Thunderchild145

Obviously, you have never worked a CCU or ICU

True. I've obviously been told wrong that all V-tachs will eventually deteriorate into codes. Ah well.

LMAO!!

Yes, and if you drop a bottle of NitroStat, the resulting explosion will blow a crater the size of Terra Haute in the ground too. Always.

Here's an ALWAYS rule for you: ALWAYS think very carefully, and do thorough research before putting your reputation on the line with an "always" statement. :wink:

Don't patronize me. I'm not a retard. I've just been taught incorrectly.

We had one where the pt complains of SoB but has a SpO2 of 98% but we put them on a nasal canula anyway, well, since their complaint doesn't warrent getting directly into the ER, they get put into triage where there is no O2 and the nurses wern't going to just give him a bottle of O2. He asks us to take him to a different hospital but of course we cant since we've already transferred care. Anyway he leaves, calls a friend to pick him up from the hospital.

Strangely enough: Picked up the same guy for an MVC 30 minutes later. I don't get it. He wasn't driving, his friend was.

Anyway, back on topic. I'm pretty sure that if you call for an ambulance from an ER here you just get a police response, too, but I can't swear to it.

What, starts out asymptomatic but ends up coding and dying? This happens all the time. V-tach is a non-surviveable rhythm. Even without symtoms it has to be converted or the pt will code. Always.

We have a system here (CernerWorks) and you put your values into the system and it actually comes out with that for you. High, Low, or Critical. I honestly don't know what a determanent for Critical is but like ERDoc said it all depends who you ask on what critical is.

I had heard the Fentanyl didn't have the same vasodilater effects as morphine, so no.

ALS has a job to do, just like BLS. It's nice when the medic can focus on ALS because the BLS is being taken care of. It's hectic when this doesn't happen. On some patients, there just isn't a whole lot of ALS to do, but there is typically quite a bit of BLS so in all honesty the BLS should keep the basic busy such that they wont need to worry about ALS interventions that are beyond thier scope. I'm not "bashing" basics. The honest truth is I thought the paramedics job was easy till I learned to do it. It's not as cut and dry as EMT-B school. These things take time, and frankly I'd not let my partner do anything (other than like I said, push the buttons on the monitor. The exact ones I tell him to.) that could be considered ALS. He's seen the procedures done a million times, but he's never been formally trained how to do any of it. He hasn't practiced for weeks on dummies or done them on real people. At all. Ever. If I can't get the IV, then I can't get the IV. They'll get one in the ER. I shouldn't expect him to do any of that, and he shouldn't expect me to let him. It's not his job.

Even if the EMT-B is a medic student, he's not acting as a medic student if he's at work. Legally, he's an EMT-B.

From what I know: "Tactical" Medic isn't really another level of care. The minimum required competancy before you start Tactical school is EMT-B. You do not have to be a paramedic. Also, the courses are only 4-6 days long. It's basically integrating what you know with situations you're not used to operating in.

Firstly, three relatively unrelated questions.

What kind of medic is too busy to spike a bag on a Long-Distance Transport?

If you were on a transport, and (I'm assuming) transporting, why were you in the back, spiking a bag?

Isn't spiking IV bags a basic skill anyway? (It is here. EMT-Bs spike bags all the time. Usually while the medic is getting the IV started)

Kay. Now that that's out of the way.

I had some time to think about this, and I reread the original post. I totally don't get a basic pushing MS, because there is nothing immediate that would even seem to go along with my last post. (Does MS come in 5mg vials? I've only seen 4mg and 10mg. I -know- MS doesn't come in prefills. Unless you count the fact that that little narcotic vial can be placed in a carpu-ject and pushed directly.)

After rethinking, I can't really think of any good reason to have a basic push meds. I know that when I was a basic, I'd be scared as hell. I know for a fact that I would probably mess something up. Also: This would only go against the basic a little. It would go against the medic a whole lot. Being a medic now, I'm a little iffy about losing that license cause I decided my time was a little short. I'm still okay with defib though. If I interp the rhythm, I'm cool with them pushing the button.

Lets be honest. In an ideal situation, the paramedic is able to do every single thing he needs to do in an orderly manner with plenty of time to spare and there won't be any problems.

Is EMS an ideal world? Sheeyah. Right.

There are 5 rights to med administration. If I check all those and then give it to a basic to push, I am sure the patient is getting the drugs he needs. I'm not saying I do this. I don't. I'm simply stating that for example, if I'm on the other side of the patient from the drug box or the monitor or whatever ALS instrument, and something needs to happen..

Say the patient codes. I look at the monitor and interpret a V-fib, and I say "Charge it and shock him!". I see that as the same thing. I make the judgement. I don't do the actual mechanical part of it, but I'm supervising -everything-. While I don't let my partner push drugs, I don't hesitate and niether does my partner in a "Charge it and shock him!" situation.

So yeah. In the end, I'm not saying it's legal, or even right. Quite the opposite. But I can see where it comes into play.

lol. That's not a bad idea.

Hmm. This is a tough one. The newspaper has the right to reveal whatever they want and dont have to worry about HIPPA. The provider can pretty much tell the entire story of what happened, but can't reveal a name or any identification. However, since the newpaper already had I.D. he pretty much knew that if he told them anything, there would be a name put to his story.

I know it is even against HIPPA (In the hospital, if someone calls asking how Tom George is doing) to tell them anything specific. I would think this is something similar. At the very least, this guy should probably get a verbal warning and some sort of HIPPA familiarization. Toeing the line means you probably dont know when to stop.

