fakingpatience

Looking for advice anyone here might have. I'm a new medic, and I just got a brand sparking new EMT partner, just got his EMT-B, has not even worked for a month yet. He's not stupid, and wants to learn, but I guess I'm just trying to find the right balance between showing/ telling him how things need to be done and being too bossy. And as a new medic I still have a million things running through my head, and tend to get frustrated with myself, and then less patient with my partner when I need to walk him through the simple things. Also, he is twice my age, which makes it a little more awkward for me to be the one "in charge"/ mentoring him How do you help your new partners? What were some things you remember your partner doing when you were new that was great or terrible?

1. What sort of education do you have? I have a bachelors, along with a separate associates for my paramedic certification. 2. What was your career path from college to present? Why did you decide to follow this career path? I started volunteering as an EMT my last year of college, and decided that I liked the field more than what I was getting my degree in, so once I graduated got a full time job as an EMT, then went to paramedic school 3. What are your basic duties performed during a typical day? Week? Month? Do you have a set routine? What are the major job responsibilities? Trying to describe the basic duties isn't easy! Respond to 911 calls and transfers and take care of patients. Also as everyone else mentioned, inspect the truck and other station duties (cleaning up). Don't have much of a routine aside from attempting to check the truck first thing, as you never know when you'll get a call or how long it'll take (we do LDTs also which can take us ~6 hours at a time) 4. How much variety is there on a day-to-day basis? Generally it varies a lot, you never know what you are going to get. 5. How many hours do you work? ~60 6. Does the typical EMT have a set schedule or are the hours flexible? 24 hours on, 48 hours off 7. Which skills do you feel are most important to acquire? Learning how to interact with people. Assessments 8. What types of technology are used and how are they used? How often are changes made when it comes to new technologies? Cardiac monitors, laptops. Frequent changes in terms of new supplies. More then changes for new technologies it is changes in keeping up with current research in best practice. 9. What educational program do you recommend as preparation? What kinds of courses are most valuable in order to gain skills necessary for success in this occupation? College level EMT course (usually 100 level) 10. What degree or certificate do employers look for? What kind of work/internship experience would employers look for in a job applicant? EMT certification. Some places also favor volunteer experience with local ambulance service. 11. How can a person obtain this work experience? Most areas have places that will hire people without experience, to get your first "foot in the door" job. Just remember if they are always hiring and willing to hire brand new people, there is probably a reason for their high turnover. 12. What entry level positions are there? EMT- basic 13. What steps besides meeting educational and experiential requirements are necessary to "break into" this occupation? Make a good impression during school and clinicals 14. What are opportunities for advancement? To what position? Is an advanced degree needed? (If so, in what discipline?) Becoming a paramedic (1-2 years of college), management 15. Is there a typical chain of command in the field? Completely dependent on the agency you work for. At my agencies we have a shift supervisor on duty each shift who is our direct supervisor. Some trucks are run basic/ paramedic, and at some agencies the paramedic is considered in charge of the ambulance. 16. What are the different salary ranges? Depends where you live. For emt-b I have seen hourly rates range from $7.25 to $13 17. What other kinds of workers frequently interact with this position? PD, fire, nurses, doctors, aides 18. What are the main or most important personal characteristics for success in the field? Willingness to learn. Able to take a joke (you will be teased by your coworkers, but not usually in a malicious manner). Comfortable with people. 19. What are the satisfying aspects of your work? I love my job, getting to help people in their times of need, even if the help just consists of comforting them. 20. What are the dissatisfying aspects of the work? Is this typical of the field? Low pay, long hours can take a toll on you. Lack of respect from other agencis 21. How would you describe the atmosphere/culture of the work place? Friendly, however there is frequently a lot of gossip 22. Is there evidence of differential treatment between men and women EMTs with respect to job duties, pay, and opportunities for advancement? Depends where you work. For the most part I have not experienced any differential treatment, but there will always be 1 or 2 assholes out there. 23. What do you feel are the toughest types of problems and decisions that you must make? Ethical dilemmas when it comes to patient care. Not second guessing yourself 24. What are the demands and frustrations that typically accompany this type of work? What are the greatest pressures, strains or anxieties in the work? As said above, long hours, low pay, lack of respect from other agencies (police, fire, drs, and nurses) 25. What do you know now which would have been helpful to know when you were a student? Realize that what you will learn in school is important, but the real learning (especially for EMTs) begins in the streets. 26. Any other important questions that I have not asked that would be helpful in learning about the job or occupation? Thank you for your time.

