Bieber

I agree with focusing on the associates level for now with increased undergrad options, although I'll state that it was the humanities, fine arts, etc classes that I found the most worthless in my educational endeavors so far. I'm immensely thankful to have found an undergrad program that focuses on the meat of healthcare instead of that junk. Addendum: Not that I don't think that the humanities and fine arts classes are worthless, I've just always resented the idea that someone who otherwise excelled at the core classes could fail to obtain a degree because they couldn't recall who came up with some psychological theory or who painted what picture.

A&P, pathophysiology, microbiology, biology, chemistry, even a bioethics course would be beneficial I think.

I thought about taking CCEMTP this summer, but I decided to focus on my bachelors instead. From what I've heard from those who have gone through the CCEMTP it's a great course, but I wish we would devote as much energy toward higher level degrees as we do to alphabet classes.

I think anyone striving for more knowledge should be given the chance, Mike.

I'm with Bernhard at on this. We know too little about trauma, and what we do know is inconclusive when it comes to the effect of times and survival, but it tends to lean toward the notion that people who are going to die are going to die regardless and people who are going to live will live regardless; our role should be to focus on that narrow subset of folks for whom airway management and hemorrhage control may make the difference.

Because nitro can cause reflex hypertension and tachycardia. Beta blocker first. Haha, nah, I actually knew about Marfan's myself. It's a genetic disease of the connective tissue that can cause spine and especially heart problems--especially valvular and aortic disease. Look for tall patients with long, slender limbs and fingers, pectus excavatum (or carinatum), and a family history of Marfan's syndrome. It's a dominant trait, so one of their parents should have had it as well if I'm not mistaken.

Man, I think I'll just get the patient in the ambulance and expose them in there. There's too much fighting on scene for me to work.

In medical patients there's not usually as great a need to expose the patient as in trauma patients, but again, if you need to do it just do it.

I've dealt with a number of false and pseudoseizures. In my limited experience, though, it's extremely difficult to try and discern whether or not the seizure was truly psychogenic in nature or intentionally faked. Trying to determine the intent or absence of one by someone who on outward examination SHOULD consciously know they're not really seizing isn't an easy thing; I think in general we err on the size of assuming the person is full of shit and forget that fake and psychogenic are not the same thing.

Like Dwayne and others have already said, life comes before dignity. Do what you feel you need to do when you feel you need to do it. Tarps would be nice, but honestly just expose them if you need to. Alternatively you can unstrap them from the cot in the back of the ambulance to fully expose them--as long as you remember to strap them back in before you guys start transporting. Unfortunately as long as we continue to use death--I mean spine--boards, straps are going to have to be worked around to deliver patient care.

Yep. Marfan's syndrome. He's tall, got pectus excavatum, hypertension, a history of a "connector" disease, sharp chest pain radiating to his back. No aspirin, definitely no nitro, no oxygen. Let's get a couple of large bore IV's NS TKO and take him in nice and easy non-emergency traffic. Let's also consider an anti-hypertensive (labetolol or metoprolol I'm thinking) and get him in. Let's also get another blood pressure and compare it to the opposing arm. He's got a bum aorta. "Lincoln, I think you may have a tear in one of the large arteries of your body. We're going to get you in and checked out by the docs. Try to relax and not worry, we're going to take very good care of you."

The hell? Lincoln, is that normal for you? Any recent trauma? Ever had to receive CPR? Noted, his pressure is steady for now but I'll keep an eye on it. I'm thinking anteroseptal ischemia based on that, however along with the rest of his presentation I'm growing concerned that this could be related to his aorta. Prinivil? Does he have a history of high blood pressure? How tall is he? Any history of connective tissue disease (Marfan's, Ehler's-Danlos syndrome, etc)? Great scenario so far, man.

Hi, Lincoln. Can you point to where exactly the pain is? Does it go anywhere? Let's push on his chest and see what kind of response we get. What makes it better? What makes it worse? Position? Exertion? Movement? Touch? Let's go ahead and put him on the EKG as well and get a 12-lead while we're at it. PMH? Meds? When did the pain start? Has it been continuous since onset? Have you ever had this pain before?

