up cold soup. (Maybe dashboard the sealed can of soup when you start your shift) Cup of noodles need hot water, Alot of the industrail coffee machines have Hot water Spigiots. Buy your soda/juice/coffee/water from the same convienience store, and always flash a non-creepy smile. You will get to know the staff, build rapport, and will find your coffee may get comped once in a while, or if you know them well, ask if you can nuke your food in their microwave. Also their hot water... Swinging into a local grocery store takes no longer than fast food, for a bag of premix salad and sunflower seeds, dressing and cottage cheese. A pouch of Chicken ( the kind next to the tuna) really kicks it up a notch. Read the newspaper and grab the fast food coupons and put in an envelope in your truck. There are definatly days a BOGO Burger at Carls Jr. with the price split with you and your partner, works well. Fireman1037 "Not the firemonkey Dust warned you about"

You guys forgot the most important tool we have on our bus. The Lifepack 15 with the 12 lead crainial cord attached to see if they have brain activity.... Fireman1037

lets not forget some of the meds gone by the wayside. Thiamine Phenergan(promethizine) Vasopressin Vecuronium in lieu of Rocuronium Morphine for fentenyl then back and now have both. Demerol (Meperidine) Tnkase and those are just what i remember from when I started as a basic back in 03 to becoing a medic now.

Started with this name on mIRC, Back when I was a rookie, teenage, volunteer, whacker from hell. Green light on the dash board. Ready to save me some lives! I have sense mellowed out, Been out of a fire department since 2005, and have focused my energies on EMS. The 1037 was my first Badge number. Fireman1037 "Not the firefighter Dust warned you about"

I know its not what you had, but it meets alot of the design aspects and ran into it while cruising sales. http://www.qmuniforms.com/Brands/5-11-Tactical/Knives-Tools/5-11-Tactical-Side-Kick-Rescue-Tool.axd Fireman1037 I know its not what you had, but it meets alot of the design aspects and ran into it while cruising sales. http://www.qmuniforms.com/Brands/5-11-Tactical/Knives-Tools/5-11-Tactical-Side-Kick-Rescue-Tool.axd Fireman1037

Paramedic emergency care by Bledsoe is an older single large volume. I also liked mcgraw-hill EMT-Paramedic. It's got practice questions and a test. It's kinda like paramedic cliff notes. And I purchased both for under 50 shipped from amazon used. Fireman1037

Hmm, here I go replying off the top of my head. . . So as great a drug as Amio is, it has a crazy long half life. So if you have some one who already has conduction issues, and may have a new one, it seems to me to be more appropriate to hang some Lido, and have the ability to still to an electrophysiology study, some time in the next few days vs. Several months if you went the Amio route. If the research shows Amio to only be margionally better in codes, it seems to me there is still a place for our old girl, Lido, here at the ball. Fireman1037