fakingpatience

I'm a new medic, but so far I've been fairly liberal with pain medication (morphine, its all we carry). Our protocols however are very conservative on what you can and cannot give morphine for (only standing orders for isolated extremity injury), so I end up making frequent calls to med control for pain medication outside of protocol. So far I haven't had anyone who is med seeking, but as said by others, who are we to judge whose in real pain and who just wants pain medication? I will also usually ask patients before anything if they want me to give them morphine for their pain. Some patients who are in significant pain might refuse, if they don't like narcotics, or have a history of addiction. As far as pain medication for undiagnosed abdominal pain, I'll call and see if I can get orders, and it's usually a tossup which doc I get. From the doctors I've talked to, it's a fairly old rule to not give pain medication to undiagnosed abdominal pain, especially since now most patients will get an abdominal scan anyway and doctors are less reliant on their physical exam. The pain medication can also help to narrow down the source of their pain by dulling it, so the left over pain is more at the site of the pain, not where it radiates to, and making the patient more tolerant to a physical exam. (sorry, don't have any sources for this last bit, just what I've gathered from talking to various doctors).

I wish I could say I have an idea of what the EKG is, but I don't. The initial strip is bradycardic, with what I think may be a PJC causing the irregularity. 1st 12 lead appears to have a RBBB, but it looks more like a LBBB in the 2nd EKG. I'd want to know if his pacemaker is constant or demand, and what it's limits are set to. Bottom line, it's an ugly looking EKG. I'd advice the pt to transport to a PCI capable facility, and fax both 12 leads to his facility of choice (if he is reluctant to a PCI center, I'd send the 12 lead to the closest facility and see if they'd even be willing to accept him, they are known for transferring everything). I'd start by treating his GI symptoms, IV w/ NS fluid bolus once his D-stick is normal, 02 titrated, zofran for persistent nausea. As far as him being persistently bradycardic, I'd want to know why his pacemaker was implanted initially, what his base problem was, as perhaps that is what is causing his current bradycardia (along w/ potential malfunction of pacemaker)... Interesting case!

Short and sweet question for y'all. If you could pick up right now and move to work in an EMS system somewhere else, where would you go and why? Not using where you have ties to/ family as a point of consideration. There is such a huge variety of places in the United States alone, I'm curious to see some opinions.

My agency only carries valium, can give 5mg, then a second 5mg, have to call for any additional dosages ... This area isn't so big onto the whole "progressive" thing (also only morphine for pain, no other narcotics). So far I haven't been impressed with the valium's ability to control seizures.

I would attempt a 250cc fluid challenge. If no improvement with the fluid bolus (not expecting improvement), I would consider presser agents (dopamine). Get her pressure high enough that she is perfusing end organs, and I can give pain management. I don't know the proper dosage for fentanyl (we only carry morphine out here). In your setting, I would definitely want to be flying this patient.

With the + JVD and hypotension, I'm thinking cardiac tamponade, but I don't know if it could occur suddenly like that

I honestly hate using the backboard, but under current protocols get in trouble if I don't use it on many patients. One trick I have found for "padding the voids" is to lay our thick blanked folded up 4x on the backboard. With this it is almost the same width of the backboard, and provided a much softer surface for the patient to be laying on. The downside is that it is warm, and can get scratchy, irritating some patients. Another idea to help the back be straighter is to put a couple pillows under the patient's bent knees. This helps flatten out the back and is more comfortable for patients. As far as securing the backboard to the stretcher, we have shoulder straps for our stretchers. I put those through the 2 top straps of the backboard, then buckle them into the waist stretcher strap. I put the 3 other stretcher straps over the backboard and pt and secure them, although I suppose it would be more secure to slide the straps through the side holes on the backboard (where you have the backboard straps), to prevent additional movement. I have never really ran into the problem of the backboard moving too much on the stretcher. If I were you I'd be working to stop the usage of backboards, rather then teach the EMS personnel to pad and secure the board better.

Thanks, you guys were right, I did pass! I still think it was odd how few ALS questions there were on the exam. Most of the questions seemed too "easy" to be testing the ALS level of knowledge, so I figured I'd gotten the easy questions wrong, and never even made it to the harder ones. Now onto the skills testing!