Any peripheral / dependent edema (might not be in legs on pt if she is bed confined) ? Any improvement in GCS with 02? Quick BGT and pupil check. Lets place an IO before cardioversion. Highly considering RSIing (+ gag reflex), either way, lets get our airway kit out before we cardiovert, should things go poorly.

Clinical sites are all extremely different on what they allow students to do. If you found a place that is proactive with teaching students, and likes having you there, take full advantage of all the clinicals you can do there! Unfortunately some sites don't like having students (more so hospitals having EMS students) and it makes it much more difficult to have a good clinical experience.

I took an "accelerated" EMT-B program about 4 years ago. It was 10 college credit hours over the summer, either 4 or 5 nights a week for I believe 4 hours a night, with occasional weekend classes. My program also incorporated shifts in the ER, with first response FD, and on the ambulance. Officially we did 12 hours in each setting, 2 6 hour shifts each, but most people (myself included) worked the entire shift each time, so we did 24 in the ER, 24 with the FD, and 24 on the ambulance. IMHO the program I went to was better then the "full length" program from which many people graduated. The full length program only required 4 hours in the ER, no other ride times, and seemed to teach the students through more route memorization than actually learning the whys and hows. I had an EMT rider with me from a 2 year high school EMT program, who had been in the program for a year and a half, who didn't know what the term "contraindication" meant. Island medic, we were never ever allowed to use the DCAP-BTLS acronym in my program! I don't think the length of the program matters (as far as how many weeks/ months it is crammed into ) as much as the caliber of the program and the instructors you have. I would highly recommend you choose one which requires shifts on an ambulance, as that is the perfect time to see if you truly like the field, and to really see what EMTs do on a day to day basis.

I was wondering about hyperkalemia when I saw the T waves in the 12 leads also. Are you saying that the "hyperacute" T waves can be a sign of occlusion, similar to ST segment/ J point elevations? And this pt was indeed having an NSTEMI? Not being a smart ass here, we didn't learn much beyond ST elevations and depressions in my medic class, trying to teach myself the other info now... From looking at the 2 12 leads in comparison with one another, it appears the T waves became much larger in the leads they were elevated in (V2-5) from the first to the second capture. Did you give him any antidysrythmics in addition to electricity?

I know its a long shot, but could we consider giving glucagon, to possibly counter the beta-blockers she takes, on the chance she received an excessive dose of those, not allowing the dopamine drip to raise her BP and HR?

Sorry if I missed it, but hows her mental status? Is she getting "tired of breathing"? I agree, after all the fluid challenges, along with no urine output, she needs a pressure agent now.

Once we are on hospital property, the patient is technically the hospital's patient. We are waiting inside a hallway of the ER for a room, the only equipment we have with us is the cardiac monitor (which some supervisors encouraged us to turn off once we had been triaged and were just waiting for a room, to "show" the hospital the patient was their responsibility... I refused to do that). We were not allowed to further treat the patient, as they were no longer "our" patient, and as the patient was not in an ER room and being seen by a dr, the hospital would not treat them either. On 1 call I was able to give my waiting pt additional pain medication that I had left over in the vial (was going to waste) with permission from the attending Dr, but this was an exception, not at all the norm. If we had fluids or anything running we would continue that while waiting, but not start anything new. Now typically we were not kept waiting with "critical" patients, however on occasion we have been (such as the a-fib w/ RVR patient, another patient on CPAP... both of these were at the same hospital) Believe me, I know how bad for patient care this sounds, thats why I got out of that system as soon as possible (started my new job this month!)

