Bieber

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?

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.

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.

So, the overwhelming sense I'm getting here is that I should have just shut up and done it without protest. Which, yeah, you are all right--I didn't do myself any favors by speaking out. And maybe the only way to get anywhere in this business is to just shut up and go with the flow, especially being new to it; and maybe I am very fortunate to still have a job after doing what I did. So for the sake of my career, I will accept that I made the wrong choice there. But the one question nobody has answered is whether or not it was right for us to have left that guy there. I get it, my job is to do what my service tells me to do and any deviation is going to lead to me ending up on more people's shit lists. And I get that if I don't pick my battles more wisely, if I don't learn to shut up and do what I'm told, I'm going to be blacklisted. But ethically, is this right? Is it really okay for us to help someone make harmful decisions? I'm not talking about letting someone refuse service, I'm talking about actually helping them make bad decisions. Yeah, the guy had a home health aid, but no one else that came and could be with him or take care of him. Should we be complicit in people's bad decisions? I got into this business to help people, and it's a pretty shitty feeling to know that in order to preserve my job and my standing in my service that I have to shut up and just "go with it" when we take someone who could have found another way home back to his apartment where we KNOW he will be in a bad situation, a way that didn't make us at least in part responsible for what happens to him after he gets there. It's a shitty feeling to know that if that guy dies there in that apartment, I'll have helped him get there and left him there knowing he was helpless as I walked out the door.

I don't disagree that the patient has the right to do whatever they want, my point of contention is whether or not we should be helping them by providing transport for these people. We may not have the power to stop them, but is it right for us to be complicit in their harmful decisions? I may try to find out more about my service's policy, however the way things are I'm a bit afraid of possible recourse for probing too deeply into this matter.

Hmm, that's not a bad idea. Now to find one that hasn't been overdone, such as ETI. Standby.

I suppose nothing more than trying to be firm in my principles. I know I didn't accomplish anything, but I didn't want to just cave in on my principles either. Perhaps they did, though it didn't sound like it. Yeah, I think so too. He said he wouldn't be able to feed himself or go to the bathroom, and yeah, he was competent and understood he needed help. Stubborn. I'm not sure. I assume it was a formal discharge since the patient had been cleared medically. Sorry, I meant acting as the tech on the call. That's all correct. But are we obligated to help the patient along? I mean, if someone wants to refuse care and go back home that's their right, but do we have a responsibility to ferry them home and leave them there? Is there any legal obligation for EMS providers to provide a ride home for patients leaving the ER? And should we have any hand in it knowing it will be deleterious to a patient?

This is a great site where I've found a lot of interesting research on various practices in EMS. I haven't gone through and examined all of the studies just yet, but if someone wants to highlight one in particular feel free. http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm

(Disclaimer: some details have been changed to further preserve anonymity.) So I worked yesterday as an EMT with a partner I had never worked with before. For those of you who don't know, I'm done with paramedic school and my practical boards, and I'm taking the written on the fifth, just as a little FYI. Anyway, our last call yesterday was a transfer of a patient from the ER of a bigger hospital who was going back home. The patient had been brought in by EMS earlier yesterday for bilateral knee pain and stated that they had fallen the day before. The patient usually got around with a walker but said that since the fall they hadn't been able to get around at all and the ER had diagnosed him with just a sprain and had put a splint on his left leg. I was up to tech since it was a code green and while my partner was in the hallway copying down the patient's information I was in the room talking to the patient, and I asked the patient if he was able to walk at all. The patient said no. Then I asked the patient if he was going to be able to get around with his walker even to get to the bathroom or the kitchen--no. The patient also stated he lived alone in an independent living apartment and had a home health aid that came in every day. At that point I went out into the hallway and told my partner that, hey, this person isn't going to be able to get around at home and take care of himself, we can't just leave him there. My partner said something about it being cute that I "cared about the guy" and then said they were going to "throw the patient in their bed and leave". At this point I was very uncomfortable with the whole thing, and my partner asked if I wanted him to tech, and I said yes. The patient couldn't even slide over from the hospital bed into our cot, we literally had to slide him over, which we did. From there we loaded him up and I drove to his apartment and we got him into his room on the cot. The patient asked us to put him in his bed and we had to actually physically pick him up and put him in it; it wasn't like he used us for support while he stood himself up and turned to sit down--we literally had to do all the work for him. He had a stand next to his chair with a phone on it, and I asked him again if he was even going to be able to go to the bathroom, and he said no. My partner told the patient he was going to be calling us right back, and the patient acknowledged that that was true. Apparently the hospital had tried to convince him to stay and go into a nursing home but he had adamantly refused and repeatedly told us he didn't want to go to a nursing home. When we left and got back to the station my partner chewed me out about not taking the call and basically said if I pull that shit again that "no paramedic's going to back you up for that" because I ought to be taking all of the code greens as an EMT, and there was talk of an incident report but he said he wasn't going to write one up but he did show me the part-timers' evaluation form that the lieutenants fill out for us at the end of every shift and asked me in a knowing way what I thought I should get for my evaluation that day. I really, really don't like to leave someone at home who is incapable of getting from point A to point B, and I remember during my internship neither I nor my preceptors would ever let a patient stay at home if they couldn't get around. And I get that the hospital can't make him stay against his will, but why does that mean that WE have to help him to his own demise? The guy could have taken a taxi or found some other way home (actually, he couldn't, since he couldn't get around, which is why WE got called, but still in principle he could have). I kept thinking about what my preceptor told me once after I had particularly screwed up a call during internship and tried to refuse someone I shouldn't have, about how I would NOT leave HIS family like that, and I kept thinking that, if this patient had been my preceptor's father, what he would say to me for leaving him at home helpless. So my question to you is this: was I wrong to protest teching that call on principle? Should I have just shut up and take him home without raising my voice against it? As far as I know, we have no obligation to provide a taxi service for patients going home from the hospital, only to provide transport and treatment to patients going TO the hospital. And yeah, I know that guy was going to find a way home one way or another, but I strongly feel that we should not be involved in helping someone to harming themselves. The first and highest edict in medicine is primum non nocere, first do no harm. But I feel like by having had a hand in putting that man in his home and leaving him there helpless, we have caused harm.

