jjones1418

I think your motives are good, such as better preparation before arriving at a call, but at what cost? I'm not talking on a phone en route to a call, because I'm too busy watching for idiots trying to hit the target on the side of my ambulance. I'm an extra set of eyes for the driver. Also, I understand the need for preparation, but I've never spiked a bag on the way to a call. Can't say that I see a need for this, ever. I'm not sure that I've ever known anyone to do this either. How does this work for you guys? I'm all for the EMD portion of asking questions, I guess. It's what accepted as a national standard. Where I used to work, call-take and dispatch were separate. Someone answered 911, EMD'd the call, and put it into the computer. Then, it popped up on the computer screen in a different room, and the dispatcher then dispatched the appropriate unit. Our system was busy enough that even with 2 dispatchers, they didn't have time to answer all of the calls and dispatch units simultaneously. We had 2 dispatchers, sometimes 3 for EMS and 2, sometimes 3 for Fire. I don't have a clue how many call-takers we had, but they answered all the calls for Fire, Police, EMS in the entire city. I'm sure it was a few. Anyways, to answer your question, I think it's a bad idea for paramedics to be calling people on the way to the call. I think it would only add to the accidents we had responding, providing more of a distraction than it's worth. I personally am thankful I don't have to deal with some idiot on the phone quoting shit he's seen on Rescue 911. As an example... "Um yeah, I think Billy Fred here had one of them thar colonary arrests." That's the shit I wanna try to decipher while clearing intersections and watching for morons.

This one kinda slipped by me. I just caught it this morning, as I am up for some strange reason at 4:00 am... I am having trouble seeing your question, as it looks like you're trolling for someone to say that paramedics aren't good enough to take a patient on "titrated drips" as you're calling them. But as you gave examples....... In my practice, I'm not really going to be "titrating" Heparin or Integrilin, but I could be titrating Diprivan. I also make sure I spell the drug names right when I write them on my chart. Some of us knuckle-dragging paramedics are half-way intelligent and take it as an insult that you "should maybe not be putting so much faith at the medic level." Before someone starts off with a state-of-the-disunion address about EMS education, and all that, that's a different thread. After all of that, to answer your original question.... Medics are functioning this way elsewhere, and some of us are doing a decent job at it. If it's not working for your system, rather than take away a medic's ability to take a certain patient, consider education. Maybe have your medical director come in and do an inservice on the common medication infusions that you transport. And your second question, "how do you decide if MICU or Advanced ALS?" I'm guessing, although Advanced Advanced Life Support is rather redundant, that this would be a paramedic ambulance and an MICU would be an RN/EMT-P ambulance. My answer is assuming that you're not letting paramedics take the SCT calls anymore... With a response based on this assumption (uh oh), I would have something in writing that had this determined. Maybe a sheet in dispatch that has a checklist... Send MICU for any patient that has/is on 1) ventilator 2) multiple IV medications infusing 3) blood products hanging 4) TPN hanging 5) You get the idea..... Put the checklist in dispatch and make it a predetermined assignment.

Thanks dust. That's what kind of replies I was looking for. Also, I believe Dallas has Dopamine now, not that they will ever use it. It's in Biotel's protocols on their website. I know Farmers Branch has it, as I have a few friends that work there, and they're Biotel. Also, there are a few different sets of protocols in Biotel, but I think they just recently added the Dopamine, say in the last year or two. I couldn't work in that system. These poor guys have to call after the 2nd round of meds in a cardiac arrest... "Umm, yeah. He's still dead... What now?"

I'm not seeing much IABP use here, but most of the patients I see are from smaller hospitals. We're usually taking them to places that can place IABPs. I'm sure they're being used. I'll have to ask a few of our nurses that work at the larger hospitals. I don't know of a ground EMS service around here that HAS a balloon pump, but they do transport patients with them. Some of the metroplex hospitals can place them and use the CCT trucks for transport to different hospitals.

I guess I should have been more clear. I see that from the responses, basically everyone carries Dopamine, and a few utilize Epinephrine, Dobutamine, Levophed, or Vasopressin. What I was looking for, is when you use a particular vasopressor. Do you have the freedom to choose if the patient condition, in your opinion, needs a different vasopressor? For example, "This patient has X, I can go with A, B, or C." If so, what do you look for in your clinical assessment to choose an agent? Or, are you dictated by protcol, that you use X for Y and A for B?

Just some food for thought, and because I need something good to read... Anyone care to discuss their use of vasopressors and the rationale for using a specific one? This is directed to you MD guys as well. I'm just looking for a few points of view, as to compare and contrast to current rationales that I have heard. Also, if you want, discuss interchanging other medications with vasopressors and how ya do it.

echo Ruff... Nice post though, that it only takes one paramedic and a competent partner to run a code. That may be right on scene, but what do you do when it's time to transport? (Because we transport all full arrests, right? /sarcasm) I've actually run a code where it was just me and my EMT partner, and I didn't have anyone in the back with me. When you're out in BFE, there's not much you can do. You can't do anything for the patient. It's an exercise in futility. It's impossible to do effective compressions for 20 minutes. Now if you meant something else, please correct me. I couldn't tell from your one-liner if you did. If you meant "well when you have a firefighter driving and an extra firefighter blocking traffic and it's across the street from the hospital and you have the auto-pulse and you get them back and don't have to do compressions anymore and blah blah blah without punctuation....", please tell me.

I think Vent was pointing out spelling mistakes, questioning the validity of the OP's decision of who or why gets transported.

