Bieber

I believe nitro also relieves esophageal spasm, if I'm not mistaken. Although that brings up a good question that I hadn't questioned nearly as much as I should have. What IS the correct dosing for nitro? If pain relief isn't indicative of effectiveness (though my protocols say nitro till relief of pain), then when and to what end should nitro be given, if at all? Wasn't there a study that said nitro doesn't improve mortality/morbidity?

We use fentanyl around here and to be honest it's been fairly rare that my patients have ever reported much (if any) relief from it. Our standing orders are for 1 mcg/kg followed by a second 1mcg/kg if no relief after I think five minutes. I'm not sure if it has to do with our fairly short (around 15 min) transport times or if perhaps the dose is too small. I've never given more than a hundred mics to anyone before, and I've never redosed anyone either. How long did it take your patient to start getting some relief? Also, do you usually give pain management on scene? The only time I've ever started an IV on anyone outside of the truck has been on code blues, and I can't imagine doing much on scene unless it was like a diabetic emergency or an arrhythmia type deal. At least from the paramedics I've worked with so far and from my experience with my preceptors, everyone around here is very much "load and go" with very little scene time. I assume that's probably because our times are what's looked at when it comes to performance evaluations, and nobody wants to spend time on scene to get a line or push any meds unless they're critical. Do you guys have that kind of restriction or are you guys fairly free to take as much time as you need? Also, out of curiosity, do you usually get your IVs on scene or in the truck?

We use the Plano 747. -calcium -epinephrine (for cardiac arrest) -lidocaine -dextrose -aspirin -nitroglycerin -atropine -adenosine -magnesium -ketorolac -epinephrine (for allergic reactions) -diphenhydramine -metoclopramide -solu-medrol -glucagon -albuterol -thiamine -labetolol -4 way stopcock -narcan -meconium aspirator -umbilical cord clamps -lancets + bandaids -needles -syringes -saline bullets -alcohol preps -tourniquets -IV needles -tape -laryngoscope blades + handle -syringe for ET tube -volutrol -sodium bicarb -dopamine (premixed) -lidocaine (premixed) -1 L NS bag -10 gtts admin set + 2 extension sets -adult and pediatric thomas tube holder -nebulizer mask -adult and peds ET styletts -surgilube -ET tubes (2.5-8.0 x2 each) -250 cc NS bag -60 gtts admin set -emesis bag -short and long arm boards -sharps container -biohazard bag -occlusive dressing -4x4's -BP cuff -Glucometer -Magills As a general rule, I bring the box and the monitor in with me on all medical calls. For traumas I just bring the collar and board. Fire brings in their O2 and we have a D cylinder and some masks on the cot, so I don't usually bring in our airway bag unless it's a respiratory call and we're on scene first. And by hip pouch, do really mean to say fanny pack?

If they want to delay EMS in order to "hone" their skills, why don't they just leave the ambulances where they were initially and have them always respond without lights and sirens to the scene? The science suggests very few calls are actually time sensitive, being restricted primarily to cardiac arrests, strokes and MI's, and at least this way in addition to fire getting to practice you get the added (and much more important) benefit of EMS crews being at reduced risk of getting into a car accident.

