Bieber

We're da ambulance drivahs.

Weee-ooooh, weee-ooooh!

I agree with 4c6. Remember, the first rule of medicine is primum non nocere--first do no harm. There may not be any way to prevent that man from exacerbating his injury (even after the police have wrangled him in he's still gonna be squirming until the sedative takes effect), but you don't have to be the ones to get him riled up, and you definitely don't have to be the ones to get a bloody nose or worse when that patient starts fighting. Our job is to treat, not to get into scuffles with patients, and as a general rule I'd leave as much of the rough housing to the police as possible.

I'm hoping someone will respond as I keep hitting brick walls when trying to get some answers.

I think I would like to be a paramedic.... I say "think" because there are some things I need to know before I decide.

What I REALLY want to know is how can you tell if you can handle it.... all the things you see that is....

I am scared I won't be able to handle some of the gross factor... but these might just be normal jitters everyone is faced with. I can watch gross stuff on t.v. and find it fascinating (surgeries etc) however it is so different t.v. v.s. real life...

Is there any general rule of thumb or test to determine if this is something you can do.

I assume with exposure, practice and education I will become comfortable with all types of sights and situations but before I commit to schooling I would love to know if I am being realistic.

The other question I have is with regards to amount of time spent on your feet. I started running to get in shape to be accepted to the paramed program and in the process injured my foot very badly ... I have been trying to heal it over a year to no avail and I wonder how much time is spend continuously on your feet ? I know something like nursing would be out of the question for me but I wonder what thoughts were on it from a paramed point of view.

Any advice would be so appreciated..... THANKS

Hi and welcome to the forum.

It's great that you're not only interested in paramedicine, but also that you're cautious about it as well. Becoming a paramedic takes a lot of time, patience, money and endurance and you obviously recognize that and want to make sure it's the right thing for you before you jump in both feet first. The first step to becoming a paramedic is to become an EMT-Basic first. This requires a one semester class that is probably offered at one of the local community colleges or universities in your area at the completion of which you'll have to take your state and national board examinations to get certified

Probably the best way for you to figure out if you can handle the job and whether or not you'll enjoy it is to be exposed to it. I would suggest calling up your local EMS service and asking if you could do a ride along to see what the job is like. Don't know if you'll be able to, but if you can you should go for it and if you can't then I would suggest taking an EMT-Basic class because you'll have to do ride alongs as part of the program where you'll work several shifts on an ambulance as a third person.

I'm afraid that I don't know of any quick and easy tests to tell if you can handle the job, but I will say that the human mind is remarkably capable of adapting and overcoming. You would be amazed at how much you can handle given enough exposure to something but only you can decide if the job is for you. The majority of our day to day calls are not gruesome scenes from a horror movie but every now and then you will definitely see some gruesome things. I will say that at least in my meager and humble experience even the worst injuries I've seen are never quite as bloody and over the top as they present in horror movies like Saw.

As far as your foot injury is concerned, the amount of time on your feet depends on how busy your service is. I will say that I work for a busy service and even on a busy day my feet don't ever get near as sore as they were when I was in clinicals working in the hospital and on them all day like the nurses are, HOWEVER my back was never as sore at the end of the day during clinicals as it is after a day of working EMS. In some services you're running calls all day and in some you're lucky to get a call once a day, so it all depends. How bad is your foot injury? What's your level of mobility right now? Most services require you to be able to get from point A to point B without difficulty and also require you to be able to lift somewhere in the area of 150 pounds unaided and to carry all of your equipment to the scene and back, which can easily be up to 60 pounds or more, but you should always have a partner to help you and shouldn't ever lift more than you're capable of lifting.

Good luck in making your decision.

I think I would hold off on anymore adenosine or diltiazem. If I'm seeing some flutter or P waves, then I'm thinking more and more that this is an accessory pathway issue and I want to avoid any AV nodal blockers. I'd rather go with amiodarone, diltiazem and adenosine might shut down the normal conduction pathways and pre-excite the accessory pathway.

Hmm, can I change my answer to symptomatic and stable? I guess that's pretty much what I implied in my treatment, in any case. O2, IV, patches, try to calm the patient and go ahead with the lidocaine bolus followed by a drip if no rhythm changes with O2 and relaxing him.

Wide and fast I'm going to call it V-tach until proven otherwise, though I'd like to print out a strip to make sure it's not a pacemaker deal. Patient said no history, but I want to check anyway. I'm going to call him unstable due to the poor skin condition and shortness of breath, however since his blood pressure is okay I'm going to slap the patches on and try to get an IV and bolus in 1 mg/kg lidocaine and be ready to cardiovert if he doesn't make it that long.

