Bieber

So, after reading another thread I got to thinking that it would be nice to have a place where we could all share our knowledge and form a compendium of evidence based medicine in relation to the treatments we in EMS and emergency medicine in general provide, have provided, or may provide in the future. I am aware that many if not most of the treatments we give are not supported by scientific evidence, but I realized after reading another thread on here that there are more treatments unsupported by studies than I thought. The rules of the thread are thus: every point is disputable, however all claims must be backed and supported by references to peer-reviewed academic studies. And while the studies may tell us one thing, I also want to know what your personal and individual experiences with these treatments are; because we all know that what we read in a book and what happens in the streets are two very different things. The goal is to find as much credible evidence for or against as many prehospital treatments as possible, and also for in-hospital treatments. Oftentimes, we look at these studies in relation to how we in EMS should be doing things, but what about the hospitals? Are they advising us against the same unfounded treatments they themselves continue to provide and are any of these treatments beneficial for ANYONE in any setting?

This sounds very much like a myxedema coma to me. The history of recent illness could have caused her thyroid hormone levels to fall, and if I'm not mistaken can't penicillin also cause thyroid hormone levels to drop as well?

A paramedic isn't a paramedic because they can push drugs and intubate and manually defibrillate someone, a paramedic is a paramedic because they have the knowledge and the education. Not to diss EMT's, because until January 5th I'm still an EMT myself, but the truth is that you're right, the majority of patients don't NEED an IV and a monitor, but they DO need a paramedic's knowledge and judgement. As far as pay-for-transport goes, I will refuse people if I don't think they need to go to the hospital or if I think there is another more appropriate place for them to be seen, such as by their family doctor (if they don't want to go to the hospital, of course), but the day I am asked to get payment before transport or payment as a requisite for transport is the day I'm done. That's not what I signed up for, that's not what I believe in, and that's not what I will ever practice. I'm not a salesman, I take care of people.

I'm a dreamer, but oh well. Just tread carefully on my dreams. The end result would be a Bachelor's of Paramedicine. Classes during and following the spring semester of the second year until the end of the program would be five days a week 9a-5p and during clinicals and internship each student would be precepted by and paired with an individual RN/paramedic with whom they remained throughout the rotation and would follow their preceptor's full time schedule. I'm not sure what the end total hours would be, but for the internship and clinicals it would be one year each of full time paramedic and RN work. Classes and sections should cover each topic to the full extent possible having each class every day five days a week for each semester going into and including chronic and non-emergent diseases not typically managed by EMS providers. Year 1 Fall Semester -Anatomy and Physiology I (with lab) -English I -College Algebra -Psychology I -Biology I (with lab) Spring Semester -Anatomy and Physiology II (with lab) -English II -Chemistry I (with lab) -Biology II (with lab) Summer Semester -Medical Terminology -Pathophysiology -Clinical Anatomy Year 2 Fall Semester -Chemistry II (with lab) -Microbiology -Emergency Medical Technician-Basic -Pharmacology Spring Semester -Immunology -Cardiology (including CPR + ACLS) -Endocrinology -Pulmonology Summer Semester -Anesthesiology -Pediatrics (including PALS/PEPP) -Gastroenterology -Nephrology Year 3 Fall Semester -Obstetrics and Gynecology -Infectious Disease -Neurology -Traumatology (including PHTLS) -Hazmat/Operations Spring Semester -Clinical Rotations (ER, ICU, OR) Summer Semester -Clinical Rotations (Elective Clinicals; e.g. flight medicine, rural medicine, etc.) Year 4 Fall Semester -Clinical Rotations (PICU, OB, Clinic/Physician's Office) Spring Semester -Field Internship Summer Semester -Field Internship Year 5 -Fall Semester -Field Internship -Ambulance Operations (including CEVO) Do I think this will ever be reality? I doubt it, much as I might wish it.

To be honest, I wouldn't be comfortable transporting a post-seizure patient BLS. I've always made them code yellow, meaning they get the monitor and an IV, and several times I've been thankful for it when they started seizing on me again.