Hi, everyone. I'm writing this thread looking for some advice and criticism regarding my future career plans. As most of you know, I just finished paramedic school and became certified (shift number two this Saturday) and I'm working part time for my local service (applied for full time, don't know when that might happen though I heard rumors about March) and going to school. My initial plans were to complete a Bachelor's in Biology and apply for PA school, but after some soul searching I really think that EMS is the place for me and where I'd like to stay long term. Now I'm not saying that PA or med school might not be in my cards, but if they are they're further down the line. What I really think I'd like to get into is critical care transport. As most of you who speak to me on the forums know, I am a huge, huge proponent of paramedics obtaining higher degrees. I can't think of any other single thing that will advance our profession as much as increasing educational standards; and I believe a large part of increasing educational standards nationally comes from increasing our own personal educational standards. I've been speaking with the folks over at the University of Pittsburgh about their Bachelor's of Emergency Medicine program. Right now I'm eligible for my Associate's in Applied Science as a requirement for my paramedic program (no word yet on exactly when I'll get the actual degree, I think they do that this spring), and I think--I THINK--I am eligible for advanced standing within the program which would allow me to complete the senior year and (finally) obtain my Bachelor's degree. Part of the senior year is becoming CCEMT-P certified, which, while I know there are some shortcomings to that certification, I still think isn't a wholly worthless class and certification. The same college through which I attended paramedic school also offers a three semester paramedic to RN bridge program, which I think I would like to get after completing my Bachelor's degree through U-Pitt. So my questions to you guys are: from what you know of Bachelor's degrees in EMS, and especially if anyone here has been through or knows a bit about the program at U-Pitt, do you feel that this would be a good degree to obtain that would strengthen my clinical knowledge? And do you feel that having a Bachelor's in EMS along with my RN would make me a strong candidate for critical care transport? Bear in mind, the entire process would take around two years from now and I would like to work full time throughout it and feel it would probably be wise to have at least another full year of 911 work before I entered the critical care realm. Also, because I am less familiar with critical care services than I am with 911 (though I did work dispatch for a critical care transport service prior to entering paramedic school), can anyone give me a rough estimate of the salary range (in Kansas or comparable) I can expect working critical care transport? I really feel like this might be where I'm supposed to be, and I feel very strongly that EMS is hindered when paramedics who obtain higher degrees move out into other professions (essentially leaving only those without in EMS), but at the same time I DO want to make a decent living--but I'm not in this to be cruising in a corvette or anything too fancy. Thanks for the advice, and for those of you stuck in the storm with me be safe.

This sounds like a complicated case, and to be honest I would have stayed on the safe side and gone down the cardiac route as well, and I'll tell you why. To my knowledge, the most common chronic EKG changes following an MI is chronic Q waves. Now cardiology is one of those subjects where you can go as deep as you want into it, and I'm sure there are some real cardio wizards out there who could probably tear that simplistic argument apart, but that's my understanding. Secondly, it's true that an MI is NOT the most common cause for ST elevation, but there's some factors that we in the prehospital arena have to consider. First, what is this guy's baseline EKG? We don't know. We don't know if this is what his EKG always looks like or if this is truly new ST elevation; because of that, in the absence of the patient saying he always has that on his EKG, we have to assume it's new onset until proven otherwise. The second thing you ought to think about is his age, and how that can alter the presentation of an MI. To be honest, you make a better case for this being an atypical MI than for it to be a GI issue. When was his last BM? Has he had GI issues before? Any dark, tarry stool or bloody vomit? Recent fever, cough, nausea/vomiting, diarrhea? Are those PVCs a known issue? If not, you'd better assume they're acute, even despite his age, and the most common cause of PVCs is myocardial irritability, which is more consistent with an MI than a GI issue. Did they go away with O2? Now, am I convinced that this is definitely an MI over anything else? No. With a recent history of pneumonia, there's a ton of possible diagnoses and you're unlikely to make a definitive diagnosis in the field; he could have developed pericarditis (though to my understanding the EKG generally presents with a different morphology of the ST segment than in MI and the elevation is diffuse except for V1 and also I believe AVL). You said his rhythm was irregular? History of a-fib? You also say his abdomen was distended, was that per the patient's own assessment? And you mentioned you palpated for any pulsatile masses, did you also have a listen? I've heard from a physician that the more effective way of assessing for an abdominal aorta is to actually listen for audible bruits over the aorta. Is the dark colored urine new for him? Anyway, I'm not trying to knock you, but as you can see this is a complicated patient. I don't know if you can make a definitive diagnosis in the field, but I wouldn't feel comfortable ruling out an MI in the presence of ST changes, dyspnea, and abdominal pain. Great case, let us know if you find out any more about it.

What do you put as the chief complaint on your chart? Or do you just leave it blank? Also, do you have to complete and fill out a full patient assessment? Get a full set of vital signs?

We do document, even disregards. It's just more minimal than if we were doing a full patient assessment and report.