Thanks for all the kind words and advice, everybody. I've finished my guide and gotten it laminated and ready to go in time for my first shift as a paramedic this Sunday. Hopefully I won't need it, but like Dwayne said, it definitely makes me feel more comfortable and more confident knowing I have it right there. Of course, working my first shift as a paramedic with my former preceptor might counteract that confidence, haha!

The format of my guide ended up like this:

Medical Triage/Transport Criteria

Glasgow Coma Score

Trauma/Transport Triage Criteria

Burn Triage/Transport Criteria

OB Triage/Transport Criteria

Drug Formulary with the drugs, dosages (adults and peds) and number of repeats by standing order and under which protocol we can give them by standing order highlighted (if applicable) along with a lidocaine and dopamine clock for me to review from time to time (I currently feel comfortable with those, but it helps to look it over every now and then since we give both of those drugs so infrequently.

APGAR score.

Nothing wrong with having a cheat sheet, especially for things such as a commonly prescribed medication list, a drip calculation list, lab values, and stuff of that nature.

Really, the only stuff that needs not be in your pocket guide that you NEED to know back and front are the "OH SHOOT, I NEED TO DO THIS NOW" medications, stuff that the situation does not lends itself to peaking inside a book.. You need to know the dosages of the emergent medications we carry. without thinking about it. You need to know Epi 1:1 for an allergic reaction. You need to know the dosage ranges of your ACLS drugs. You need to know your RSI ranges. Pediatric Epi dosages.

Other things, such as Solu-medrol, the drip rate for Tridil, the rate for Mag Sulfate, stuff that is a bit further down the line, and not as often used, can wait till you can look it up. Pediatric dosages can wait until you double check them, especially with a Broslow tape. You are not less of a medic for not memorizing every damn word in your guidelines / protocols. There's a reason a copy is in the back of every ambulance.

I completely understand wanting to have a quick reference guide. I don't recall ever using mine on a call but I like knowing I have it in case I need it.

I have found it helpful when I don't know what a medication is prescribed for...

I use the Informed Brand EMS field guide. ALS version.

When I first started I made my own little guide with phone numbers to all the area ER's and all the hospital codes. That didnt last long though. Lol

Thanks. I actually use my pharmacopoeia on calls quite a bit, if I don't know what a medication my patient's taking is for or whatever, and my idea of making a little pocket reference came about after I started writing down the local hospital info on some pocket cards. I usually keep my protocol book in the back of the ambulance, but having something a little bit smaller is more convenient and I'm not too proud to admit that, hey, I'm new, and even if I wasn't I'm not perfect. I know my ACLS stuff fine, but if I'm just running a medical code yellow or something like that and I want to double check something and I have time, why not?

http://www.tarascon....ucts/?bc=9305-0

I have this; its small and it tells you almost all the medications on the market; FDA approved. It has sections on BCLS/ACLS/PALS. Its geared for the MD but I've been using this brand of pocket guide for medication for 10 years.

Luckily, in NYC; Medics must refresh every 3 years on the Protocols and its a 100 question exam (pay $25). Plus, all NYC Continuing Education (we have to do 72 hours within a 3 year span) given always re-introduces the correlating Protocol(s) in the lecture. So the Protocols are pretty fresh in our heads.

This pocket guide is awesome and inexpensive. They do have this on ebay for less; that's where I purchased mine. Good luck...

Thanks for the link. I have the old one that I carry with me, I didn't realize they already had the 2011 edition out. I'm not sure if there's ANY sort of protocol testing at my service (as far as I know there isn't) and unfortunately our protocols aren't the clearest or the most progressive at the moment. However we just got a new medical director and I heard there should be some revisions in the upcoming future, so hopefully that'll fix some of the existing issues.

I don't feel uncomfortable with ACLS or drips, I think I could probably spout that stuff off backwards and forwards in my sleep and I think cardiac arrests are probably some of the easiest calls to run. It's mostly my protocol specific stuff, for example just for adults we have seven different protocols for fluid boluses that vary based on dose and on the specific protocol we're working under.

Also, I'd like to clarify, that I do feel competent in everything that I'm required to be competent in and I made it throughout my internship without needing any guides or references. However, as a new paramedic, I am, like I said, paranoid about making sure I know what I'm doing and having a resource to double check myself with because I will no longer have a preceptor in the back to double check my work. I'm big on double and triple checking the drugs/treatments and dosages I give with my partner and with my available resources, which is why I'm making out a small little reference guide to carry with me. This isn't something I plan on pulling out on a cardiac arrest (I know how to run those), but rather more for those stable code yellows.