./facepalm

Those standing orders seems to contradict one another. You give the fluid bolus to bring pressure up and then you take fluid off with the lasix. End result? That NS that was in your IV bag is now urine covering the patient and overall the condition doesn't change much other than now your pt is probably a little hyponatremic. Anyway, I would not have given a bolus or lasix, as both are contraindicated.

PS. It is CABG, not cabbage. lol

The Renin-Angiotensin system is being disabled by the ACE inhibitors. Otherwise, yeah.

The fluid bolus increases preload. When the ventricles fill, the increase volume forces them to expland more and therefore like a rubber band, contract more forcefully. This increases the blood pressure only because of the basic equations of perfusion. Stroke Volume x Heart Rate = Cardiac Output, Cardiac Output x Periphreal Vascular Resistance = Blood Pressure. Basically in order to increase blood pressure we have to increse heart rate, stroke volume, or periphreal vascular resistance.

Anyway yeah, so the fluid bolus would increase preload which would increase stroke volume, which increases cardiac output, which increase blood pressure.

As far as the "pipe" problem they're referring to another part of those equations: Periphreal vascular resistance. The meds this guy took are blood pressure meds (Altace [Ramipril] and Toprol-XL [Metoprolol]), and most of them decrease one of the three componants of blood pressure. Some decrease 2 or more. Ramipril is an ACE inhibitor which would explain the vascular problem and Metoprolol is a beta blocker which is keeping his heart rate low. Also Levodopa is a dopamine precurser prescribed for Parkinson's. This guy is probably vasodilated (when combined with the slow heart rate and the physiological inability to increase said heart rate due to beta blockers, resulted in a really, really low blood pressure.)

You've probably been told to be wary about giving fluid to elderly people because it can cause pulmonary edema. Just keep listening to lung sounds and make sure you don't overload them.

My friends and I were having a discussion about religeon versus atheism and when I showed them this one of them showed me a counter-point that can be found here: http://www.atheisteye.com/thegodlessbastard.htm

Nope. That's it for me.

It would be something to think about. Did I read wrong that the patient's HR was still in the 50s and there was still no readble BP? If after 250mls the pt is still that bad I think it's probably time to try something else.

I'm not trying to chew your butt.. Your post just confused me.

I don't know what caused me to spontaneously think of this, but glucagon works to counteract beta-blocker overdose. This isn't a BB overdose per se, but can't it be used to lessen the sympatholytic effect of the blockers? So yea, I'll go with glucagon, 3mg IV and see what that does.

Wow. Bad luck. Something got to his brain stem. Can't usually live through that for long.

From what I've seen, oxygen at the very least makes the patient feel like something is being done to help them. It doesn't sound like a bad idea as a medic that if you don't know what to do, have your partner put them on oxygen so they don't see you sweat while you deliberate your options =D

I've really only heard of one example where oxygen is harmful to patients, and even then it's not really harmful. That's in COPD patients who are running on hypoxic drive (and only about 33% of patients with COPD actually function on hypoxic drive. The rest still run on hypercarbic drive like the rest of us.) Anyway these people slowly stop breathing. (Note:Slowly) So what, if they do stop breathing, bag them. This really isn't a big deal. If anyone else has heard of a situation where oxygen is detrimental to the patient, I'd love to hear about it.

Really, if it's not hurting, and it might help, why not administer it? Now there's no reason to go gung ho and blast them with 15 liters via NRB every patient every case. Overloading someone with oxygen can cause vasocontriction, and for some people thats an un-good thing. Titrate to pulse ox and that kind of stuff. Good rule of thumb is that for every liter you administer by nasal canula it increases inhaled oxygen (FiO2) by 4% (Room air is 21% oxygen. You do the math)

Anyway, can oxygen by itself save a life? No. Probably not. By "save a life" I typically think someone who is really, really bad. (Real bad asthma, real bad truama, anaphylaxis, status seizures.) Oxygen alone will not miraculously cure thier ailments. But for someone having trouble breathing (Your average COPDer for example) if you can convince them that the mask is -not- smothering them and is in fact helping them, oxygen will do a lot of good to calm them down and prevent and reverse hypoxia.

Anyway, that's my 2 cents.

I would have to agree that bagging while doing compressions would not be effective and would at best cause alot of Gastric Distention. So that is kind of odd to me. A couple other things in this scene don't make sense to me, maybe someone can help me understand or you could clarify.

He was in V-Fib, You shocked him at 360J? Right off the bat? And that converted him to PEA, but he had pulses? You should have gone through the 200J, 300J, 360J on a Monophasic Defibrillator or the 120J, 150J, 200J on a Biphasic Defibrillator. Maybe clarify for me because on the last post you said he converted to a First Degree Heart Block, which also isn't PEA. Thanks.

Most of this has already been said, but you are right about bagging and doing compressions at the same time. On a non-intubated patient, you do cycles of 30:2 -or- you can leave out the bagging and just compress at 100 compressions/minute. On an intubated patient, you compress and ventilate at the same time, 100 compressions/minute and 12 ventiltions/minute.

Second, as MedicRN pointed out, this treatment was based on the new guidelines for ACLS. Stacked shocks have been eliminated. You shock at 360J for a monophasic, 200 for a biphasic, 360J if your not sure which one you have. (That probably shouldn't happen)

Third: ANY rhythm without a pulse is PEA. (Pulseless Electrical Activity) The exceptions are of course asystole, v-fib, and pulseless v-tach. These rhythms are expected not to have a pulse. Sinus rhythm with a first degree AV block, in the absence of pulses is PEA.

Fourth: You asked if the patient was in PEA but had pulses? That's a contradiction.

Wow. That was a bad move.