Bieber

As with all scenarios regarding respect for the individual patients' sensitivities, I'll make reasonable accommodations for my patients, but ultimately I have a job to do and that comes before their personal and emotional comfort.

Either fire or us bring portable suction in for cardiac arrest calls, otherwise we don't bring it habitually. Thus far, I've never needed it except on code blues.

I believe my service's policy is to make every reasonable accommodation for service animals with the understanding that if transporting the animal would be detrimental to or interfere with patient care or endanger the patient or crew then it will be left on scene and arrangements made to ensure another ride for the animal to get to the hospital. Honestly, I would much rather NOT have an animal in the back of the truck, but as long as it stays out of the way, I guess it wouldn't bother me too much.

As respectfully as I can say this, I haven't heard an idea that made me cringe as much as that in a long, long time. That's equivalent to saying that we shouldn't change ANY part of our practice if it could affect people's jobs. Science says transporting dead people is bad? Too bad, keep doing it, 'cause the hospitals might have to lay people off if they're not making enough money from continuing field codes. EMS isn't about saving people's jobs, least of all firefighters', and I for one am not going to advocate the maintaining of a system, no matter how long it's been around, if it's no longer the kind of system that's going to move EMS forward or benefit our patients. I'm not out to help maintain anyone's livelihood but my own, and this attitude of neutrality with respect to fire-based EMS has to stop--because I guarantee you that, from what the IAFF promotes, they're not out to protect the livelihood of anyone but firefighters. I've said it before and I'll say it again, the biggest reason why EMS is run by everyone else BUT EMS is because we are too damn neutral. We're all a bunch of cowards too scared to stand up to the IAFF and our national organizations are too scared to take a stance AGAINST fire based EMS. But you know what? We are the only ones who don't think there's a war going on for control of EMS. The IAFF has made itself clear: they are out to take EMS, and they'll use whatever tactics they have to to get a hold of it. If you want to see EMS grow and prosper and progress as a profession, then YOU have to be willing to say NO to any person or any organization that would seek to lower EMS educational standards.

Wow, what a day! It all went very well, and I had some very good and interesting calls. Got to see (and convert) my first SVT, rate of 180. Had a little trouble with the four-way stopcock, but in the end it turned out all right. And I saw an atrial flutter with a rate between 280-290 with new onset CHF. Tried some diltiazem, but it didn't slow down a whole lot. I think after that, I feel a lot more comfortable handling some heavier call loads and some tougher patients. Thanks for the kind words, everyone.

Couldn't find a better place to put this thread, so this is where it ended up. So as some of you may know, I work for a busy urban service part time (I've applied for full time, just waiting) and recently got my paramedic certification in January. Thus far I've worked two shifts as a paramedic, totaling one call each of those shifts that I was up for; one ALS and one BLS. But tomorrow I'll be working my first shift at one of our busier stations (AVERAGE of 6-10 calls in 12 hours) tomorrow. To be honest, I'm a little nervous. It's only half a shift, since I have an exam tomorrow evening, but it's still a little nerve wracking. On the bright side, I'll be working with my former preceptor, but this will really be the first time I'll be working a heavy call load as a paramedic. I'm still a little nervous, being new, but hopefully it'll be a good day. Anyway, I guess I didn't have too much direction for this thread, but I am a little anxious about it and wanted to vent. Wish me luck, I'll let you guys know how it went tomorrow evening. P.S. Actually, to give this thread a little more direction, I'll add some questions! 1.) How long did it take you to really start feeling "comfortable" as a paramedic? Obviously there are always calls that make you pucker no matter how experienced you are, and you'll never experience everything that EMS could throw at you, but in terms of feeling like you can handle your own without sweating too profusely? 2.) Do you have any good (or bad) "first day" stories?