Wow! I gotta say, I pretty much vehemently disagree with everything you've said except for numbers 4, 5, 7 and 8. In fact, if I may I'll respectfully state my points of contention hopefully without sparking anything more than a friendly debate. While that is good in theory, the reality I suspect would be a watering down of all skills to only those with the least risk. "Just load 'em and drive, 'cause if you do anything wrong it's MY butt on the line." Furthermore, aren't medical directors already at least in part liable for the actions of the employees they supervise? Are you saying there should only be paramedics and EMT-I's? I disagree with you. It's not about paperwork, it's about education and knowledge--which WILL make you a better paramedic. Furthermore, even if paper alone does not make you better, it DOES improve the image of the profession (which, while admittedly is not and should not be our primary focus, it IS something we desperately need to improve) and add more credibility to us. YES! 110% yes! I also agree with this in general. In the sense that nobody should be working more than 12 hours without a break, however I understand that many services are pretty slow and you're not likely to go without sleep at some 24 services. Eh... I don't know about this one. Yes, but can we also include a written "knowledge test" as well? Yes, though I don't necessarily agree that polos are unprofessional, however I personally prefer button ups. How about we just hire those who are qualified, able and willing to do the job? I agree with financial responsability, however I'm leery about a for-profit service. That's not really what I feel medicine is about, and I'm nervous about getting into any kind of system where we might be required to acquire payment prior to transport or as a requisite to transport. I'm not a salesman, and I really don't want to be one. And I'm not in favor of monopolizing EMS and kicking out private services all together either.

Excellent point, Chbare! And one I forgot to mention earlier. You're one hundred percent right, data interpretation, including relevance, relationship, and variable factors, is a major drawback to studies done in the field of emergency medicine. It's often cited, but perhaps not nearly enough, just how hard it is to get reliable, understandable, straight forward information regarding the results of studies done on emergency medical patients. To use another example, though I'm afraid it's far more simplistic than yours but still one that I like to present, you could say that in a study of mortality rates that patients who are intubated by EMS personnel have a higher mortality rate than those who are not intubated by EMS. And without the relevant details, it sounds like intubation is a bad idea (and bear in mind this is just an example, not to start a debate on prehospital intubation), however all that study would actually say is that sicker people die more often. For studies on EMS practice to be truly sound and not just number crunching, we have to look at all of the relevant variables. Great post, Chbare, and definitely a take home point with all of the studies presented in this thread: proper interpretation of the data.

In the U.S., I'd like to see an associate's degree as the bare minimum for paramedic certification in EVERY state (mine has this requirement, but I'd like to see everyone have it as well) with more Bachelor's degree options available along with other higher degrees similar to what nursing has, first and foremost. I'd also like to see a stronger unity between EMS providers with more power in our national associations and more professionalism across the board. We are professionals and we ought to act like it, however many services are decidedly UNprofessional in their conduct and practices. I'd also like to see an increase in wages and--and this is going to be one of those that a lot of people disagree with me on--the complete abolishment of volunteer services. I have yet to see a volunteer hospital or a volunteer ER or any nurse or doctor put in the amount of volunteer hours that we in EMS seem to be willing to put in, and I think it hurts the profession when we sell ourselves so short. We provide a service and we deserve to be paid for it.