If you're unsure if something is being done improperly, I would consult your administration about the matter as they are more versed in your local laws, protocols and procedures than anyone here. For me, though, where I work, we can document minimally on a no patient or "assist a citizen" with no signatures required. The crucial part is determining whether or not this is a patient. I won't say whether your partner was right or wrong, because I don't know your system and I don't know the full details, but you need to ask yourself: is this a patient? That is, do they have a medical complaint? If they're alert and oriented x3, competent to make their own decisions, and deny having any complaints, then I would call them a "non-patient". There was a really good video I watched during paramedic school by a paramedic turned lawyer about these kinds of things, that is, determining if someone is a patient or not. The gist of it was, if they have no complaints, no visible injuries, and they're competent to make their own decisions, they're not a patient. And perhaps that's what your partner is getting at, but again, I couldn't say. What are the protocols governing no patients in your service? Are you required to do a full assessment on everyone regardless of whether or not they have a complaint or not? Now, I'm not saying you shouldn't use your head. If someone fell, you need to not only determine if they injured themselves but what caused the fall as well. Were they feeling weak or lightheaded? Have they been sick recently? Did they lose consciousness? Did they help themselves down or did they hit their head/neck/back on anything? You'll never be wrong to err on the side of making someone a patient, but don't forget that not everyone we see is necessarily a patient either. And maybe that's your partner's comfort level and he/she's making decisions from experience.

Couple of questions. Did your paramedic program require you to take A&P as a prerequisite for paramedic school? If not, it's going to be all new material for you and shame on them for not requiring that at the very least. Anatomy and physiology is a tough subject that requires a lot of tedious studying and rote memorization, like all of medicine. My best advice to you is to take advantage of all the materials available to you; go to the library or bookstore and pick up a book on A&P, preferably one with interactive CDs if visual aids work best for you. A simple google search will turn up loads of information on anatomy and physiology, but to be honest there's no substitute for a fully dedicated A&P class. If you have any specific questions relating to A&P there are tons of very bright people on these boards that will be happy to explain them for you. Good luck in paramedic school.

Whoa! You guys aren't getting time practicing live intubations in the OR? That's something you need to be talking to your program director about. Intubation is a difficult technique that requires a lot of practice (and a lot of continual practice) to maintain your skill level. You don't want your first live intubation to be on a code blue patient in the field where it's hectic, you want it to be on a sedated patient in a calm OR with an anesthesiologist and a CRNA at your side.

Great information, everyone! Especially from the Doc.

My advice, as a new paramedic who just graduated, is that you need to step up and take charge of your own education. I used to be a fairly quiet guy, and when it comes to social hour I still am fairly quiet, but when it comes to work I get loud--just like you need to be. I'm going to be brutally honest with you and tell you this: nobody is going to make you a paramedic but yourself. You say they aren't explaining things to you, have you been asking them questions? You made it sound like you didn't know what questions to ask; start with the clinically relevant ones. Is this the normal presentation for this condition? What is the long term treatment? What are the goals of emergency treatment? Don't know anything about a patient's condition? Time to start asking questions, and more questions, and more questions--until they're so sick of hearing your voice they tell you to piss off. Doing clinicals is a GREAT experience, and something you can get a LOT out of, but YOU have to take charge and take advantage of it. I saw a lot of people in my EMT and paramedic class go in, get their competencies, and go home. And that may have worked for you as an EMT, but it's time to put on your big girl paramedic pants and go above and beyond. If a patient goes to the cath lab, you need to ask if you could come and watch the procedure; or to surgery, or to the CT scanner, or wherever. The worst they can say is no, and throughout all my clinicals I was never turned down; because of that, I got to witness multiple surgeries (outside of our scheduled OR time), a heart cath, and a lot of other very cool, very interesting things. Pretty soon you're going to be hitting the streets and YOU are going to be the one making the decisions, and if you can't step up and advocate for yourself and your own education how in the world are you going to advocate for your patients? Yes, you should be helpful, but you're not there to learn to play gofer, you're there to learn to be a paramedic. And you don't become a paramedic the day you pass boards, or the day you get your cards; you're becoming a paramedic now, throughout this whole process. And right now you're determining what kind of paramedic you're going to be. I'm not trying to make you feel bad, but you HAVE to be in charge of your own education. Your paramedic program isn't going to make you a paramedic, only you can do that. And you have to come out of your shell and start chasing down opportunities, because they're not going to come to you in a silver platter. The nurse has no vested interest in making you a paramedic, neither do any of the doctors. And they're NOT going to go out of their way to help you in this journey. It's on your shoulders. So it's time to buck up and start taking control of your own education, instead of waiting for someone else to hand it to you. Quit waiting for them to teach you and start ASKING them to teach you. Carpe diem, seize your own education.