Let's make patient contact. What does he look like? Skin, level of consciousness, work of breathing? Levine's sign? Let's feel for a pulse too, how's that? Describe your pain to me, sir. While you're doing that, let's get him on the pulse ox and get a blood pressure while we're at it.

I tend to agree with Kiwi on the benefits of simple, concise PCR's. At my service, our ePCR's generate a narrative format that imports information inputted above (vitals, treatments, etc) and we type in an HPI, review of systems, and outcome. I'm not near as concise as Kiwi is, but I'll give an example based on the scenarios above. Scenario 1 Intro: On (date), unit (#) responded to (hospital A address) on a reported (dispatch code for non-emergency transport) C/C: Patient is a 70 years old female, c/o unknown medical HPI: Patient is being transported today from (hospital A) to (hospital for continued care following a right knee replacement surgery. At time of patient contact, patient presents alert and oriented x3 in no acute distress. RN staff state that they administered pain medication approximately one hour ago. Patient is pain free at this time. PMH: right knee replacement Allergies: NKDA Medications: None Assessment: HEENT: pupils left (reacts) right (reacts). Normal on inspection. Neck: Normal on inspection. Chest: Equal chest rise, adequate depth of respiration. Lungs: right (clear), left (clear) Abdomen: No complaints. Pelvis: Not assessed. Posterior: Not assessed. Extremities: Neurovascular function intact x4, bandage to right knee (presumably). Injury: None. Systems: CV: Radial pulse strong and regular. Resp: rate (normal), (unlabored) Neuro: AVPU (alert), initial GCS (15) GI/GU: No nausea/vomiting. Integ: skin color (normal), temp (normal), condition (normal), less than cap refill (2sec), edema (none). Vitals: (time) BP:120/70 HR:70 R:16 Sats: 99% Provider Impression: right knee replacement, non-ambulatory Treatment: Assessment and transport. Outcome: Patient was moved from scene to the ambulance via stretcher. Patient was reassessed en route with no additional complaints or acute changes noted en route. Patient care was transferred to RN staff at hospital B. On to scenario numero dos.... Intro: On (date), unit (#) responded to (incident location) on a reported (dispatch code for diabetic emergency) C/C: Patient is a 30 years old male, c/o diabetic emergency HPI: EMS dispatched by PD for a patient complaining of a possible diabetic emergency. PD states that the patient was found in his current state. Patient has a history of diabetes and reports having taken his insulin today without eating afterwards. Patient presents verbal confused with no injuries or other complaints at this time and states that he took his insulin earlier today and has not eaten anything since then. PMH: diabetes Allergies: NKDA Medications: insulin Assessment: HEENT: pupils left (reacts) right (reacts). Mucous membranes moist, no abnormal nose/ear discharge. Neck: Normal on inspection. Chest: Equal chest rise, adequate depth of respiration. Lungs: right (clear), left (clear) Abdomen: No complaints. Pelvis: Not assessed. Posterior: Not assessed. Extremities: Neurovascular function intact x4. Injury: None. Systems: CV: Radial pulse strong and regular. Resp: rate (normal), (unlabored) Neuro: AVPU (verbal), initial GCS (14) GI/GU: No nausea/vomiting, incontinence. Integ: skin color (pale), temp (cool), condition (moist), less than cap refill (2sec), edema (none). Vitals: (time) BP:100/50 HR:100 RR:20 Sats: 99% BGL: 20 (time) BP: 100/50 HR: 90 RR: 16 Sats: 99% BGL: 200 Provider Impression: diabetic emergency Treatment: (time) IV access; 20 ga; L AC (time) NS 1000; rate: TKO; dose: 40 mL (time) Dextrose; dose: 25 gm; route: intravenous Outcome: IV access was obtained and patient was administered dextrose following which he had an immediate increase in his level of consciousness and a complete resolution of all symptoms. Patient was reassessed and was made to eat a protein-rich meal in our presence and was advised to recheck his blood sugar in 2 hours. Patient was also advised to follow up with his regular physician. Patient refused transport via EMS and signed the refusal form. Patient left on scene with PD. (I added my own little spin to this... enjoy! Also, Dwayne, please see this and rage at the refusal!)

