fakingpatience

I'm moving to California, and trying to puzzle through all the required documents to apply to work at AMR. I received my state california card through reciprocity, but to apply for work I need

* CA Drivers’ License

* H-6 DMV Print out of Driving Record (Online printout not acceptable)

* Ambulance Driver’s License

* Medical Examiner’s Card

Getting a regular CA driver's license I assume will be a fairly straight forward process, just turning in my other state's license.

For the Ambulance driver's license, it says I need to take a test... Does any have information on what is tested? Is there a book available, like there is for regular permit tests to study from? Also, it says a medical examination report is required... Is there only 1 of these, or is there a separate medical examiner's card I need to get also?

Thanks in advance for any advice!

Not toe pain but transported a patient for gum pain x4 months, already seen a dentist for it, no new changes. Oh and it was 0200 and she was a block from the ER

Some community colleges offer EMT-B during the summer semester. Not cheaper, but definitely less time then a regular semester. Mine was around 2 months long, we met 4-5 times a week for ~3 hours (I could be really off on the numbers though, it was a while ago). It was worth 9 regular semester credits through the college.

Hmm according to this my ears are over 40 years old (I'm in my mid 20s).... I thought my hearing has been worse lately!

Out of curiosity, is there a reason everyone wants a beta blocker instead of Cardizem?

Capnography shows "sharkfin" waveform, but his etco2 isn't high, but I'm wondering if that is due to his increased respiratory rate compensating for that.

High ammonia levels

Does anyone on here work EMS in Israel?

Our protocols specifically said that if you aren't certain if it is SVT or other rapid atrial rhythm to give a trial dose of 6mg adenosine, to slow the rhythm down for diagnostic purposes. Personally the a-fib RVR pt's I've had have been fairly irregular rates, so it wasn't needed, however I did have a pt in a regular a-flutter (1:1 conduction) undecernable to SVT at the rate. Gave 6mg of adenosine, and the rhythm slowed for ~10 seconds, long enough to see the flutter waves and determine a calcium channel blocker was needed (didn't carry cardizem there so opted to not treat and wait till we reached the ER as pt was stable).

What training are you planning on getting to run that ultrasound machine? I'm curious not argumentative.

Will the hospitals trust a paramedic's reading of a portable ultrasound in the field when they often do not trust them with their 12 lead interpretations.

Do you really need a ultrasound in your ambluance and what will it be used for?

I honestly don't know what training they are planning on doing.

While it would be nice to say that the hospitals will trust our interpretation, honestly just like 12 leads they probably will not and will still do their own exams. For us it would be useful in destination decisions, and if a patient needs to be flown to the big city. Also at a recent training I learned that the ultra sound can be used to determine if the patient is hypotensive due to low volume, or poor cardiac output (helping determine if pressers or fluids should be given).

Sorry I have been absent from this thread for so long, but glad for the discussion it has generated.

Believe me, I am fully aware that the problem is me, not my partner; its not his fault that he is new, he can't change that and he does want to learn, but it is my fault that I am impatient. I have many faults, both as a person and a medic, and before was lucky to have understanding partners who helped me "mask" them at work. Thank you all for the various advice.

To answer some questions, I am a new medic (less then a year), and new to the company (just a few months), but was a full time EMT at another agency for 3 years prior, so I'm not brand new to the field.

I agree with what some of you said about it being a partnership, not the medic "in charge." I don't like being "the boss" on the truck, am used to working more in partnership with my partners, but up till this point I was spoilt with really good, experienced partners who I could trust (both as an EMT and as a person), and whom I just clicked well with. I didn't need to worry about simple things like even them knowing how to park the ambulance... I've always (including before I got my medic) disliked the saying "An EMT saves the medic," I think that a good partner saves their partner, regardless of the skill level of either.

My partner and I had it out after our last call, both spoke our minds and pointed out quite bluntly some of the problems that we were having with one another. Hopefully having it out in the open now will help us both to be more mindful and work together better, I suppose only time will tell. I know for my part I am going to be more conscience of how I speak to my partner on calls, and trying to take time before and after calls to explain things.

Sorry for the long delay in the resolution of this case.

I ended up giving this patient 1 L of NS fluid on the way into the hospital, along with 100mcg fentanyl and 4mg zofran. He was much more comfortable with the pain medication. Stayed alert and oriented the entire ride, in fact joked with me "Its a good thing I'm talking to you, otherwise you wouldn't know if I'm alive!" when I was having trouble palpating a pulse. His blood pressure was 74/41 when we arrived at the hospital, so no significant change with the fluids. In hind site, I don't think I would have given him the L of NS, would have gone to a pressure much earlier.

Like many answers, a AAA was top of my list of differential diagnosis. However that was not the case. His abd was distended from ascities. Had 7L drained off in the ER, and they could have drained more, but his pressure kept tanking. Got put on a levaphed drip and antibiotics and admitted to ICU. I was told he was diagnosed with peritonitis and that his "levels" were off (sorry, don't have any specific values).