Thanks, man. I really appreciate that. Like I said, once I get my Bachelor's (somewhere between two and five semesters left) I'm definitely going to start looking around for someplace that's a little better fit for me, though hopefully we'll have some good changes here in the not too distant future. I get a lot out of talking with everyone here, and I only wish more paramedics and EMTs would take advantage of the internet to come together and learn from each other and each other's systems. THIS is how EMS will grow and evolve and change.

That's a good point and something I've personally not been exposed to yet, for me the truck has pretty much always been just a little ways away. I think I've only ever had to go up seven floors total while working so far, it was a parking garage and we took the stairs (it came out as a possible code blue so we left the cot behind for the moment). We definitely don't carry every piece of equipment we could possibly need with us on every call (I've already mentioned the IO, but now that you mention tension pneumos I recall our pneumo kits stay in the truck not in our box and I don't think our protocols allow for us to use an IV needle to decompress). I would agree with you that we should carry every drug and treatment that we might possibly need to treat all of those possible conditions, and with the exception of a few pieces of equipment I think we do. Unfortunately, I'm not in a position to make policy around here to change the storage policies on those pieces of equipment we don't bring in on every call.

Haha! Whoops, sorry everyone. Open mouth, insert foot. If it makes you feel any better, a nurse once asked me how old I was and I asked her, "How old do I look?" and she said, "I'd say eighteen, but that's only because I assume you have to be at least eighteen to be a paramedic." And my (apparently) youthful appearance doesn't always inspire the greatest confidence in my patients, so it's somewhat of a double edged sword. No offense intended, guys! I call everyone under 21 a "kid" and everyone over 35 an "older person". As for the monitoring = IV, yeah, unfortunately my system isn't the most progressive in the world. I disagree with it, because in all honesty I can find almost any reason to place a patient on the monitor (and very few reasons NOT to). The explanation that was given to me was that if you think the patient needs the monitor then you think the patient is ALS (i.e. more than just code green) and all ALS patients get IV, O2 and monitor. I don't like it, but I don't have very much say (see, none) in how things are run around here. We just got a new medical director and I heard we're going to have a protocol revision the second half of the year, so hopefully we'll have a little more flexibility with that as well. Dwayne, no, I don't have to place O2 on a patient unless their SpO2 is under 95% (well, sort of, everything above a green is supposed to get at least an NC though it's not the worst offense if you don't put it on them as long as their sats are above 95% and you're not giving a respiratory depressant), but you mentioned a patient complaining of chest pain and how you would just give aspirin and document no 12 lead changes. Unfortunately, around here, we HAVE to run the full protocol once we've started it unless we get online medical control involved. And pretty much ANY patient who complains of atraumatic chest pain (and sometimes even patients complaining of chest pain following trauma, such as a car crash, under the idea that the start could have given them a heart attack) gets the full chest pain protocol (ASA, nitro if not right wall MI, and fentanyl if no response to nitro x3) regardless of what the 12 lead shows. Seriously, I've had to go through the whole chest pain protocol on patients that, in my humble (and then still student) opinion, were NOT complaining of cardiac type pain. Including a patient with a history of panic attacks, stated they felt just like they always did during a panic attack, had the numbness/tingling in their fingertips, recent stress at work; and also a patient involved in an MVC who had chest tenderness to palpation, stated they had hit the steering wheel with their chest, no radiation or crushing type sensation. Neither patient had 12 lead changes, but they said the magic words "chest pain", so it was out of my hands. And I'm not trying to say that I'm so good that I shouldn't err on the side of caution if there's ever ANY doubt that a patient's chest pain might be cardiac in origin, but I also don't feel too stupid to not be granted at least a LITTLE bit of slack when it comes to distinguishing cardiac chest pain from any other kind. I would much rather work in a more progressive and liberal system where protocols were "guidelines" as opposed to strict rules, but unfortunately until I finish my Bachelor's I'm kind of stuck here.