I've never used either of those sites, but one we used in my class is an EKG simulator, helps with repetition and quick recall of the base EKG. Edited to fix broken link

(Sorry, this is rather disjoined) I just took my national registry paramedic CBT today. Fairly certain I failed. The test cut me off at about 90 questions (I last looked at the numbers at Q78, only had a few after that). It seemed like there were very few questions geared towards ALS knowledge, and I know I got some of the questions wrong, which is leading me to believe that I failed miserably At least my state doesn't care if I'm nationally registered, my state test is scheduled for next month. Trying to look at the NREMT-P CBT as good practice, and now I know I really need to study for my state test (which my job depends on). I hate this wait for the official pass/ fail notification!

Respiratory rate became somewhat irregular, and it looked like she may be aspirating, so I put in an OPA, suctioned, and assisted ventilations. This was after witnessing her seizing for ~10 mins and 5 of valium IM (slight delay on scene for an ambulance, as we were in a fly car). The seizures did not have the "violent" flailing... I was also told that if you touch an unconscious pt's eye and they have no response/ eye does not attempt to close to that stimuli, it is a good sign they have no gag reflex. Was true for this patient at least, can't speak to it as a rule though.

How reliable is this? I had a patient I am 99% sure was in status epileptics, elderly lady seizing 10+ mins, seizure would occasionally break, for max 10 sec, where pt would have some response to pain, then would begin seizing again, eyes deviated, no gag reflex, no change in seizure activity with valium. But her pulse ox remain high 90s the whole time (although we did have her on supplemental 02 from the beginning).

So I called national registry, to try and get an answer straight from them. They were surprisingly helpful over the phone. My program is not yet accredited with CAAHEP/ COAEMSP, but because I finished before the end of the year I am grandfathered in, and can take the national registry. With the transition program, anyone who takes the NREMT-P test before January 1st 2013, regardless of when you finished your paramedic program, will have to take a "transition class" by march 2017. From what I gather no one is yet certain what the transition class will look like. NREMT says it is up to each state, but my state (who wants nothing to do with NREMT) does not know what the details of what they will do will be. The transition course will cover information included in the new curricula, but not mandatory in old, here is the list: BiPAP-CPAP-PEEP,Access indwelling catheters and implanted central IV ports, ETCO2 monitoring, Morgan lens, NG/ OG tube, additional physician option medications, and chest tube monitoring. If I chose to wait and take the national registry test after the first of the year, all the above topics are likely to be on the computer section of the test (but not on the skill stations). I think I'm going to go for my NREMT-P now, and just plan on taking whatever transition course they come up with later. I really didn't learn much about the above listed topics, so I (a) might fail the NRP test if I'm tested on the new information, and ( should probably sit in on a course teaching about them more in depth. Well hopefully some of this information helps someone else in the same dilemma as I on whether to take NREMT-P now or wait

Would you be concerned with too much fluid for this patient? I only ask because I had a similar patient during paramedic ride time (he felt dizzy and vomited, so he took 2 nitros, which bottomed out his pressure, 60 something systolic on my initial assessment). My preceptor wanted me to be cautious with fluid administration, because he said that once the effects of the nitro wears off, and the patient vasoconstricts, they could go into fluid overload if you gave them excessive amounts of fluid. I ended up 500cc, which along with low semi-folowers (was sitting up on toilet initially) brought his pressure up into the 90s, and resolved his dizziness. So obviously not as severe as the pt you are describing, but I still wonder if that would be a consideration.

Does anybody have a clear understand of the NREMT-P to NRP transition? I recently finished my paramedic program and am looking at getting nationally registry certified. When I looked on NREMT website, it looks like if I take my test before the end of the year, I will have to complete the transition to the NRP in a few years, but if I take the test after the year, I will not have to. Will the test change a lot then? I am debating if I should take the test now, or wait. I do not need it for my current state certification, just want to get it for the future. Any insight is greatly appreciated!