So, the topic is cardiac arrest and transport! Here are your questions: 1.) Do you transport cardiac arrests? 2.) Do you WANT to transport cardiac arrests? 3.) What are the benefits gained? 4.) What are the risks? 5.) Should any code blues be transported or should they all be called in the field if no return of spontaneous circulation? I'll answer the first two questions now, and the rest after some of you more experienced folks have weighed in. In the system I work in, we work asystole codes and then call to terminate resuscitation if there's no rhythm change or return of spontaneous circulation after we've done our three rounds of atropine; all other rhythms, we transport after we've gotten our frontline meds in. I would rather we did NOT transport ANY person without a pulse, however that's not the standard currently held by my service.

Padding under the knees or elsewhere prn. I would put a blanket over the board if necessary (which, the way the weather is going, might be more frequently in the upcoming future.) We use the headbed, the efficacy of which I've heard is questionable, but there's not really anything that we do right now that could keep the patient from compromising their own spine if they wanted. For pediatrics, we use the LSP pediatric immobilization board--which I really like. I wish they made an adult size version. We have soft cots, haven't ever used one, though. X over the chest. I would immobilize the entire spine if I thought any one part of it needed to be immobilized. Nope. And I helped out as a patient for an EMT class today and they used both a strap and tape over my neck and I absolutely hated it. Felt like it was choking me, and I'm not ever going to be doing it on any of my patients. I strap the arms while I'm loading them, and get them out in the truck--one for an IV and one for BP. Oh, and on another note, I absolutely refuse to be boarded ever again. =) That's how bad my experience with the EMT students today was.

You know, I don't have the 12 lead anymore, but I don't think I saw anything concerning on it. No peaked T waves, no ST changes there might have been some pathological Q waves from his previous MI's but I can't remember. It was a pretty benign 12 lead if I'm recalling correctly--nothing that led me toward hyperkalemia or a STEMI, anyway.

That's along the same lines as what I was thinking, Dave. All throughout transport I was sitting there thinking this guy had to have had an MI that took out his SA node (or at least severely damaged it). I did ask him about his carvedilol, but he denied having taken too much of it or any recent changes/noncompliance in his medications. Because the patient maintained cerebral perfusion (no change in mental status) and a pressure >100 systolic, I decided to give supportive treatment only. I consulted with the physician at the hospital and he agreed to monitor the patient and to go ahead with 0.5 mg of atropine if he started to crap out on me, but though he continued to look like crap throughout transport he stayed stable and I didn't have to intervene with fluids or raise his rate. The patient in this scenario ended up being hyperkalemic. I wish I'd found out more about the cause of the hyperkalemia, but I'm guessing he must have taken too much of his potassium by accident or that his electrolytes must have gotten a little screwed up while he had the flu.