I like to have enough in my box to run a full code without having to run back out to the truck (though the EZ IO stays in the truck, so we would have to run out for that), and enough to get my patient from point A to point B alive. Personally, I prefer doing most of my treatments in the back of the truck than on scene unless they're "must be done now" stuff; i.e. codes, unstable arrhythmias, active seizures, etc.

We keep those in the truck, probably not a bad idea to keep them on you, though.

Bumping this thread back up so it's visible to NannieKane.

This thread's already been done before. I bumped it up, it's in this same subforum titled "What does your department carry in your ALS or BLS bag." Enjoy.

I have a question. You said this guy was being transferred for a diabetic foot issue? I assume this was a code green (or I, depending on where you are)? If this was a low priority patient, why did you put the monitor on him at all out of curiosity? I don't know how it is for you, but unfortunately for us an IV or a monitor automatically makes a patient a yellow (code II) where I work, though I assume you may have more freedom to place the monitor on a patient without having to upgrade their status. I'm not sure how my treatment would have differed if at all, because like I said where I work if we put the monitor on someone we automatically have to make them a yellow and stick them with an IV, but I will say that if I'm putting the monitor on an older person (>35 years of age) I feel that a 12 lead is almost obligatory. But you've already recognized that, and I'm no one to criticize you. I don't know if anything you could have done would have changed this patient's outcome. People die, and for all the treatments we can provide we're all really pretty powerless (all of us, not just paramedics) to do much to stop the Reaper. Tough call, man.

Oh, well duh. Sorry, I think I had just woken up from a nap when I posted that.

What do you mean by single role paramedics? And why do you believe that fire based EMS is the way to go?

With all due respect, I will never say thank you for the IAFF working to bring down educational standards, for twisting the facts in their addresses to the general public, or for trying to replace me or any other paramedic with a firefighter so they can keep their jobs. The way I look at it, the IAFF is a drowning man who's latching onto EMS to try and keep afloat, regardless of the fact they're bringing us down with them. I feel bad for them, I really do, they've worked themselves out of a job and now they're trying to keep from going under, but that's their problem to figure out--not ours. EMS is emergency medical services, not fire and emergency medical services. I get that they're drowning, but they don't have to bring anyone down to Davy Jones' locker (+1 for using that phrase in an EMS discussion) with them. Yes they have, but at what cost? This industry is about what's in the best interest for the patient, not "what's in the best interest of keeping firefighter jobs"; and because of that, an organization that exists solely to keep firefighter jobs is NOT working in the interests of the patient but in their own interests. Yes, I can. And I gladly will. I learned from day one that EMS has to constantly fight for its very existence, and I for one will not give up on a progressive, constantly advancing, constantly improving EMS. I will fight for an independent, high quality, progressive and advancing EMS as unapologetically as the IAFF fights for a fire based EMS. Don't get me wrong, I'm not inherently opposed to fire based EMS--if it's done right. But the fire based EMS that the IAFF endorses and that many fire departments seem to endorse is not the kind of EMS I will ever support. You're a hundred percent right about that.

So it occurred to me the other day that I've never put down an NG tube, not even on my cardiac arrests that I'd intubated. I always checked to make sure we had them fully stocked on the truck, but I never did use one or even really think about it. What about you? When's the last time you put an NG tube down? Do you drop one on all intubated patients? Does anyone know if it significantly decreases mortality from aspiration in the prehospital setting or has any studies touching on it? Also, do you deliver any medications by NG tube such as activated charcoal for unresponsive non-narcotic OD patients? It's been a while since I've even read up on NG tubes so that's something I'll need to go back and do today or tomorrow, but I was just wanting to get some feedback from you guys.