MSDeltaFlt

It can also be used, I believe, for symptomatic A-Fib with RVR. However, it's contraindicated for Dig Toxicity. Since we can't check Dig levels prehospital, you won't be able to give it at all if they take Dig. Know an ER MD who swears by it.

In my career I've only handled 3 different epi's

1:100 (Racemic)

1:1000 (multi-dose)

1:10,000 (bristo-jet)

This is my second cardiac arrest post resp arrest via COPD(asthmatic) in the past month or so.....

52yr old male C/C resp distress. Found him tripoding against a desk at relatives home. Only had Albuterol with him. Took 10tx prior to EMS intervention and w/o relief. Pt's severely hypoxic and uncooperative due to this current condition.

PMHx asthma, cardiomyopathy, HTN.

I put him on high flow O2 immediately, flowed by another Albuterol. Needles to say, it wasn't working. Pulsox on high flow reading 73%, poor reading via cool/diaphoretic exts. Pt became combative, punched co-worker in face and could not sit still with O2 in place. We attempted to restrain him and place the mask back on his face, but he wouldn't sit still. I couldn't get an IV yet because he was fighting us. He was now doing the 'guppy mouth' breathing so I grabbed the BVM and went to nasally intubate him. He went into resp arrest, vagalled down into his 30's, then went into cardiac arrest. 8.0ETT, 14g Lt EJ, 1mg Epi and 1mg Atropine IVP and CPR. I never got him back.

No in-line nebs at this job.

No CPAP due to short transport times in city(approx <5mins, entire calls approx <15mins).

No Solu Medrol.....took it away for now.

No 1:1000 epi SQ due to peripheral circulation shut down.

This call from Pt contact to ER doors and care transferred to ER team was 12 minutes.

I felt I could have done more, but not sure what. Hands tied due to lack of meds/equipment. What could have been done differently? :?

As far as inline nebs go, PM me your email and I'll send you to pics I've got for inline nebs that are cheap as all get out and very simple to set up. Vent knows what I'm talking about.

I've tried put them in this post, but it just won't work. That or I'm not holding my mouth right.

As far as handling the pt goes, it sounds like you were stuck on "B". He was too air hungry from hypoxia and his CO2 was through the roof so much that you weren't going to get him to anything compliant. The pt was behind the 8 ball before 911 was dialed. You did everything you could.

Holler back and I'll hook you up.

I think you miss my point. Everybody wanted her to go the hospital except her. If she can answer all those questions I mentioned appropriately, then you need informed consent to treat and transport. Until then, you can't touch her. It doesn't matter what everybody else says. You get the refusal, explain to everybody there, even her Dr on the phone, that you can't touch her, and to please call you back if anything changes.

Also, the operative phrase was not what you highlighted. It was just before. it said "according to my assessment".

Plus something else you missed the point on. Why was the crew called in the first place? Grandma kept losing weight. What's the most common symptom a geriatric shows when sick? Altered LOC. When you have an ALOC, you can't refuse, because you're not in your right mind.

With respect.

I believe this would be pretty much the same regardless of the state you live in, so here it goes:

I would explain to her, her family, Dr, etc, that if she didn't answer these questions correctly then, according to my assessment, I would be forced to deem her a danger to herself and transport her to the hospital as any normal and competent person would want me to do as a patient advocate.

1. What's your name?

2. Where are you?

3. What day/month/yadda is it?

4. Why are you here?

Then I would advise her of what might happen if we leave, and have her repeat the possible consequences.

If she could do any of that, then you can't touch her.

My humble thoughts.

On my clinical rotation got to bag a patient on the way to x-ray but the respiratory therapist said that I was bagging to slow and that I should bag once every 6 to 8 seconds. And that the patient was on a vent where the patient needs only about ten breaths per minute.

I learned in CPR that you bag a patient once every 4 to 6 seconds if they have an advanced air way. And when I asked another student that goes to another school he was taught 6 to 8 seconds. But if you do the math if you bag once every 5 seconds it is about 12 times a minute, if you go faster the patient will not get enough air! Less than 4 seconds and then that is to fast.

I was bagging the patient once every 5 seconds that means she was getting 12 breaths a minute. I learned that you count one one-thounds to keep the breathing rate the same well bagging.

Was I right or wrong? What is right? Do I do what I was taught? Dose being on a vent make a difference or not?

You were bagging around 12 times per minute. Once every 6-8seconds is 16-20 times per minute. Were you wrong? No. You were doing what you were trained to do. Was the RT wrong? No. She probably had ABG's to tell her what the pt needed.

Now I love having students in the middle of everything. They get so much hands on experience, and you get to teach them all the way through it. However, Vent's right. That RT was probably pulled between 2-3 areas at least. She's been there, and so have I. At times, it ain't fun. Nurses complain about the miles they walk in a shift. They can't touch what RT does in a shift.

Does being on a vent matter? Kind of. The ABG's, CXR matter. The vent will help you on "how" to bag the pt.

If the vent is ventilating fast with high pressures, then you're going to bag fast and possibly squeeze harder than you normally would.