All right, I'm going to weigh in on this but if my thoughts are jumbled and and I'm not thinking very clearly, it's because I've got a lot of stuff on my mind right now. First of all, I'm all for smarter use of lights and sirens. Should we keep them? I think so. But should we run hot to every call? Heeeell no. AMI? Cardiac arrest? Difficulty breathing (tentatively)? Sure, those conditions MIGHT actually have a LITTLE clinical benefit from getting there a little bit sooner. But should we be speeding to get the patients to the hospital or running hot to the hospital with ANY patients? Honestly, no. Can anyone think of a single medical condition that would benefit to getting to the hospital two minutes sooner? I say two minutes because I think all of the studies I've read on running lights and sirens put two minutes on the high end of possible time saved from running hot. So, is there? First of all, let's ask ourselves, what's the WORST thing that can happen to the patient? Well, the worst thing is that they go into cardiac arrest, and you know what? We can treat that just as good in the back of the ambulance as they can in the ER. What else? Are there any conditions out there that will benefit from an extra two minutes? And if the patient is going to go into cardiac arrest within two minutes if they don't get to the hospital within that time frame, is there any definitive treatment that can be initiated and take effect within two minutes that we can reasonably believe will stave off cardiac arrest? In fact, is there any treatment that can be done only by in-hospital personnel that can be initiated and take effect and reasonably prevent a patient from going into cardiac arrest within, say, ten minutes? How about fifteen? Now when we get to the twenty or thirty minute mark, it becomes a little more reasonable, but that is not the kind of time we can expect to save from running hot unless we were driving seriously dangerously. Seriously, work it out in your heads. The clock starts ticking, this patient has twenty minutes to live, if you drive regular traffic you can get them to the hospital in in fifteen minutes, and being generous, let's say you can get them there in ten if you drive hot. What definitive treatment can be given in ten minutes? For ANY medical condition? Stroke, well they got to do a CT first to make sure it's not a bleed; AMI, no way they can cath 'em and reach the occlusion in ten minutes; trauma, won't see a surgeon have a guy open in under ten minutes starting from the ER doors; sepsis, antibiotics don't work THAT quick. The WORST thing that can happen to these patients is that they go into cardiac arrest, and we can treat that in the ambulance. However there is, to my knowledge (and if I'm wrong help me out), NO definitive treatment that can be given in the ER that we can't give in the truck that will mean the difference between life and death that can be undertaken in under ten or fifteen minutes. And the studies don't even indicate we can get THAT much time out of running hot, but they sure as hell say we can risk not only the patient's life but OUR lives as well from driving like madmen to the hospital.

Hey, everyone, So, Wednesday is going to be my last day of internship. I took my class finals about two weeks ago (and passed, thankfully) and tomorrow I present my research paper, class presentation, and my case studies. After that, the only thing left is board prep and boards and I'll finally be done. Unfortunately, my fiancee recently went to basic for the Air National Guard and pretty much found out that the whole military thing is nothing like she was told and that it's not for her and she wants out. I wasn't ever much of a fan of her going but now I'm stuck trying to figure a way out for her. So it's been a kind of hectic and emotional end to things, though I'm hoping that things will get better and she'll get out within the next couple of weeks. If anyone has any advice on that, send me a message. Looking to the future, what were your first experiences as a brand new paramedic just out of school? How did you change from when you were an intern and what was different for you being the second one on the truck?

Is this an inferior wall MI or just right sided? What does V4R say? Anyway, assuming I have at my discretion and authority to treat with those medications as I wish, this is my treatment: *Nitro x3 or until systolic <100 (actually, I think wants it gets in the 110-120's I might go ahead and reassess from there) or pain 0 with a fluid bolus running concurrently and another on hand for severe hypotension, with fentanyl substituting that if no relief after x3 nitro and holding both if the patient's pressures start going down. Basically, if I can keep my preload good and still dilate those coronary arteries, that's my goal. *Gonna hold on the Lopressor. Yeah, it's not a bradycardic right sided AMI, but the rate's about where I want it to be anyway (and maybe it'll come down with some pain relief, too) and I don't want to stunt the SA node any more if it's part of the infarcted tissue. *Heparin 60 U/kg up to 4,000 units bolus then 12 U/kg/hr up to 1,000 units per hour. *Plavix 300 mg PO.

So, I'm going to be graduating from paramedic school with my AAS in December and I'm looking toward the future. I absolutely love working as a paramedic, but I originally got into EMS to get a taste of medicine after I decided I wanted to go to medical school and I'm ready to get headed back down that path next spring. I don't expect to be able to work a full time schedule (it's set in such a way that I can't have the same days off every week), but I'd like to work as many hours as I can. However the university I went to prior to getting into EMS has very few online classes and the schedules are horribly non-conducive for working people and basically made for the 18 year old student who plans to live at the dorms, and to take the classes I want (and need) to take this coming semester I would have class Monday through Friday with only the weekends off. Being the brand spanking new paramedic that I will be, the absolute most thing that I need to continue to improve my abilities is to get experience and I'd like to get as much of it as I can. So, here's my question for you people who have or currently are working EMS while going to school: how did you do it? Did you sacrifice time at work for school, or did you take online classes or did you just suffer a horrible schedule trying to juggle both? Also, if for anyone else here from Kansas, does anyone know about Fort Hays University's online classes?