Real quickly to clarify to everyone: the service for which I am writing these protocols is NOT the service I work for, nor do I have any formal affiliation with them at this time. I would LIKE to work for them, pending a protocol revision, however at this point in time I am ONLY writing their protocols for them. The reason for this is that their director is only an EMT and they only have two part time paramedics, one of whom approached me to write their protocols for them. The service I work for (not the service I'm writing the protocols for) has a protocol committee which submits protocol revisions to the medical director who must approve them and then they must be approved by the local medical society. The medical director of the service I am writing the protocols for, I can't speak for; however I assume that their standard is to write the protocols which must then be submitted to and approved by the medical director. Also, with all due respect, while I agree that were this a larger service the protocols ought not come from a single paramedic, I do respectfully disagree that the protocols should not come from paramedics in general. I feel very strongly that in order for EMS to come into its own as a profession we MUST, absolutely MUST be the creators of our own destiny. As I've said before, I don't feel that I am the best person to write these protocols, but I have been offered the opportunity to do so and I won't shy away from it; and though I may be inadequate I intend to do my very best to provide a set of protocols that are grounded firmly in science (I've already included in my rough draft that oxygen is NOT to be given wantonly or arbitrarily) and that they are representative of the "best practice" and highest standards I can accomplish. Paramedics ought to be the leaders in the field of paramedicine, and though I feel we will always need medical oversight, I also believe that we should be the ones creating our own protocols (to be approved by a physician) and not simply sit back and have no hand or no guiding hand in the practice of paramedicine. We need to be reviewing the current research and our current protocols and be able to justify everything that we do, and I feel that, though I may not be deserving or capable of this, I will surely try and in doing so play some small part in turning paramedics from "the guys who get their protocols from people who've reviewed the research" to "the guys who review the research and write their own protocols to be further approved by their medical director".

I don't have time to respond to your thread in its entirety, but answering your question about where I am, that would be Kansas.

Hi everyone, Well, it seems a cold day in hell has come upon us and I, of all people, have been offered the chance to write a set of protocols for a small and rural EMS service. The opportunity landed in my lap after a former classmate and colleague who works for this service (one of their only two paramedics) mentioned they were in the process of revising the protocols and asked me if I would like to write them for that service. I have been interested in this particular service for a while and had even been tempted to work for them, but for one problem: their protocols are absolutely atrocious. Not in that they're particularly bad in se, but only that the way in which they are written is completely incomprehensible. They include drugs not carried and exclude drugs that are carried. Because I don't think I could make heads or tails of their protocols if I tried, and because I refuse to work ALS if I can't or don't understand the protocols, I have thus far not sought employment with them. But thankfully, they've made the wise decision to clean up their protocols and I've been given a rare opportunity to take part in it, and though I am certainly not the appropriate person to do so I would like to give it my best shot. I asked for a list of drugs they carried and was told that I could select whatever drugs I wanted, citing that with the new protocols they would adjust their drug stock as needed. Now, I know the drugs used by the service I currently work for well, and I'm familiar with other drugs that we learned about during paramedic school, but having never administered many of them, I have less experience with them as many of you however there are several drugs of which I've heard good things and I'd like to get your input on them and on these protocols in general. I'm going to do some further reading on each and every one of these drugs, but I'm looking less for a textbook answer from you guys and more of your own personal experiences with these drugs and your opinions of them as clinicians. As I develop these protocols, I'll add more to this thread and address each section individually, but for now I'd like to stick to the drugs alone. And so, without further ado, let's begin! Pain Management -Fentanyl - We carry this drug at my service and I'm a big fan of it, so I would definitely like to keep it here however I oftentimes feel frustrated by how limited we are in terms of providing pain management on a wider scale so I would like to consider some other options and get your feedback on them. -Morphine - Though it's popularity seems to be fading, I still feel like there seems to be an appropriate time and place for this drug. As the service in question is about an hour away from the nearest hospital, and because if I recall correctly morphine lasts longer than fentanyl, it seems like it would be a good option to have. I know it's use in MI has been called into question, but what about for general pain management and its use in conditions such as pulmonary edema? I've heard from at least one paramedic that he's never seen anyone in acute CHF dry up as quickly as they did with morphine. -Ketorolac - I've given it a couple of times, including once for kidney stones and though I haven't ever seen its effects firsthand (too short of a transport time), how do you feel it stands for mild to moderate pain and also, do you feel it's useful in the relief of pain secondary to kidney stones? Antiemetics -Reglan - Another drug we carry at my service, and one with which I've never had any problems but as a drug that I know seems to be falling out of favor, I would like to know where it ranks alongside two other drugs: -Zofran - I've given it during clinicals and it seemed to work well. I know of a neighboring service that carries it and everyone there seems to be a big fan of it. -Phenergan - Given it during clinicals, don't recall much about it to be quite honest. Between these three, which do you feel has the greatest effect on nausea with the fewest side effects and associated risks? Bronchospasm -Albuterol - Use it at my service, I'm used to it, seems to work fine for me. But (and this is for those guys who are big on RT) what about some other drugs such as... -Xopenex - I've heard good things about it, never used it. -Combivent - I know the hospitals around here seem to use it a lot. I know it's albuterol + ipratropium. Is there a big benefit to this over albuterol? Sedatives -Ativan - Real familiar with this drug. It's what we carry and it seems to work pretty good. But, having never used or administered any other sedative, I'd like to know how it stacks up against a couple of others: -Valium - My service used to have it before I was here, don't know why they got rid of it to be honest. I know it has a pretty short half-life compared to the others, which may or may not be good for a service an hour away from the nearest hospital. -Versed - The one experience I've had with Versed was not a good one. We had a transfer patient who was tubed and the doctor wouldn't give him anything more than some Versed and refused to give us an order for Ativan. The guy was bucking the tube by the time we got to the receiving hospital twenty minutes later. Nitroglycerin -Tablets - This is the way I've always given nitro, it works fine but it's not very controlled. -Paste - I've heard this route is even less controlled than the tablets. -IV Infusion - Don't know of any services around here that use it, but I've heard from a lot of paramedics that it's by far the most controlled way of giving nitro. Those are the main drugs I'm curious about, but if anyone would like to throw in some other drugs for consideration or some ideas for these protocols, I'd be really interested in knowing your guys' opinion. There's no guarantee that my protocols will be approved, or even that I'm competent enough to make a decent set of protocols, but like I said I would like to try and hope I can do a half-way decent job of this.