If the pt is assisting the vent, then you'll have to assist the pt with your bagging. You'll have to bag "with" the pt.

If they're on a lot of PEEP, then you'll need to put a PEEP valve on the AMBU bag.

You don't want to bag too slow. Remember swimming underwater and you almost didn't make it back up in time? The pt will be feeling the same thing if you bag too slow.

You also don't want to bag too fast. Ever blow up too many balloons at one time? The pt will be feeling the same thing if you bag too fast.

Simply put, bag as you've been taught until someone, who has more information about the situation than you, instructs you to bag differently. But make sure they have emperical data to back it up.

You did good.

As an AMLS instructor, let me give you the basic "gist" of the class. AMLS will teach you to assess, come up with field Dx with differentials, and properly treat your pt without lab values, SpO2, EtCO2, Accu chk, ECG, or CT's... all in 10 min or less. They will show you some hands on assessment tests that physicians are taught. It is an excellent course. I love it.

Paramedics "waste" too much time on scene.

-Some do. The good ones don't.

Paramedics all think there god and treat EMT's like $hit.

- Again, some do. The good ones don't.

We don't do enough cardiac arrests to warrant a Paramedic.

-True ACLS/PALS/NRP/PHTLS is code prevention. That's where a medic shines in my honest opinion.

2 good EMT's are as good/better than 1 Paramedic.

-Not in code prevention. See above.

Paramedics waste valuable time starting I.V's on traumas when they should be transporting.

-Not the good ones. They get them enroute.

Paramedics lose their BLS skills and we(EMT"s) end up picking up the slack.

-A good medic has strong basic skills.

Hope this helps.

We have a ton of ambulance transfer requests where I live, not unlike most of you. In my state there is a sheet that lists what is considered medical necessity and what isn't. If a pt does not meet medical necessity, I will inform everyone involved that I am not refusing to transport the pt, but I cannot bill their insurance. That would constitute insurance fraud of some sort. Someone's paying for it: EMS, hospital, pt, or family, but not their insurance, and I will not falsify the report.

Humbly.

-Chuck Norris can slam revolving doors.

-The Big Bang was actually Chuck Norris roundhouse kicking God in the face.

-Chuck Norris has counted to infinity. Twice.

-Chuck Norris can hit you so hard that he can actually alter your DNA. Decades from now your descendants will occasionally clutch their heads and yell "What The Hell was That?"

I got a million of 'em.

-Chuck Norris once shot a German plane down with his finger, by yelling, "Bang!"

Well, Chuck Norris can reach a GCS of 16.

Why? Because he wills it so.

That's nothin'. This one time, at band camp, I saw a medic write a GCS=1

To answer your question, firedoc, it depends. Once an EMT, always an EMT? I believe you have to answer two questions first. 1) Do you romanticize the career, or 2) do you answer your calling?

If you do romanticize the career, you will soon find out that the honeymoon is over. EMS is not always fun, at times very UN-fun. Very rewarding as you well know, but no fanfare or tickertape parades; just a pat on the back or a firm handshake from your partner saying, "Good job. See you tomorrow. Drive safe." is all we can count on when we make the "big saves".

There's no romance in this career. It is a definite calling. When you do answer your calling, in whatever career you choose, it is the best damn job in the world. That's where the longevity comes from.

My humble opinion.

EMS= Extra marital sex...doesn't it?? :roll:

Unfortunately it usually does in my experiece of observing. But it depends on the crew makeup (emotional/maturity/psychologically) and the overall mood of the base/shift.

Louis Grizzard once said, "Naked is when you ain't got no clothes on. 'Neked' is when you ain't got no clothes on and you're up to somethin'."

There is a service I work part time and a crew (who no longer work there) were walked in on and they were "neked". Hence why they no longer work there.

But there are others, my full time base, where the crews are very comfortable with each other, and their families know that their family members are safe with the crews.

My 0.02.

jwraider,

Having COPD Exacerbation and CHF at the same time is not that uncommon. Give a neb, or don't give a neb; it really boils down to the breath sounds. Not the audible sounds. You must put your stethescope on the patient and actually LISTEN. Listen to all lung fields: front, back and side. Listen for Rales. Where do you hear them? Where do they stop? Are there any Wheeze? Where? Musical wheeze? Coarse wheeze? Do you hear any Rhonchi? Where? How about any air exchange? Do you hear any? Or do you hear nothing but the crappy breath sounds forementioned?

If they're full of fluid, I'm not going to give a neb. Giving a neb in fluid filled lungs is an excersize in futility IMHO.

Hope this helps.