Not at all, UglyEMT. I can understand where you're coming from, and I know your heart is in the right place. Don't ever worry about offending me, I've got thick skin and I don't take things personally. This is exactly why EMS entered the world of the internet, so we could have these kinds of discussions and learn from each other.

Thanks, Dwayne. I'm humbled by the praise of someone like yourself. The protocols I work under allow pain management for patients complaining of chest pain, abdominal pain, and isolated trauma with a blood pressure >90 mmHg and no mental status or respiratory impairments. Unfortunately, I work in a very much "cookbook" and "mother may I" type of service. But we just got a new medical director, so I'm hopeful for change and more independence to use our heads. Exactly. And I'm not claiming to be an expert or anything, but it seems like there is a very vast difference in the way people complaining of pain who DO have visible signs of it (in their presentation and vitals) act versus how those who don't have those physiologic changes act. I'm not saying it's a fullproof tell, but it's just one of those extra things that makes me go "Hmm..." Haha, thanks. Oh great, you mean it's never going to go away? Haha. Never got to play with it, I'm afraid. Well, except at the dentist's office. My service used to use it a long time ago, but they got rid of it when people were showing up at the hospitals with empty tanks after only transporting one patient for the day so far... Haha. So I can't attest to its effects or safety, really.

My dictionary defines diagnosis as "The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data." Like I said, you can call it whatever you like, and I'm not saying that we can accurately diagnose every disease in the field (because we obviously can't), but what we do fits the definition of a diagnosis. I respect you and your method of doing things, and if your way of doing things is to not refuse any pediatric patient or most adult patients, then I respect that too. Like I said previously, people have their own ways of doing things and honestly I completely agree that the safest thing is to NOT refuse any patients. However, I do refuse patients, adult and pediatric alike, and I am likely to continue to do so; that's how I've been instructed, and that's my comfort zone. Not at all. You're entitled to your opinion. And you can think I've got a big head and I'm full of it, and that's all right with me too. And you can call what you do whatever you like, but what I do falls under the definition of diagnosis and that's what I'm going to call it. Can I diagnose everything? No, not at all. Not with my limited resources, and I'm not arrogant enough to think that even if I did have all of the resources that I currently (or will ever, for that matter) have the knowledge to diagnose everything. That's just unrealistic. I make decisions based on my diagnoses and I live with them, for good or for bad. I will always err on the side of transport, but I will also refuse patients that I consider to be in no immediate danger and have no suspicion of going south and who don't want to go to the hospital. And one day that may come back to bite me on the ass. I hope not, and that's why I do my best to expand my knowledge, to better my ability, and to try and make the right decisions. I fully understand the risks I'm taking, and I'm not afraid to come right out and admit it to you guys. And yeah, I'm green as hell, but I'm also following the guidance and leadership of my preceptor, who I consider to be an excellent paramedic, and maybe I'm arrogant to think that because he does it I can too, but I'm at that point in my internship where I'm the one making the decisions, and he hasn't stopped me from refusing anyone yet, so I can only take that to mean that he trusts my judgement enough to trust me to make the right call for my patients. As I grow in EMS and learn more, maybe my opinions will change; but they are what they are right now.

I don't think it's quite that straightforward. And I'm sure if you work in the field you'll agree with me on that. The fact of the matter is that we do diagnose, however you want to spin the terminology, and our diagnoses guide our treatment and even our recommendations to the patients. Do you have a problem telling a patient with a small cut on their finger that they don't need to go to the hospital? I feel that it is our job as medical professionals to be educators as well as providers, more than ever when it comes to pediatric patients and their parents. Because I don't know about you, but I have refused several parents who called for their kids and I have had no qualms doing so. Parents freak out, and that's understandable, but I think that we have to be educators and patient advocates and explain to parents (and all patients for that matter) that first off, we're not doctors, but this is what we're finding, this is what would concern us, and give them their options. They can choose to follow up with their doctor, they can choose to go into the hospital themselves, and they can choose to come with us. But, and this is especially for those pediatric patients, I am going to be upfront and tell them if the patient is stable and I have no suspicion of acute or potentially life-threatening illness or injury, that if they want to go with us we're more than happy to, but you're basically going to be paying for an expensive taxi ride unless something drastically changes. And also, if they choose to stay home, here's what they can do to try to relieve your symptoms.