I am curious why some of you would have held off on giving fentanyl, I though it is safe for hypotensive patients as it does not vasodilate like morphine would.

I'm going with a dissecting aorta and I am looking for a chopper. Fluid replacement needs to be balanced with the likelihood of increasing his already pretty nasty bleeding. I would titrate fluids to keep MAP at 60 and would start thinking about vasoconstrictors. Have you got an anxiolytic/amnesiatic agent on board?

Crappy weather, no ones flying, sorry!

For pain/ anxiolytic drugs you have fentanyl, morphine, dilaudid, ativan, valium, versed, and etomidate

Your pressor options are dopamine, levaphed, or mixing an epi drip

Out of curiosity, why are you wondering about an amnesiatic agent?

Aussiland: Thank you, yes the medication is lactulose which causes his chronic diarrhea.

You start asking the patient more about his pain, he says that it is in the center of his abdomen, radiating into his back; "feels like it is ripping me in half." Pain is 10/10. Try as you might, you cannot feel any pulsating masses. As mentioned before, his abdomen is extremely distended and rigid. No molting noted in his extremities, just very very pale.

Attempt to lay the patient flat, but he develops a panicked expression and tells you it is much more difficult to breath. You settle on a low semi-folwers position.

As DartmothDave suggested, when you ask this patient about his blood pressures, he says running in the mid 90s systolic is not unusual for him. His BP was last checked after dialysis treatment 2 days ago and was in the mid 90s; was 120s systolic pre dialysis.

You have your second IV, but all you could find is a 22G in his R hand (did I mention your partner was a wizard for finding the aforementioned 18?)

Place the patient on nasal cannula at 3 lpm and his spo2 improves to 99%

Start Normal Saline fluids running wide open and hit the road. Oh, did I mention you are ~45 mins away from the nearest hospital?

En route you go to take your next blood pressure using the autocuff and you hear a loud hissing noise from it; the autocuff just broke (gotta love technology!) Grab the manual blood pressure cuff, but you are unable to hear anything. No palpable radial pulses, no palpable brachial pulses. Patient is still Sinus tach ~110 on the monitor, AAOx4.

How much fluids do you give this guy?

Any pain medication? (you have morphine, dliaudid, and fentanyl at your disposal)

Full set of vital signs:

BP 68/42

HR 110, sinus tach

RR 18

SPO2 92%

Skin Pale, cool, diaphoretic; no jaundice noted (sclera white). Decreased cap refill. Good turgor.

Temp 36.8* C

Pt c/o severe abd pain, increasing over 24 hour period.

Doesn't know what brought on feeling unless; is ill frequently, attempting to get on list for liver and kidney transplant.

Vomited 1x today, small amount, mainly bile.

Lung sounds have a trace of rales in the bases, otherwise clear.

Didn't get abd sounds, sorry!

Abdomen is extremely distended, rigid, patient tells you it is normally large but not this large. You can feel a non-pulsating mass in the upper R quadrant.

Perhaps you could tie 8' strap/ backboard straps to the ends of the seatbelt on the bench-seat, to make it longer. Or if that won't work (if the end you need to click it into is flush so you can't tie anything onto it and isn't compatible with the backboard straps) use the backboard straps to tie it to the side of the stretcher, so it can't go anywhere.

For better or worse, I think that it is human nature for us to go more out of our way/ try harder to help those who are nice to us and/or acutely ill. Another way to look at it is perhaps not being able to get his wheelchair to the hospital in the ambulance would be a deterrent to him abusing EMS and hospital resources. Does your town have a public bus? If it does then to be ADA compliant they need to have a way to transport wheelchair users also, maybe he'd rather go to a homeless shelter that is on the bus route then part with his wheelchair to go to the hospital just for a bed/ meal. Has your agency looked into contacting any social services resources to work with him?

Different techniques, but using the same machine though correct?

Can the wheelchair fold? What problem did you see when trying to get it to fit into the ambulance?

So, I found studies showing the use of transcranial doppler ultrasound to evaluate intercerebral blood flow.

"Cerebral angiography shows acute occlusion in 76% of acute MCA territory infarcts within 6 h of stroke onset.⁴ Follow up studies show spontaneous recanalisation in the majority by the end of 48 h and in up to 86% by 2 weeks.⁵ TCD can detect these angiographic occlusions with high sensitivity and specificity, and has a high positive predictive value.⁶

TCD has a specificity of 90% in demonstrating MCA occlusions in patients with acute MCA stroke within 5 h. Alexandrov et al have shown major arterial occlusions in 69% of patients with acute hemispheric stroke, who may be eligible for thrombolytic treatment.⁷ Recanalisation can be inferred by TCD by the appearance of flow in the vessel or an improvement in the flow, with or without reduction in the PI in the proximal segments of the vessel. Thus, in the setting of acute ischaemic stroke, TCD can reveal the presence of arterial occlusion and it can also show whether recanalisation has occurred following intravenous thrombolysis."

