AZCEP

Wow Dust, you must be slipping Enroll in a paramedic program and obtain it when you get done.

I've had it happen a couple of times. It does tend to surprise you a bit, but it really isn't an anomolous thing to have happen. The rate of atrial discharge is slowed enough that the SA can resume it's proper function. Most texts don't bother to mention it, because it isn't supposed to work that way, but we all know that if a patient has read the "book", they have surely forgotten what it said.

The SLAM course is good, but dollar for dollar, I got more out of the Difficult Airway Course. The style of the instructors, and the small interactive groups seemed a little easier to acclimate to. Take either one, and you will not be disappointed. If you can't take the course, and they can be tough to get to occasionally, buy the Manual of Emergency Airway Management on it's own. It is the text for the Difficult Airway Course, and should be mandatory reading for anyone that picks up a laryngoscope.

That's pretty reasonable P3, but my take is a bit different. I anticipate every prehospital airway to be difficult, and use the bougie for each attempt. The cases you list are good times to have alternatives ready, but if you can use a bougie to prevent needing one after looking why not? To each their own.

For me, it was a combination of things 1. The weather was negatively affecting my performance too much. Working in the desert southwest for the last 16 years, high temperatures were part and parcel of everyday activity. The summer of 2007 was especially rough due to the number of calls that forced us into extended durations in the heat. I just had to find something else to do. 2. Too many disagreements with medical direction over how patients should be managed. Our protocols were very open and loosely written to allow us leeway when necessary. I was/am confident in my ability to make a decision, but our new medical director isn't. He felt that we should be calling for assistance more often, instead of doing what we know should be done. I just got tired of it. 3. After 16 years in the streets, enough was enough An opportunity came up, and I jumped at it. It may not be the right decision, or even the best choice available, but it is what I'm going to do.

"There wolf, there castle." --Igor "Why are you talking that way?"--Frederick "I thought you wanted to."--Igor "No, I didn't want to."--Frederick "Suit yourself, I'm easy."--Igor

After 16 years of running all manner of calls with a number of different agencies ranging from big to small, I've decided that I'm tired of the restrictions that go hand in hand with working under a "borrowed servant" profession. I'm starting medical school Sept. 1st, and hope to get to a point where my decision is the end of the discussion on what should be done.

The presence of hypotension is a good indicator that some fluid replacement is needed. Even with a strict cardiogenic origin, patients tend to be volume depleted and will respond favorably to a challenge of fluid. Atropine might be considered, but it's use in the presence of AF isn't really warranted. Perhaps application of pacer pads in preparation of what might be needed would be a better option.

Except for the little matter of his rate being 60/minute. No dig eh?

Post resuscitation hyperglycemia is widely held to cause a negative influence on neurologic function. Using dextrose containing solutions, when not indicated, is not acceptable practice. All of the medications used in an attempted resuscitation have indications for their use. Administration, "just to see what happens", is not listed for any of them. If you have reasonable suspicion of a cause you might be able to justify something. Otherwise, don't do it.

Defibrillation does not "kick start" or re-establish "normal" cardiac activity. The act of defibrillation eliminates all electrical activity from the myocardial tissue. The benefit of early defibrillation is in the ability to conserve what energy stores the myocardial tissue has before they are used by the horribly inefficient fibrillatory cycle that presents as VF. The "electrical" phase of cardiac arrest is the short period of time that the myocardium is best able to respond to a defibrillatory shock. This happens within 4 minutes of arrest, and chances of success are reduced by approximately half for every minute of duration. The "mechanical" phase of cardiac arrest is a period that follows, approximately 4-8 minutes from time of arrest, with complete elimination of any type of contraction, fibrillatory or otherwise. This period is best treated with effective compressions to supplement any blood flow that the heart can generate. Following this is a metabolic phase that is highlighted by the buildup of metabolic waste products that must be eliminated/managed before attempting to manage the presenting problem.

Biphasic/monophasic does not apply during TCP. Pediatric energy levels have not changed, and does not differ between mono-/biphasic equipment. The initial energy setting does not change for adult or pediatric. Peds are still treated with 2 joules/kg for the first shock, and 4 joules/kg for subsequent. Adults are managed with the maximum device allowable throughout.