Does your agency not have a jump bag they take in on calls? Thats where all my bandaging supplies and PPE have been. I do carry a few pairs of rolled gloves in the ankle pocket of my pants, protocol book, scissors, a pen and a marker in my side pocket. Not sure what else you'd need to carry on your person vs in the bag. I've seen a couple people with fanny packs, but they were never approved by the company. They carried items that were included in our drug box, but so they could just bring their pack instead of the big tackle box we used as a drug box, if they were feeling lazy. Also sometimes carried items our company wouldn't stock, so we "borrowed" from the hospitals. Usually had a work up kit, zofran, ASA, nitro, a few syringes, high pressure IV tubing, a pediatric pulse ox, can't think of what else. I'd be careful with carrying a pack like that though, as many of these items you shouldn't be keeping with you away from work. Sorry I can't be more helpful, best guess is to just ask the other people at your service what they carry.

My longest wait time was 6 hours. Average was an hour or two. I saw 2 major problems with the hospital systems (not counting the fact they were taking an ambulance off the street), 1, they wouldn't let us put BS patients in the waiting room (I got told "I already have to many patients out there, that won't help me any" when asking the charge nurse if we could put our patient there). And 2, occasionally we were waiting the extended times with actually sick patients, who are then not getting any further treatment, as we are on hospital grounds and can no longer treat them; a few weeks ago I waited an hour with a patient in a-fib w/ RVR rate ~170, after telling the staff numerous times my concern for her. The hospitals would have us stay with patients even if they had open beds, if they didn't have enough staff to "open" those rooms. I considered this using us as extra staff, why pay to have appropriate staffing when you can just keep EMS crews there to watch the patients for you? Officially we weren't supposed to be kept waiting longer than 30 mins, but no company in the area would let the crews put the patient in an open bed and leave, as this would anger the hospitals, and their main concern was keeping them happy to keep to contracts.

Is his skin still flushed and warm? You said his RR decreased, is that because he is getting tired of breathing/ lethargic, or is relaxing? What is the pulse ox? Here is my thinking "aloud" Types of shock: Hypovolemic: Possibly, but where is he bleeding into? Skin should be pale/ cool/ clammy Neurogenic: Doesn't quite fit with his initially elevated HR, but possible. Unlikely traumatic, but possibly a bleed? Cardiogenic: 12 lead is clear, but could possibly be NSTEMI or other. Don't really think pericardial tamponade, no hx or s/s/for that. No s/s of CHF Anaphylactic: Could possibly be a severe reactions, without respiratory compromise, however what is he reacting to? Fits with the sudden onset, tachycardia, hypotension, sudden diarrhea + vomiting Septic shock: Doesn't' fit the sudden onset. He is slightly febrile though I'd be tempted to give him epi at this point. Would help with the refractory hypotension, and if cause is anaphylactic could assist there also.

I don't like that his HR dropped with the blood pressure, to me shows that he is not compensating as well anymore, could go very quickly into decompensated shock. I'd grab an extra person and begin transporting emergent to the nearest surgical center (provided it's not to far away). Large bore IV, fluid challenge to achieve radial pulses/ SBP ~90, getting ready to use pressor agents. Also be prepared for him to code. I'm thinking that he either ruptured an aneurysm, or has a major bleed of an abdominal organ. Is his abdomen still soft? No palpable masses? Would love to have an ultrasound... Again, what color was the BM? Any metalicy smell? If I carried fentanly I think I may consider that as well, to see if we can get the pain better under control to pinpoint its origin.

Lung sounds? Skin condition/ color/ temp? You say he "collapsed," did he fall down, get dizzy, pass out? Did anyone witness his collapse and can describe it, specifically if there was any seizure like activity? What color is the diarrhea? Any nausea?

Not judging you at all, but I don't understand why they would want you to use an IO above an EJ? I would think an EJ is less invasive, and some patients can have really"good" EJs, making getting the line easy.