Well, that didn't quite work out! Over the last week or so I've been trying to make this thing with U-Pitt happen and, unfortunately, it didn't. The problem was all financial, it would have cost about twenty grand for the two semesters I'd've been attending and that's something of a deal-breaker, unfortunately. That's all right, though. Taking what little I know about the healthcare industry and what you guys have so graciously offered, I considered going for my BSN instead and became rather depressed when I realized just how much more schooling that would entail for me. My unfortunate situation is that, though I have 115 credit hours, not enough of them are in one concentration to earn me a Bachelor's and the courses a nursing degree would have required are almost all ones that I do not have; so in essence, I would have had to start from scratch. However, after some careful reflection about my options and also what my own personal career goals are, I've decided to resume the path I had been on pursuing a Bachelor's in Biology with a few twists to it. In addition to my Bachelor's in Biology, I'm also going to try and get my Associate's RN. The tough part was deciding which program to choose from; because I can bridge to RN in three semesters (summer included) through the same college I got my paramedic, however I wouldn't be able to start till next spring--or to start a regular RN program at another college this fall that does four semesters and only spring and fall. My eagerness to start the program is hard for me to restrain, but I think that the bridge program is a better fit for me. Following the bridge program, I'll only have one more semester of classes to get my Bachelor's as well. So my (presumably permanent but knowing me still tentative) plan is to get the rest of the prereqs for the bridge program as well as work on some Bachelor's classes this year, start the RN program next year and continue to take a few Bachelor's classes in addition to that (one or two a semester tops) and finish my RN the fall of 2012 and my Bachelor's the spring of 2013. The good thing about this route is that it also gets me all of the pre-PA classes I need, so that remains a possibility I wouldn't have if I'd gone the BSN route and if it fails or I decide it's not for me, I'll have a Bachelor's and my RN to keep my career viable and my options open. Thanks again to everyone who helped me out with this, especially to Dwayne for giving me some good advice on the side. Don't know what the future holds for me long-term, but I think this path will make me a better clinician no matter where I end up.

Also, what's the starting salary and cost of living in the surrounding area? What kind of shifts? What opportunities for advancement are there?

Not to get into the age old intubation debate, but don't most systems say ETI first and THEN blind airway? Personally, in my system, those are strictly backup airways; first line is ETI. Good deal. Any change in his respiratory rate or mental status? If we're not getting any change after a while, we might need to start thinking about RSI. From here, there's not too much we're going to be able to do prehospitally. We need to start getting this guy packaged and ready to go to the hospital where he can die peacefully. The goal's going to be to maintain an airway, but without an OPA he's going to be getting a lot of air in his stomach and if he doesn't start breathing more effectively I'm going to go with RSI; we also want to maintain that pressure with fluids and maybe try another 5 mg of glucagon IV or another 0.5 mg atropine. How far away are we to the nearest appropriate facility?

What is the patient's response to treatment?

Well, I heard some gurgling so can we first and foremost move him onto the cot where he's laying supine, open his airway, assess for and suction any secretions present? Let's also elevate his legs, see if he tolerates an OPA and start assisting ventilations with a BVM and O2. I'd also like to place him on the monitor and assess his rhythm as well as run a 12 lead. His blood sugar's also extremely elevated, does he have a history of diabetes? I believe verapamil overdose can cause hyperglycemia, but we ought to find out his history nonetheless. Let's put the patches on and prepare for pacing and also get two large bore IV lines and start bolusing in NS to try and get his pressures up, we can also go ahead with 5 mg glucagon IV and 0.5 mg atropine to try and get his heart rate up. As slow as his heart rate is, I want to hold off on intubation for as long as we safely can to reduce the risk of reflex vagal bradycardia. When did he take the drugs? How long has he been like this? Any past medical history? Any history of previous suicide attempts? Allergies to medications?