What is wrong with people "buying" this? Sadly, almost all of it is true where I work; 5: Ambulances tend to explode- while we haven't had any exploding ambulances, they are poorly maintained, have died on calls, and have had health hazards (and we were not allowed to pull it out of service) 4: Patients abuse the system in ridiculous ways- Really, everyone in EMS has experienced this at one time or another 3: The burn out rate for crews is sky high- again this is a given at many (private) companies, I was actually surprised how accurately they were describing our long hours, sleep deprivation, and the effects of the stress of the job 2: Procedures are constantly changing, then changing back- They even used the perfect example of bleeding control and the use of tourniquets coming back into use! 1: Crews are constantly getting attacked- Ok, out of all of them, this is the one I have found to be the least true, at least here Personally after reading the article, I feel almost certain it was written by someone who was/is in EMS

Wow, so many great answers! Sorry it's taken me so long to reply. Paramedicmike, I love this response! I have trouble coming up with eloquent, polite responses like that, now if I can just memorize this one! Now as far as some of the other points go. Many of you have mentioned moving on to nursing. Personally, I dont' consider nursing a step "up" educationally, more of a step "over" (not considering higher level degrees like MSN or NP). True there is information that they learn that we in EMS do not, however the opposite is also true, we learn/ go more in-depth on topics that are not applicable to the nursing field in general. That said, I am not trying to demean nursing in any way, I am sure nursing student/ nurses have heard the same sentiment "why don't you go on from just being a nurse" DFIB, I agree, I do not think that I am too smart to be in EMS. As someone else mentioned, I think a lot of it comes down to motivation. I am in paramedic school because I truly enjoy EMS, and will research more in depth in topics when it is something I enjoy. I also happen to have a fairly good memory for protocols and algorithms, which, while I know will not necessarily make me a better street medic, helps me do well in classes. A good number of my classmates (read- firefighers) are taking their medic simply because their department got a grant, and their chiefs encouraged them to go. Some of them have said flat out "I hate EMS" or "I don't need to know this, the paramedic ambulance will be on scene a few minutes after I get there anyway" I think it is easier to "look good" when being compared to people who simply do the minimum, just to get the certification, but don't care about the knowledge itself.

I may be wrong, but I believe that a-flutter can (although not commonly) be irregular also, due to a variable conduction, so this is not always a reliable method of differentiating a-fib from flutter.

Hello all, I have been absent here for a while, but I was hoping people here could help me out. I am currently in paramedic school, finishing in August, and working as an EMT. I love the program, and am doing fairly well. I feel very passionate about EMS, while I might not like my job (my company, ect.) I love the work I do. Recently during clinicals, from doctors, and from lab instructors in school, I have been hearing "you're too smart for EMS", or "What do you plan to go on to?" How should I respond to these people? On one hand, it is an amazing compliment they are giving, but at the same time, why do I have to "go on" from EMS? Why is it looked upon as though if you are smart (good at book learning) you cannot stay as "just" a paramedic? The only way for our field to advance is if people stay in it, and work to advance it internally, not just use EMS as a stepping stone to another career.

Sorry for jumping in here so late. Just another idea, why don't you consider taking the collage A&P concurrently with your EMT course? Depending on what kind of student you are, and you other obligations, it should be very doable to take Anatomy and Physiology at the same time as EMT. As far as the education discussion, I took my EMT class when I was 3/4 of the way done with my Bachelors in Social Work. I finished the last year of my BA, and then decided I wanted to work as an EMT. I don't look at all the time and money spent getting by BA as wasted though. The background knowledge I learned while earning it, and even some of the major-specific classes I have taken have proven very useful in my job as an EMT. I just finished a Survey of A&P class, as I am preparing to enter paramedic school in the fall, and while the survey was good background knowledge, I wish that I had taken the more in-depth A&P 1 and 2.

Unfortunately, the Magnums have still not proven to hold up well, I just broke the zipper on my new pair of Magnum boots (I've had for about 5-6 months). Oh well, back to the quest of finding boots that are comfortable and hold up well

So Ruff, what did the hospital end up finding on the scans?

I was thinking Todd paralysis also, following absent or partial seizures. However, I don't think we can rule out something more dangerous such as TIA or bleed. With her hx it sound like we don't know how long it normally takes the paralysis to clear up (since it happens before bed and then she wakes up fine) so we don't know if this length is "normal" for her or not.