I am an EMT and I have a partner that does a lot of questionable things. I just wanted to ask for some advice and input. We get called to a patient having chest pressure. We get on scene, pt. is ambulatory. Pt. walks to the cot and we load pt. up and start treatment on scene. Pt. was shoveling the driveway when the pressure starts. Pt. describes it as being in the middle of the chest and a little bit of back pain and it is more of a pressure type feeling than pain. Pts. medical history is high cholesterol and a smoker. Pt. is in late 50's and does have a family history of MI. Pt. is also vomiting. My partner can't hit an IV after 3 attempts. I set up the 12-lead and what I see is not "normal" to me. I am just getting ready to start a medic class so I haven't learned how to read a 12-lead yet, but when I printed off the strip it say acute mi at the top. We are 45 minutes out from the nearest hospital and we do have access to a chopper 1 mile down the road. Pts. vitals are 98/P pulse is running 50-55, O2 sat is 94, pt. has some shortness of breath, as well as vomiting, color looks like crap...grayish, and pt. is clammy. My partner gives her a spray of nitro with no IV line established and then we take off. We go non-emergent. We had sent the EKG to the hospital en route....next thing I know, dispatch is telling me to tell my partner to contact the hospital immediately. The hospital precedes to explain to my partner that this pt. is critical, having a right side MI and needs to go straight to the cath lab. It's almost like my partner didn't even know what was going on or how to read the strip. I then get upgraded to emergent. We get to the hospital and the doctor's are pissed! Pt. goes staright to the cath lab and my partner gets to have a little talk with the supervisor. My partner says that he is "sick" and that is part of the reason he made poor decisions. What are your thoughts?

EMTgirl, you had a middle-aged man with new onset midsternal pressure and back pain, borderline BP, and bradycardia. Regardless of what the 12 Lead said, I wouldn't give NTG without a line. If I couldn't get a line in the arm, I'd go EJ. I'd go EJ in a heartbeat regardless of what the protocols said. I do this because my med controls know me and trust me, and they expect me to do what the pt needs. I'm just that aggressive.

Regardless of the situation, a middle aged man is not supposed to have a HR that damn low and having pressure in his chest. That is just not supposed to happen. So I would get aggressive on that alone; even more aggressive with what I believe your 12 Lead said to boot.

Some may agree. Some may not agree. Those are just my thoughts.

With respect.

The phrase I use in dealing with any psych pt is not PC, but it helps me to better grasp the situation: "When faced with a crazy person, you have to ask yourself 2 questions: Are they crazy 'cuz they're sick, or are they crazy 'cuz they're crazy?"

This woman is "crazy" (for lack of a better phrase) because she is sick from a chemical imbalance in her head. She has a chronic condition that requires treatment. And, since she is a proven danger to herself and/or to others, she does not have the right to refuse said treatment.

It sounds as if the events you told us are relatively recent. She needs to be institutionalized until this episode is under control. Ending her career now might be a little premature. It might need to be tabled, but not ignored.

With gas being over the $3/gl, I do the speed limit. Don't need to sticker my car.

Has anyone ever had difficulty with a nurse or other medical staff? We had one ER nurse that gave everyone a hard time. She made a comment one night that she would prove a medic wrong even if they were not. And we were standing right there. :angry4: Most of the docs didn't like working with her. Some had gone as far as refusing to work if she was there. I don't know if she had a power trip or something or what, but making a call up or giving report directly to her was very frustrating. And she would purposely try to trip you up with questions. Maybe she had an inferiority complex or something. She was a wide as she was tall. She seemed book smart but when it came to practical skills she was useless. Who knows? :dontknow:

Sorry for the late post. Been out of town a while. Depending on the state (if I'm thinking properly), you can really make an ER RN's life a living hell if he/she's being a bit nasty.

I've informed several that if they pushed the issue, every single pt I would bring in would be fully packaged on LSB with at least 2 IV's and on a CM - acting as a proper patient advocate... and I know how to document on my chart. Ensuring that every single pt would be brought back in the ER. After hearing that, a couple of particularly bitchy nurses got REAL quiet REAL quick.

Also, you do not have to give a RN a bedside report where I come from. You only have to give report to someone of equal or higher training. Could be the ER doc. The RN must be informed of the pt. Simple. Give bedside report to med control, and INFORM the RN that there is a pt that requires their assessment. They have absolutely no say so in the matter.

This may differ from state to state so I may be way off and do not mean to offend. Just FYI.

Not to mention that we can't even agree upon what "all appropriate questions" are. I have yet to see any EMT school teach them to a medico-legal certainty.

We are kind of thrown to the wolves upon graduation, aren't we?

As long as they are conscious, alert and oriented to all appropriate questions, the they can refuse,, right??

It's a bit more complicated than that as is stated above.

You're right. I thought I forgot to add something. Thanks.

I may not be legally savy in every state, however, if you are 18 or older, or an emancipated minor, Conscious/Alert/Oriented to at least 3 of the following: person/place/time/events, verbally appropriate, AND not a danger to yourself and/or to others, then you have the right to refuse just about anything you wish.

Any deviation in the above, as patient advocates, you WILL lose your right to refuse.

Due to HIPAA regulations, we do not have the complete story here, for we were not there.

With respect.

1700#?!? Damn! The heaviest I ever transported was a 700 lb'er I DC'd from our ICU to the ICU in her home town. Our maintenance dept bolted 2 beds together. We had to leave our stretcher at the ER and had her on the floor of our truck. She was barely able to fit on their single bed at her hospital.

Upon sliding this pt from the floor of our truck to her ICU bed, the bed rolled over my big toe joint; during a particularly strong gout flare up.

I stopped crying the following week.