I don't disagree with you about it being unwise for fire to run lights and sirens either, and to be honest I don't see the sense in taking an engine to a medical call--a lot of risk for zero benefit, if you ask me. I'm not sure what VSA is, but you're correct that we rely on fallable dispatch information, however I still don't think that running lights and sirens to all calls is a wise idea.

Okay, well, this is my understanding: a DNR is not an order to withhold treatment, it's an order to withhold resuscitative efforts. Insofar as that no treatment given is for the purpose of resuscitation, or that once in arrest the patient is not given rescuscitative treatment, I don't think it's legally prohibited by the DNR. Is intubation invasive? Yeah. Does the patient WANT intubation, even if it's not for the purpose of resuscitation? Probably not. From an ethical point of view, no, I don't think intubation is the correct course of action. I would hazard to guess that when the patient signed the DNR, she may have thought that it will prohibit drastic measures from being taken up to and INCLUDING cardiac arrest. However, I can't make guesses as to what the patient would want, so I would have to defer to the pure legal facts: intubation is NOT being used as a resuscitative measure, but as an appropriate medical treatment for a patient that is still very much alive, and therefore in the absence of a DPA or advanced directions, is not prohibited by the DNR. Now, were it me in the field, I would hold on the intubation till we got to the hospital and let someone with a bigger pocketbook than mine make that call. And that's a luxury I have in the field. I don't know what the exact rules/laws are regarding physicians, but I have seen--at least in my neck of the woods--physicians withhold certain treatments not covered by a DNR per family wishes. Ethically, I think we ought to respect the wishes of our patients who are aware of their fast approaching end, and if it were within my power to realize those wishes, I would rather give them a peaceful death than a terrible life. It's a tough call, and down one route you may never know what the patient's wishes were for certain; but down the other, you could violate their trust in the medical society, in their family, and further abuse an already tormented body.

I see a third degree AV block with a left bundle branch block.

Around here, I'm not especially convinced that the nurses have much of any idea of who we are or what we can do, and as far as I know I've never heard of any nurse doing a ride along with EMS (or having any desire to). Also, around here nurses don't intubate or place central lines. On a side note, I love ER!

http://urbanhealth.udmercy.edu/ekg/read.html http://www.publicsafety.net/12lead_dx.htm http://www.sh.lsuhsc.edu/fammed/OutpatientManual/EKG/ecghome.html Have a look at those, and good luck. If you have any specific questions, I'd be happy to help as much as I can--and there's a lot of much more knowledgeable and experienced people on these forums than me that I'm sure would help.

Our ePCRs have a generate narrative function that I use, I've tried to recreate it to the best of my ability here with a basic fall scenario. I'm very meticulous about my chart writing and have found that writing them the same (basic) way every time not only helps my charting but also my assessment. Chief Complaint: Fall Past Medical History: None Medications: None Allergies: NKA History of Presenting Illness: Patient complains today of a fall secondary to slipping on a wet floor while getting out of the bathtub. Patient denies losing consciousness, hitting their head/neck/back and also denies weakness/dizziness prior to or following the fall and states they assisted themselves to the floor but twisted their right ankle when they fell. Patient denies any recent illness and states the fall was purely due to slipping. Patient Assessment: Patient presents alert and oriented x3 with a patent airway, unlabored respirations, a strong and regular radial pulse with warm, dry skin consistent in color. Patient's only injury is swelling to the right ankle; no deformity or crepitus noted however the extremity is painful and tender to palpation--pedal pulses are present and equal bilaterally with intact neurological function and no numbness or tingling. Head: Eyes PERRL. No deformity, pain/tenderness to skull or soft tissue injury. Mucous membranes moist, no nasal flaring or perioral cyanosis. Neck: No JVD, retractions, deformity, pain/tenderness to C-spine. Chest: Equal chest rise, adequate tidal volume. Abdomen: Soft, no bruising, distention, pain/tenderness. Pelvis: Stable, no pain/tenderness. Extremities: Neurovascular function intact x4, no numbness/tingling; swelling to right ankle noted, see above. Cardiovascular: Radial pulse strong and regular. Respiratory: Lung sounds clear and equal bilaterally. GI/GU: No n/v. Integumentary: Skin condition normal, temperature normal. Neurological: GCS: 15 Vital Signs 01:04 BP 120/80 HR 110 RR 18 SpO2 100% Glucose 90 Pain 8/10 01:10 BP 120/80 HR 90 RR 18 SpO2 100% Pain 4/10 Interventions 01:05 IV access; 18 ga; right ac 01:05 IV fluid NS 1000 mL; tko 01:06 EKG; sinus tachycardia, no ectopy 01:06 O2 NC; 4 LPM 01:07 Fentanyl; 80 mcg Outcome: Patient continuously denied pain/discomfort anywhere else in his body except for his ankle and was moved to the cot and into the ambulance where an IV was initiated and 1 mcg/kg fentanyl administered for pain control. Patient reported a decrease in pain from 8/10 to 4/10 following administration of fentanyl and elevation of his injured extremity and had no additional complaints throughout transport. Patient care was transferred to Generic RN.