Hi everyone. I did a couple of searches and didn't find any topics about this, so I thought I'd start one. I've gotten my NREMT cert already and I should be getting my state cert tomorrow or the beginning of next week after which I'll begin practicing as a paramedic, and I decided to start working on a little pocket guide to carry around with me because, being a newbie, I'm paranoid about forgetting something and wanted something smaller than my protocol book to keep in my shirt pocket to double check things with. So far, I've included a list of the medications we carry on the truck (and highlighted the ones we can carry by standing order and their dosages), my triage and transport criteria, an APGAR, rule of nines and GCS. I feel comfortable with most of that stuff, and maybe it seems a little subpar but I'm not perfect and until I've been doing this long enough that I can spout it all out backwards and forwards it seemed prudent to keep a reference with me.

My question to you all is do you carry pocket references/guides? I've got a couple that I've picked up at the bookstore but they're all pretty bulky and have a lot more information than I really need or already know. What guides do you use? Which do you prefer? Have you made your own guides before and if so, what did you include in them?

Thanks for the link, I've been looking at that site and is has some good information. I'm not considering taking either the CCEMT-P course or the CCP-C exam anytime in the near future, just trying to learn more about it preemptively at the moment.

Now that I've become a paramedic I'm looking toward the future and continuing my education. I'm enrolled in college for this semester and I plan on finishing out my Bachelor's degree in Biology and also thinking about other EMS education avenues after I get a little bit of experience under my belt. I would love to someday do critical care transport and after doing a bit of reading I noticed that there are two critical care paramedic certifications, CCEMT-P and CCP-C. I'm most familiar with CCEMT-P but I'm not sure exactly what the differences are between the two. I know that CCEMT-P is an actual course, but from what I've been reading it sounds like CCP-C is an exam only--is this correct? Also, is there any difference between the two in terms of which is more desired by critical care transfer agencies or the quality of education provided by either one if CCP-C comes with a course?

Thanks.

Wow, Linuss, that must be a pretty heavy bag! I'm impressed with all your medications, especially the heparin. I forgot to add Labetolol in my list, we do carry that but I've never given it. It looks like you operate under some pretty progressive protocols.

Oh, forgot to add the magills as well.

Oh, forgot to add the magills as well.

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

-4 way stopcock

-narcan

-meconium aspirator

-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

-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

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.

Littman Cardiology III.

I'm a brand new paramedic myself, so taking and keeping control of my scene is still a challenge for me and I can sympathize with you. I haven't ever had to deal with a situation like that before, but I have been on scene and felt like I was losing control. You need to be loud, have a plan, and really step up and BE in charge and let it be known that you're in charge by doing those two things: having a plan, and being loud in your implementation of it.

One quote from my AMLS book that always stuck with me throughout my internship was this: "If you don't take charge of your scene, someone else will." And during my internship, my preceptors actually told me that they were going to try to take control of my scene and I had to dominate them and maintain my control because they were going to be actively trying to seize it from me.

Can you tell us more about what kind of medications you carry on your ambulances in Spain and what kind of treatments you provide for patients? I'm curious to know how ambulances run by physicians differ from those run by paramedics. Do you treat and release? Refer patients to other resources besides simply taking them to the ER?

I'll take a whack at the low ETCO2 reading issue.

Two of the causes of poor concordance between PaCO2 and ETCO2 you mentioned: bronchospasm and PE (I suspect due to V/Q mismatch). However, COPD itself can also cause poor concordance, due to the already mentioned bronchospasm partially, but also due to an increase in deadspace and increasing V/Q mismatch.

This study of 118 COPD patients in the ED(I don't have access to the full text, so I have to trust the abstract)

http://www.ncbi.nlm....pubmed/20224417

found:

"Mean arterial PCO2 levels were 43.24+/-14.73 and mean ETCO2 levels were 34.23+/-10.86 mmHg. Agreement between PCO2 and ETCO2 measurements was 8.4 mmHg and a precision of 11.1 mmHg.As there is only a moderate correlation between PCO2 and ETCO2 levels in COPD patients, ETCO2 measurement should not be considered as a part of the decision-making process to predict PaCO2 level in COPD patients."

Similarly, this study (again, no full text for me) apparently found worsening concordance between PaCO2 and ETCO2 as degree of obstruction worsened:

http://www.ncbi.nlm....pubmed/18758420

There are several other similar but older studies with similar findings, all suggesting that ETCO2 cannot be trusted as an analogue of PaCO2 in those with cardiorespiratory disease.

One more, notably focused on prospective out of hospital use (though in Austria):

http://www.ncbi.nlm....pubmed/20224417

This all makes intuitive sense to me as well. We probably expect some degree of respiratory acidosis in COPD patients (especially the subset of "CO2 retainers"), and if these patients have systemic acidosis/hypercapnea due to inability to ventilate CO2, it makes sense that the level of CO2 escaping the pulmonary circulation and leaving the lungs to actually reach our ETCO2 detector could be lower than levels seen arterially.

