Thunderchild145

Yea, this is kinda a non issue for us because our stations have seperate bedrooms BUT assuming that myself and a homosexual partner had to sleep in the same room, it would be exactly the same as me and a heterosexual female partner sleeping in the same room. Keep it professional.

Pads? As in defib pads?

You hook up defib pads before they code?

Sometimes. Not often. If I see a truly sick patient who is in a peri-arrest situation, then yes. Also, obviously if I'm going to pace/syncronized cardiovert, then I need them on to do that. This particular patient doesn't seem like they're too bad, but some patients do warrant getting the pads on before they code.

All I know is that if I don't have an IV in a code I'm screwed, but if I don't have a 12-lead in a code I'm not missing anything. 12-lead IS warrented though. Don't think that was a bad idea at all. My reccomendation: Start the IV while your partner gets the 12-lead set up. For a patient like this who looks like they are about to code, get an IV and get the pads on.

Eh. This is obviously an opinions question, and also slightly dependant on protocols. Our protocols say no nitro without an IV line, and nothing below 90 systolic. If it's 90, yes. If it's 88, then no. Since I'll typically give a nitro before I get an EKG, my first "To give or not to give" is based solely on BP.

In either case, we'll administer fluid to a patient with a BP of <90 systolic, at this point I'll grab my EKG, and per protocols will administer nitro when the pressure reaches or exceeds 90, excepting cases where a diagnostic EKG can reveal acute right sided compromise, or the historian (pt or otherwise) can reveal chronic right sided compromise. Protocols here say no nitrates for people who are preload dependant. Same for morphine.

As far as to what happens when you do give nitro to RVI patients, yes. It's been my experience that if bottoms them out fairly quickly. I'll typically pucker my buttcheeks and squeeze the IV bag as hard as I can. For chonic patients this drop seems to be less dramatic, and I've noticed that most patients who are chronically preload dependant are typically hypertensive to begin with.

I had a patient like this in the cardiac floor where I used to work. She started with 3rd Degree AVB and then she would tense up, pass out and have 30 seconds of nothing but P waves. Woke up and said she felt like she was falling. Happeneds like clockwork every 5 mins or so. Very strange.

Well actually, there typically is a junctional or idioventricular escape rhythm to replace the sinus arrest. This is more common. What's uncommon is where the SA node fails AND the junctional pacemaker fails AND the ventricular pacemaker fails and they go into asystole. That's typically a very bad sign of some serious conduction/automaticity problems.

I wouldn't try to mess with titrating prehospital. Personally (and once again I wasn't there) I would have bagged without intubation, and administered the naloxone bolus. In the 15 minute window I just bought myself where the patient is hopefully now breathing and maybe starting to wake up, I'd get him out to the truck and take him to the hospital. Due to shorter transport times here, I think were he in this area we'd have him to the ER before the naloxone wears off, but since I don't know where the rest of you are, that may be a thing that only applies to me.

So yea, to reiterate: Narcan, then more narcan, and only then tube is what I've always been told.

EMS will almost never know if it's new or old. Your best chance of knowing in the field if a LBBB is new or old is if the patient knows that they have a LBBB. The odds are astronomically stacked against that, so I tend to treat anyone complaining of substernal chest pain according to our CP protocols, with or without presence of a diagnostic 12-lead.

Here, the scope says that a basic can administer nitro if there is medical direction to do so. Since a medic can give that direction, the previous case was totally fine here.

Unfortunately, the system you describe is inaccurate. The ACLS program is not designed to test anyone on anything more than rote knowledge. Even this takes a backseat to reference material and "expert consultation". The information that is gained from the standard ACLS class is no longer about testing the students to find out if they understand the concepts that are presented. It has become an issue of giving recognition to someone that can attend a class, nothing more.

The providers may well have the same expectations, but the emphasis has been taken away from ensuring their knowledge to flooding the market with providers that truly do not understand what they are trying to do.

My question is that if the ACLS certified professionals aren't "experts" then who should we ask in the eventuality of needing "expert consultation"?

Now I'm looking for an IV, and I want the patient to get a nitro. Patient does not have a script. Can I tell Bob to give the patient a Nitro without incurring the wrath of the board?

That happens here. All the time.

More commonly though I'll ask the basic to set up a 12-lead while I start my IV, and as soon as I have a line in place I'll give the nitro. (If I tell the basic to give nitro and then I cant get a line in, I'll really be in for it; so I like to only give it to pts with lines established. Not partially, but all the way.)

^

Isn't it generally held that a student working with a preceptor has the same scope as the preceptor? I know that according to California law, if I have an EMT-Basic student with me during a shift then the basic can utilize the full basic scope while supervised.

Technically, the school at which the EMT-B/I/P student is attending should have a medical director and the student is practicing skills under the medical director's license. Least, that's how it works here.

I took my initial ACLS 2 months ago and I have to admit, it did seem really, really easy. I spent the two months before that hearing horror stories of ACLS megacodes gone wrong and entire classes failing only to not have a single person in my class fail. I thought maybe it was a fluke.

Guess I was wrong.

Anyway, it is dissappointing to hear that the education (if you can call it that) that I got in the ACLS course is "watered down". Course I also knew from day one that since ACLS-I was that easy I'd definately want to try my hand at ACLS-EP.