Mike, would you mind sending me an example of one of your PCR's? I really want to see your format now.

I have to echo the thoughts of several other people in saying that while I'm all for people getting tats if they want them, I also think that for better or worse, right or wrong, tattoos do not present the image that our patients seem to want. I'm not sure if we have a policy regarding tattoos or not at my service, but I know there are several people who do have multiple tattoos who don't do much to cover them. I don't have any, though I've often thought about getting one. As for EMS specific tats... I don't know, they seem kind of whackerish. To each their own, but I'm not sure if I would get one myself.

Currently, yeah. By the way, did he have any cyanosis when his sats dropped?

Not directed toward me, but I'll answer from the perspective of my system. We're very "ops heavy", and I don't think we can really wrap our heads around the notion that other systems of equal size may not be just like us. We also must have a lieutenant or acting lieutenant on every truck who is in charge of operational issues. In my system, in a multi-patient scenario like this, it would fall upon the lieutenant or acting lieutenant to sit in the truck and coordinate resources while the paramedic went and tended to patient care. That said, with only two patients we'd both probably be on scene, but my lieutenant would probably step away after I gave my initial triage and focus on the radio for a moment while I worked on getting the second patient "packaged" with the help of fire crews. It's not uncommon for us to split crews, and in fact there have been several times where I would be on scene tending to multiple patients while my partner sat in the truck and coordinated additional incoming units. In our system, this would continue until either we disbanded "medical branch" or until one of our supervisors showed up and "assumed" medical branch command. Not saying it's the best system, and in fact I have a lot of beef with the ops heavy nature of our system, but just something to think about for people who are saying that both EMS personnel should go on scene. Addendum: Also, the reason for the lieutenant to stay in the truck is because we frequently utilize scene specific channels to avoid flooding our primary EMS channel. Since we each only carry one radio on our persons, the lieutenant will scan both scene and primary channels using his portable radio and the on board radio.

Dwayne, by orientation I actually meant his workplace orientation, lol! So what we've determined so far is that he's ventilating fine. Short of being unaccustomed to oxygen levels at that altitude, that leaves pulmonary gas exchange, gas transport and peripheral gas exchange as the three locations where the problem must lie. I'm still leaning toward high altitude issues on this one, though pulmonary embolism is still on my list as well. Without further diagnostic scans and without the ability to test to see if he improves with descent, I'm kind of at a loss as to how to rule in/rule out any more diseases, however. My best guess for now would be to keep him on bed rest for a few days and see how he does. If he acclimatizes and the dyspnea and hypoxemia resolve then that would support a diagnosis of high altitude illness.

I think it would be great, but I see two primary obstacles standing in the way of it: Cost: I'm not sure how much a ventilator costs, but I know it's obviously enough to be prohibitive to many services--especially those with large fleets. Knowledge: This is a secondary obstacle, because I firmly believe that EMT's and paramedics are capable of acquiring and correctly applying any new subset of knowledge and skill with the right education and training, however it ties into my first point in that it is costly to provide the right amount of education and knowledge to that many individuals. The other thing is the need for it to be done routinely so that we don't forget how to do it. I remember going over ventilators during paramedic school and playing with several different models of them and learning a lot about how to properly use one. Could I use a ventilator now? Not a chance.

First patient, open the airway, if still pulseless and apneic, then no. Triage code black (obvious death). We no longer run "blunt blues" unless the cause of their arrest seems to have a medical etiology.

I'm tending to think along the same lines as Mike right now, but I'd like to learn more. How long has he been here at this altitude? What exactly does his orientation consist of? Has he had any other symptoms? Specifically any headache, dizziness, lightheadedness, malaise, etc. Any chance we can take him down toward sea level and see how that affects him? Also, you said his lung sounds were clear, how about tracheal sounds?