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2659960/

And from JEMS:

Diagnostic Ultrasound in Stroke Therapy
Ultrasound use is an area where EMS may be able to make a significant difference in stroke assessment and care. The use of ultrasound in stroke therapy is a relatively new practice. In 1981, Rune Aaslid, MD, created the first Transcranial Doppler machine (TCD), the “UrDoppler” at the then new vascular laboratory of the Neurosurgical Department of Inselspital in Bern, Switzerland. It’s still in use today. With the recent advent of cheaper, smaller and more user friendly machines, TCD is becoming more commonplace.

Although a CT scan is a powerful tool to detect the presence of bleeding in the brain, it’s limited in its ability to detect a blood clot. The opposite could be said of TCD: Although it’s unable to easily detect a head bleed, it’s readily able to find a clot. TCD was recently compared to CTA (a special type of CT with contrast) and found to have an overall accuracy of 89.4% in detecting embolic stroke, the most common type of stroke.⁸ When diagnosing stroke, it’s important to rule out a hemorrhagic stroke (head bleed) before administering clot busters because this could cause the patient to bleed out and die.

There are only two major types of stroke, embolic and hemorrhagic. The presentation of a patient with both embolic and hemorrhagic stroke is extremely rare. So if you can rule out one, then you can generally rule in the other.¹⁰ In essence, the diagnosis of the occlusion of a cerebral artery via TCD could possibly be enough evidence to allow for the administration of tPA in the prehospital environment. But that would mean paramedics would have to perform TCD in the field.

http://www.jems.com/ultrasound-in-stroke

How does transcranial Doppler ultrasound work?

Transcranial Doppler ultrasound works the same way as carotid Doppler ultrasound, except it is done on the head instead of the neck. A small hand-held device (called a probe) is placed lightly on your head, where it gives off ultrasound waves that pass into the body and bounce off the arteries and the red blood cells moving through them, like an echo. The echo from the moving blood is detected by the device. A computer converts the echoes into moving images of the insides of the blood vessels in the brain. Colors in the graphs may be used to show the speed and direction of blood flow.

http://www.hearthealthywomen.org/tests-diagnosis/index-tests/transcranial-ultrasound.html

Hmmm... I heard that behind the ear (where the scull is thinner I guess?) it was able to, of course this is all just what I was told. I'll do some research and see if I can find anything

Manual BP 68/42, no significant change in either arm.

No hx of diabetes, BG 118

PMH: End stage liver and kidney failure, pt attempting to get on transplant list. Dialysis 3x / week, last dialyzed yesterday. No other medical hx, does not know what caused the organ failure. Aside from the organ failure, he was a healthy guy!

He is compliant with his medication, sorry I don't remember any of them aside from a liquid medication the pt states helps clear toxins from his body, and causes chronic diarrhea. No recent medication changes.

Denies chest pain/ pressure

EKG shows Sinus tach ~110 with occasional unifocal PVCs. No abnormalities noted on 12 lead

Vomited 1 x today. Has chronic diarrhea. Decreased appetite today.

You stand patient up to sit him on your cot and he starts to wobble, gets a rather glazed look in his eyes. When he is sat back down after resting a minute says he felt much worse standing, was about to pass out.

Your amazing partner gets you an 18 in his L AC.

We were looking at getting a small portable ultrasound machine for the ambulances; I've heard that it can be used also for detecting ischemic or hemorrhagic strokes, not sure the details about it though.

We usually exchange linens at the hospital. Problem comes when the hospitals are out of blankets (or the one that kept them locked away so EMS couldn't take them). Due to that we'd stock a couple extra blankets at the hospitals that had them. We have laundry facilities at the station, but we are told that under most circumstances we are to leave dirty linen at the hospital and exchange them for clean ones there.

I have typically folded the wheelchairs and placed them by the captains chair or between the bench seat and the stretcher (buckled in).

I realize this is probably the "wrong" answer, but in all honestly, in this situation, I simply wouldn't take the wheelchair, and would not go out of my way to arrange transport for the wheelchair after the pt had become physically and verbally abusive towards me. I also know that the director of my company would support me in this decision (especially with the frequent flyer we have that I'm thinking of). We will take him if he wants to go, but if we cannot transport the wheelchair then he will have to go without it, or stay home.

Was he acutely ill? Why did he want the wheelchair this time, when the walker has sufficed in the past?

I've never written one of these, but lets see how it goes!

Dispatched to residence for the "blood pressure problem." Arrive on scene, find ~50yo obese male sitting at kitchen table in well kept residence. Patient states he has been feeling ill for past 2 days, becoming increasingly weak and dizzy. Also c/o nausea and abd pain. Patient appears very pale. Says he checked his blood pressure at home and found it to be 67/41.

Ready Go!