I don't recall anyone stating in the show how long the tourniquet had been on. The guy had intact neurological function and his arm pinked up again after they got the tourniquet off, though it looked darker red than the rest of him. Didn't look swollen or anything. I would assume that he called 911 right after or as he was putting it on because in one scene he was still wrapping more cord around his arm. Now you all know what my preceptors had to deal with, me thinking of the most obscure scenarios and asking them what they would do in them.

So I was just watching Cops ('cause I'm that cool) and they had a guy call 911 because he had shot up some speed and, thinking he had taken an overdose, used a lamp cord as a tourniquet thinking that would stop it from entering his system. The cops cut the cord off of him (his arm distal to the cord was blue and purple) and he was transported by EMS, however it got me thinking. Exactly what IS the appropriate treatment for makeshift tourniquets? I know that the rule is to not release a medical tourniquet once placed, but do the same rules apply for makeshift tourniquets? Especially if they've been MacGyvered from unsafe tourniquet materials such as string or rope? It seems like the obvious answer should be to leave it there, but I'm not too proud to admit that this isn't something that came up often during paramedic school for me and seeing it on that TV show got me curious. So what do you guys think? Am I just over thinking this or should we remove unsafe tourniquets if they're in place prior to our arrival? I did a bit of reading and according to at least on article I read there is actually a fairly low risk of complications of tourniquet use or removal such as rhabdomyolysis, artery or nerve damage.

It seems like it could be a continuity of care issue. As the transporting paramedic who is responsible for that patient and for providing the hospital report, I personally don't want to have to explain why treatments were given that I didn't give--especially if they're incorrect treatments (of course excluding CPR and AED use). Around here fire responds with us on all medical calls (unless we get there first and decide to call them off if we don't need them), and there are some FF/Paramedics but they can only act as basics.

Thanks everyone for all the advice, I really appreciate it and it's good to hear a couple of different takes on the matter--a couple of ideas suggested, like the RT one, I hadn't even considered. That's what I thought. Around here most of the critical care services staff an RN and a paramedic, so being dual certified would let me work with whoever they pair me with. But to be honest, I don't have a real burning desire to work as an RN outside of transport. I might be mistaken, but from the nurses I've spoken to it's my understanding that a BSN really only seems to help with getting into management and administration as opposed to changing or advancing your role in the clinical setting. Does that sound correct to you? To be completely honest, part of why I'm so interested in this BS in Emergency Medicine is because if I AM eligible to only have to take the senior year, I'll be done with my Bachelor's a lot sooner than I would in any other Bachelor's program that I've looked at so far. My number one priority right now is to just get my Bachelor's (don't get me wrong, I DO want it to be a meaningful Bachelor's, and I wouldn't pick something like liberal arts in theatre even if THAT were the shortest route), and since I only have to take three more semesters to get my RN through the local bridge program, that seems like it would be the shortest route to obtaining my Bachelor's AND my RN. It's nothing specifically against a BSN, but I'm twenty-four and I feel like I should already have my Bachelor's by now. Thanks for the encouragement. Like I said, I'm still not sure if PA or med school is in my future, but I know for certain that if I DO stay in EMS, I want to lead by example and help set the tone for more educated, more qualified paramedics within the system and help fight against these paramedic mills that churn out medics in six months or however long they are. Thanks again, everyone. I look forward to more opinions from the rest of the forum!

I don't have time to type out a full reply, but I'd like to jump in real quick and say that I have read at least one article from the New England Journal of Medicine where nitroglycerin was shown to permit movement of a thrombus further down inside an artery in a patient with a cerebral infarct affecting the patient's vision. Here's the article, I just googled it up real quick and found it so I'm not real certain as to how common this event is, if at all. I'd suggest looking further into the studies available regarding nitroglycerin and thrombus migration, but this should get you started. http://www.nejm.org/doi/pdf/10.1056/NEJM199011153232018