Does anyone know if the experienced providers course has been "watered down"?

Now, if only they had a video of this on YouTube.

Here we are practicing intubation while doing chest compressions. That's the only thing I can assume he meant, because I can't fathom how to intubate and ventilate at the same time.

Stick it up their butt, squeeze.

Just kidding, don't actually do that.

Yea, I'm not kidding. Do it. It will work, and they wont be mad for long once they realize you saved thier life.

Ambulate Before Carry

Amen

Yea, but 60 cycle might be responsible for that notching in the R. Either way, the QRS is less than 120msec, so I'm not apt to diagnose a BBB. I've seen several things that cause R wave notching in cases other than BBB, most of them technical. (Leads on wrong. Old electrodes, and artifact can be blamed for just about anything)

Yea, we have the same protocols. Diltiazem or verapamil for SVT if Adenosine fails to convert and the patient remains stable. But we give diltiazem or verapamil for A-fib frequently when they are borderline-stable lik this guy. Obviously, he's not entirely stable, but I would use drugs to try and slow him down, not electricity.

Beleive the OP said it was irregular and the patient has a history of A-Fib. The "textbook" response is not going to be adenosine. It's going to be diltiazem and clenching your asscheeks and hoping they dont throw a clot.

But once again, I'd be a fan of improving the hypoxemia first.

AZCEP beat me to it, but yea that question was already covered on this thread. Catecholamines and beta agonists aren't going to speed this guy up any farther.

But honestly, why cardiovert first? If a tree falls in a forest and no one's around to hear it, does it make a noise?

Wait. Wrong mantra. If you cardiovert someone and their heart is too hypoxic to restart, is it your fault you just sent them into cardiac arrest?

Uh. Yea. It is.

Do you ever intend to upgrade your education, or are you through with all that book learnin?

I just got NREMT-P, so the short answer would be "Not soon, but eventually."

In short what I'm trying to say is that if I'm an ALS provider here, I can't really think of a good reason to move there and be a BLS provider. Money's nice, but I make enough to live comfortably here so that's not really an issue.

In the end, I'm only making decisions for myself. "Y'all" can choose to do whatever you want. I only know this offer isn't right for me.

Have a good one.

1) When you say "your license" does that mean mine or yours. I didn't say any paramedic in Ontario has a license, and most US medics (from what I see on these forms) don't either...

Mine, and I do.

2) Practically all level of EMS, especially the EMT-B level have zero, yes ZERO education compared to their Ontario counterparts.

True, which basically means you can perform the skill better, but if you can still perform the skill competantly with less training, is the excess (and I use that word carefully) training of any benefit?

3) Again, so you think that if people are told that "Nitro helps chest pain" or that "RSI helps people with their airway" that should be so.

A horrid generalization, but unfortunatly a fairly accurate one when you take into account that BLS providers here only have ~100-200 hours.

4) Ridiculous!? It is reality my friend! This is the reality that basically everyone who has started out in EMS (in Ontario) for the last 5 years faces.

Yeah, sorry. If you were trying to get people to come to Ontario, this statement probably didn't help much. At least from my perspective. Granted, the pay is better, but I'm pretty sure I wouldn't want to go back to being a BLS provider, and I'm also pretty sure I wouldn't want to go to school to learn for another few years to basically relearn interventions I already know and can legally perform in the US.

EDIT: Also, I think maybe you misunderstood what I said. If you start in EMS in Ontario, then you're used to having to go to school for 3 years to be an ALS provider, but for an ALS provider in the US to go to Ontario and give up most of his/her SoP, would be in my opinion, ridiculous.

Again skills/scope = education in the grand scheme.

See above about being able to perform skills with less education. Once you can do something, I'm not so much convinced that more education vs. practice on the job is really much help.

Are people possibly telling me that 1200-1600 hours of education are analogous to 200 hours of training? You aren't serious....

I can't be serious, because that's not what I'm trying to say at all. I'm trying to say that someone who can perform BLS interventions is a BLS provider, and someone who can perform ALS interventions should be an ALS provider. Since EMT-P is mainly taught ALS interventions above and beyond the previous scope of EMT-B, there is *basically no benefit to being an EMT-P in a BLS role over EMT-B in a BLS role.

*=EMT-P also has lots of other stuff like A&P, pharmacology and such, so it's not fair to say absolutely no benefit, but the skills they perform would be absolutely the same, assuming both were providing BLS interventions only.

Though, since you are trying to get people to pick up and move to Ontario, I'll stop hijacking this thread with my own opinions on the matter and let others for their own opinions. :wink:

So, good luck with that.

I've got to say no. You said in the orginal post that EMT-XYZ in the US would come to Ontario, the only catch is that if you aren't an EMT-P in the US, then your liscense doesn't mean anything. Not to mention my main point, and that's that medics in the US learn advanced skills and a lot of drugs. Granted, the education time is very short, but the scope is there. It would be rediculous for them to give up those advanced skills and drugs just because the amount of time they went to school is about the same as what the PCP went through.

In short, if EMT-XYZ can do skill ABC or give drug DEF, then regardless of how long they spent in school, that should be reflected on reciprocity for me to even consider moving.