I'm giving him a quick roll onto the backboard. Then we're getting on to the hospital. If we're BLS, there's nothing else to do, but assess, O2, and watch 'em. If we're ALS, he gets aforementioned O2, other standard stuff on the way, IV, ECG, etc. Load him up with some Fentanyl. I like the Sam Sling, if you've got it. Upside down KED works well, but it's a pain at the hospital. They look at you funny. I'm not putting a SAGER traction splint on someone with an unstable pelvis. The Hare is a different story... Maybe...

I agree with dust, that you shouldn't have to look up protocols when you're taking care of patients. You should know those backwards and forwards. I agree with him in that he denotes drug dosages as not being protocols. I checked a dose for a Levophed drip last shift. We change at least 1 page in our protocols every month. Some times it's the starting point for a drip or something specific about how often you can increase it, etc. Such was the case with our Levophed, as I remembered a change about the starting dose for it. We used to be able to start at 2 mcg/min, but recently it changed to 0.5 mcg/min. I checked it and made sure. The drip ended up at 8 mcg/min anyways, so it didn't really matter, but on paper, we followed protocol.

echo, You wouldn't happen to live in a Tarrant Co town that starts with an "A" would you?

Ah but it's not a clear cut sinus rhythm. I do agree with you that, if it were at an appropriate rate, and had p waves, it would resemble a LBBB. I'm just saying that it's VTach. Ectopic ventricular beats, then progressing to a wide complex tach resembling the ectopic foci. And you did make a good argument about the LBBB. Your criteria was accurate.

Slow it down and drop some P's in front of it? So you're saying it's a LBBB if you slow it down and drop Ps in front of it. That's like saying "we would've won the game, but they scored more points than us." It's not the case. The rhythm is what it is - A wide-complex tachycardia at a rate of 215. It matches the morphology of the ectopic foci, which we know is a PVC. I'm goin with VT. This could be as simple as lead placement, as in the leads are on the chest and abdomen, instead of the limbs. It may be why the axis of this looks different.

I think we're losing track of what's going on with the patient. It's looking for zebras while the horse kicks you in the face. He's in a wide-complex tachycardia at 215 bpm. It's VT. The morphology matches the PVCs as dust says. I don't see the RBBB either. I don't think it matters. This guy is sick, and he needs pharmacological intervention. I like how Dust alluded to his agent of choice as "bubbly." I like our prefilled syringes. No drawing up that stuff. Of course we could wait 'til that heart of his decides v-fib is a pretty line to draw on the monitor while we attempt to diagnose Lown-Ganong-Levine syndrome with WPW and a tri-fascicular block. We can ALL treat V-fib, right!? /sarcasm

What's the REMAC and NFPA? J.Jones CC/NREMT-P, FP-C

Just like my auto-signature.... Still trying to figure out what i wanna use here.... Think I'll just keep that one... J.Jones CC/NREMT-P, FP-C

Agreeeeeee with 'zilla. Find some other etiology of his unconsciousness if that flumazenil didn't reverse it. It at least means you didn't cause it with 5mg of versed IM. Hahaha. That's not too much versed at all. You did what ya had to do. Smile and walk away. J. Jones CC/NREMT-P, FP-C

nice hat J. Jones CC/NREMT-P, FP-C Flight Paramedic

#10 Blade, Trach hook, 6.0 ETT. Oh, and a trach tie. I tried to check on some studies about the QuickTrach. Somewhere, they talked about esophageal perforation during placement. I can't find them right now, so don't hold me to it. I, personally, don't like it. it's not definitive. Just about the same as the trans-jet. There's no cuff on the piece of plastic that ya ventilate through. BUT, if it's all ya got, it's all ya got. And some airway is better than no airway. Jason Jones CC/NREMT-P, FP-C Flight Paramedic

First, Why did you have a 12 lead done? I think your 12 lead looks good. Rate is normal. Slightly irregular, probably normal. QRS axis is normal. All of the durations are normal - PR=.15 , QRS=.10. QT looks good. No ST/T changes. Where are you seeing this hemi block or fascicle block? Jason Jones CC/NREMT-P, FP-C Flight Paramedic

We carry both. I like fentanyl myself. It just works so well. Like AZCEP said, it's duration of action is shorter than morphine, so it may be difficult to maintain analgesia with it. It's awesome for trauma patients, especially when a drop in BP is undesirable. ateupmedic spoke on the pharmacodynamics briefly, and is accurate. A good way to prevent/blunt the hypotension associated with the histamine release from morphine is to give a little benadryl with the morphine. Makes 'em sleepy though. We use fentanyl in our RSI protocol, use it post RSI for analgesia, use it for basically anything that might hurt. Morphine is preferred in chest pain, but fentanyl is an option as well. J.Jones CC/NREMT-P, FP-C

We carry 2 of the alternative airways talked about on our helicopter. We carry the Combitube Reg, Combitube SA, LMA 1, 1.5, 2, 2.5, 3, 4, and 5. Also carry the bougie. We are switching to the King, so I think the Combitubes are coming off. The LMAs will probably be gone as soon as the King Pediatrics get approved. I've played around with the King on the difficult airway dummy, and I like that there's only one thing to inflate when you've decided to use the thing. AND, If you want, you can slide the bougie down the King, and swap it out with a tube. I just like the Bougie though. It's just a good tool. And earlier, someone said something about not being able to hook a vent up to the Combitube, LMA, or King... I've done it to the combitube more than once, and it works fine. Picked up several patients from a hospital that EMS brought in with the ETC in place and the patient being bagged. Put em on the vent and it worked just fine. Per the King LT website, you can mech. vent a King as well. I haven't tried to do it with an LMA. J.Jones CC/NREMT-P, FP-C