There is no difference from a guideline perspective on the "dose" The current reccomendation is "maximum allowable by the manufacturer". Maximum setting for all unsynchronized shocks.

Not again!

On the whole, stay away from EMS specific anything. They tend to be diluted to the point of uselessness. If you would like a good Pathophysiology text, you can't go wrong with McCance and Huether's http://www.amazon.com/gp/search/ref=sdp_tx...mp;x=12&y=6 There's a long list of offerings, and you will have a tough time finding one better. They cover anatomy in a functional context, and discuss disorders of each system. Pick any of them and you will learn more than any EMT class can ever hope to teach. For physiology, there is but one standard to obtain. That is Guyton's http://www.amazon.com/s/ref=nb_ss_b?url=se...keywords=Guyton Tends to be a bit more pricey, considering it is directed at medical student's, but the information is well worth it. Guyton doesn't spend much time on anatomy, as that is a seperate entity altogether. Anatomy needs to come from a didactic/lab setting or you miss out on a significant portion of material.

The soft tissue swelling was made worse by aggressive fluid replacement. The inhalation issue was more subtle on presentation than we gave it credit for. A surgical airway later fluids continued.

When available, the Parkland formula is useful, but not really necessary. Consider the amount of fluid that is administered prehospital will be subtracted from the total amount anyway. Airway management, pain relief, fluid replacement, and temperature control are priorities. If you can't get the pain controlled in the first hour, you never will be able to. I've been witness to fluid replacement being done to the point the airway became unmanageable also.

Steve Berry, of "I'm Not an Ambulance Driver" fame, has the greatest of all acronyms to follow a name. MDOASAADD Mack Daddy of all Smart Alecked Ambulance Driving Dudes.

Maximize the minimums. By that I mean, try to do as much as you can without using all of the toys that you now have. Use your intrinsic senses to figure out what is going on, then add the information that you receive from the technology. Make your most trusted tool(s) your eyes, ears, and hands.

Enroll in a college anatomy and physiology course. That by itself will clear a good many of your questions up. An EMT class will only provide the most base of information, and you will not be given any great insight into what you will be seeing. Some things you can discover with experience, but you, like all other new EMTs, are not granted the information that would be useful to have. Also consider doing a search of these forums. Many of these topics have been discussed frequently, and there is much good information to be found.

Use aggressive fluid resuscitation measures with close monitoring, and let the receiving facility worry about total fluid volume after 24 hours. One of the big mistakes most will make is to under dose the amount of fluid that is given.

Brain needs sugar and oxygen, so no I would not withhold the dextrose. I might use a more dilute concentration, like D10, but not treating the problem will only make things worse.

Effective thread hijacking Ruff, way to go. A patient with an electrical burn needs significant amounts of fluid to effectively manage the problem. As Ruff mentioned with his first response, the entire body is being effected and you don't have any way to gauge the severity of the burned tissue. Aggressively manage the airway, initiate cardiac monitoring and replace fluids. One liter of saline, and one liter of LR in unison wide open and repeat until patient care is turned over. The issue with NRP is not that you are specifically a paramedic, but more that you don't work exclusively in a neonate heavy environment enough to have good clinical experience with them. The sanctioning board is very tight with this requirement, and it is reasonable for them to be.

I've only recently discovered that there is more than the three types that mobey mentioned. Our local hospital is using pump specific tubing that is 20 gtt/mL. For a disaster response team, focus on the 10 and 60 gtt tubing with a mention of the others and leave it at that. Maintaining sterility is near impossible, but needs discussed. Mobey has given you a pretty good list for setup. I'm guessing that the intent of the excercise is to see how you will deal with non-medical personnel that are enlisted to assist with the disaster. With this in mind, I'd suggest limiting the amount of medical terminology that you use. Good luck to you.

The heart and brain need sugar to function. If you've gone through your causes of cardiac arrest and can't come up with a good reason, trying some dextrose may be reasonable. It is even more so if your patient has a history that suggests they may be hypoglycemic prior to arrest.