Here is what popped up on a quick google search http://www.emt-resources.com/emt-reciprocity.html It looks accurate for the states that I personally know. Which areas are you looking at specifically?

The first assessment shouldn't necessarily be looking for DCAP-BTLS, you are doing a much faster exam, looking for major life threats. Obviously airway and breathing compromises, and major bleeding. Broken wrist? Not something you care about on your first exam. Major bleeding from a wrist lac? Big deal. The initial assessment should focus on the pt's head (mental status, airway) and core (breathing), and a "bigger picture" look for the major bleeding (including skin color, pulse quality). I start by looking at my pt before I even have approached them. How are they positioned? Are they moving at all, making any sounds? Do I see any major pools of blood forming around them? Then going closer, are they breathing? Do I hear any obvious sounds (ie snoring respirations, gurgling). Do we need to open the airway? Does their respiratory rate appear adequate? Do we need to assist ventilations? Do they have a pulse radial and carotid? Rate feel adequate? Any injuries to the chest that may need rapid intervention (ie. flail segment, open wound). Major bleeding I need to control? Only once those are all determined, and you know if you need to immediately "load and go" or "stay and play" do you move onto the full body assessment looking for DCAP-BTLS. On that second assessment, you do typically re-check everything that you checked initially, just to ensure that there haven't been any changes. Here is a link to the most updated skills sheet https://www.nremt.org/nremt/downloads/E201%20Trauma%20Assessment.pdf

Oh, we haven't looked/ tried an EJ yet? Absolutely, at this point get the EJ before any further medication

Repeat 12 lead, repeat d-stick. What is her mental status now? I'm not sure about the PO zofran you gave earlier, I know with IV zofran you could repeat a dose at this point, so since we don't have a line I'd do 0.4mg IM. Cautiously begin giving the pt nitro SL 1 pill q5mins as so long as pressure holds. Consider a narcotic pain medication IM. I'd also have the IO kit sitting out next to pt, incase she deteriorates and I need venous access. Oh, and I'd put the "oh sh*t" pads on her, just in case.

I would consider the 12 lead suspicious for at least a lateral wall MI. I would definitely bypass the local facility, if they are anything like the ones here all they'd do is yell at me for brining a pt who needs further care there and transfer her out. I agree with island EMT, time to go for an EJ in this lady and start considering an IO. I would transmit this EKG to the receiving facility, to me it's suspicious enough to "bother" them and see if they want us to begin TNK. BTW how did she get the 500cc of NS if we don't have a line? New set of vitals please

Any recent trauma/ possible head injury? Was she feeling sick/ nauseous before the seizure, or is that new onset? What's her mental status?

I tried to find some research on this but didn't see anything, so I'm hoping someone here may have some insight! If you have a patient you believe has food poisoning, and is nauseous/ vomiting, should you still give an antiemetic? Or is it better for the body to allow them to vomit to get rid of the "poison".

Going off of this, which cuff does everyone find to be more accurate on our "large" patients? I alternate between using the maroon large adult cuff on the upper arm, or the regular blue one on the lower arm, but don't seem to get reliable results with either one. My problem with the larger cuff is I thought the blood pressure cuff is only supposed to take up a max of 2/3 of the length of the upper arm (don't quote me on the number, but I think it somewhere around there), but the larger cuff is not only longer, it is wider, so it ends up covering almost all of the upper arm. What these patients need is a cuff that is longer, not wider.

It took me ~2 weeks to get my psychomotor test results posted online. CBT I got 2 (nerve-wracking) days after taking the test

How much fluid have you given at this point? Any change in lung sounds? If still no rales present, I'd place her on a duoneb, get out the CPAP if she is alert enough to tolerate it. Can we get a 12 lead? Any known allergies? I'm leaning towards sepsis caused by possible pneumonia. I'd be cautious with the fluid boluses though due to the possible CHF hx and peripheral edema, however not loving the pressor option with the afib w/ RVR...