I don't think that low ETCO2 should necessarily increase our suspicion of PE without other indications, although I think your questions down that path are appropriate. Low ETCO2 readings are expected in COPD without other co-morbidities, and I don't think that low ETCO2 is a particularly specific indicator of PE, at least not so much that my (inexperienced and very possibly wrong….) PE antenna go up with this patient. I think it's far more likely that bronchospasm and mismatch/deadspace are the root of the lower than expected capnography readings.

Great studies, man. Really informative stuff and thanks for sharing it. Where I work we only have ETCO2 for our ET tubes, so I don't get a chance to routinely monitor CO2 levels on the majority of my patients so it's getting fuzzy on me. And I agree that low ETCO2 readings in themselves don't really raise my index of suspicion for a PE all that much, however the fact that the patient APPEARS to have clear lung sounds (which as I stated above I want to confirm after I start ventilating via BVM) with such crappy O2 sats does put PE on my list of differentials. Especially if we get no increase in condition/sats with ventilation and no change in lung sounds following the albuterol (which I'm giving just in case they're diminished and I'm not picking up on it.) I'm not trying to look for zebras just yet, and once I know what kind of response I'm getting from the treatments above I'll be able to more finely tune my treatment and diagnosis, but I'm not ruling out anything just yet either and some of these findings make me wonder.

So, if I understand this correctly, the patient IS cyanotic, has present lung sounds with no wheezing, no signs of respiratory distress (accessory muscle use, nasal flaring, etc.), and is very tired and verbal. Based on his presentation, I'm gonna call him in respiratory failure and say this guy's about to go into respiratory arrest. I want to get him on the cot and raise the head of it so he's sitting up or at least at an incline, start assisting ventilations with a BVM and O2, and have another listen to lung sounds. If he's breathing that shallow, we probably didn't get a real great listen to his lungs. Now do we hear any wheezes, diminished sounds, rales/rhonchi?

Not going to spend too much time on scene, I want to get him out to the truck and get the monitor on him and start an IV NS TKO and do a quick 12-lead. I'd also like to go ahead and try an albuterol treatment regardless of lung sounds. Do we have any change in sats/condition/lung sounds with the ventilations and albuterol? Also, talking to family, has he been sick recently? And has this ever happened to him before? Has he ever had to be intubated before? I'm going to get my intubation equipment ready, but I'm going to hold off on tubing him if I don't have to.

Also, I'm a little confused about that ETCO2 reading. As I recall (and mind you, I'm sick so maybe I'm more confused than I realize), it would be hyperventilation that would cause that ETCO2 to be low, whereas hypoventilation would cause it to rise from the patient retaining so much CO2. So I'm a little baffled as to why his ETCO2 is only 31. I would expect him to be in respiratory acidosis, but that reading suggests the opposite. Though I guess bronchospasm or pulmonary embolism could cause low readings. So on that route, has he been bed bound for a while? Recent surgeries/trips or other PE risk factors? Any signs of a DVT? Also, do we have waveform with our ETCO2 and if so what waveform are we seeing?

Buenos dias y bienvenido al foro! Have you already looked into getting your medical license here in the United States? What is the process like? I know it can be difficult for doctors from another country to practice in the United States, but I didn't expect that coming from Spain you would have such difficulty. Can you tell us more about EMS in Spain? I'm interested in learning more about what things are like for you working on an ambulance as a physician.

Dwayne and Mobey your both correct. I was just wondering what do you do as a paramedic on a ift, than I would on onw as a basic on a bls. I never have did a als ift call before. So I was wondering what's different besides your patient being on a iv with meds from the recieving hospital. But thanks for the answers. Sorry if I worded the question weird.

It all depends on the patient's condition. If the patient is stable, it could be as simple as keeping an eye on the monitor and drips and transporting; if the patient's unstable, it could include managing their hemodynamic status with fluids or medications, ventilating/intubating the patient, so on and so forth.

I'm at work so I'm not going to address every post until a little bit later, but I wanted to write a little if I could and say thank you to everyone who replied, even to those of you who would have fired me. This was a tough situation for me and obviously I could and should have handled it better, but I'm thankful to hear your opinions--even those telling me what I don't like to hear--and I appreciate the support and the feedback. I just found out a little while ago that I passed my written and am now (finally) a paramedic, though I won't be able to start working as one till I get my cards, but even then it's a long road ahead of me as I continue to gain more experience and grow in EMS and struggle to find my way. I'll address some of your individual posts later today or tomorrow but I just wanted to acknowledge everyone real quick and say thank you for your advice.