I happily give pain medications out to any patient that falls into my protocols allowing me to give pain control and who I truly believe to be in pain. I try to always err on the side of caution and giving pain control, but I'm also a little hesitant to do so if my patients are able to hold a conversation with me no problem, throw a big fuss about the IV stick, or don't present in a way that is consistent with someone who is in pain. I'm also still just an intern, so it's not entirely under my control, but when I'm practicing on my own it will be and I hope to always err on the side of pain control. I'm not out to catch drug-seekers, but I'm also not completely blind is what I'm saying. Do I think basics (or even intermediates) should be giving pain control, or even performing other paramedic level interventions? Sorry, but no. It's nothing against basics or intermediates, because I'm currently an intermediate myself, it's just a matter of the level of knowledge and experience. And I'll put it this way, I've been through basic, intermediate, and now paramedic school, and though I am new to this maybe that's a good thing in this instance, because I still see just how hard it is to be a competent paramedic and I still struggle every day at work to try and meet that expectation, and with all of my education it is still very, very difficult for me. And there's a lot of EMT's out there with way more experience than me, but even so, I've been through paramedic school and I've had to sit through months and months of lectures and labs to try and learn how, why and when to give the medications and do the procedures we do and I still pause before every intervention and question myself before I do it. So while I respect EMT's and everything that they do, I don't think that a weekend class or even a week or two of classes can make them ready or ought to allow them to do the things that, after months of training, I'm still nervous to do. And this isn't to say that an especially talented person couldn't, but rather just to give an idea of how much education it takes to competently provide paramedic level care. It's just not something you can learn in a week's time. And to be honest, I really think paramedic school out to be a four year (or at least three year) program. Where I am it's a two year degree, and I still think we need more time--especially in internship.

That's a good point, UglyEMT. Thanks, I'll try to remember that if I get the chance to work on a paramedic/EMT truck. So let me ask you another question, do you like your system the way it is? Or do you wish it were different? Instead of ALS intercepts would you prefer if your service just staffed paramedic/EMT trucks? When you guys have an ALS intercept, are the paramedics able to bring all of the equipment they need into your truck, or are there things that they have to leave behind do to space/moving issues? The one ALS intercept I've done was for a chest pain call coming in on a BLS truck with an EMT-B and I in the back with a first responder driver. We brought our box, monitor, and narc box and rode with them into the hospital while my preceptor's partner followed in our truck. I was really impressed with the EMTs and their care, and I'm a little sad to say I haven't gotten to experience more calls like that during my internship.

That's very interesting, Richard. So, when there's just one paramedic on the truck they're only allowed to function at a BLS level even if they have all of the ALS equipment available to them on the truck? Is there any particular reason why that is? UglyEMT, correct me if I'm wrong, but it almost sounds like you've been rubbed the wrong way by ALS on those medical calls. Is that true? How much experience do YOU get in the back of the truck as the sole provider for medical calls? I've perhaps been spoiled by working in a system where there are always two paramedics available, and though I plan to work part-time at this same service after I get my yellow patch, I also plan on working part-time for a rural service that currently only has one paramedic and a couple of EMT-I's and a bunch of EMT's as well. There are a couple of people from my class that will be working there in an ALS capacity as well, so the service is about to have quite a few more (brand new) paramedics available to them, which may or may not be a good thing. In my limited experience, I've found dual-paramedic trucks to be very fortunate and something I kind of like the idea of, especially with me about to be a brand-spanking new paramedic myself. On the other hand, I'm intrigued by paramedic/EMT trucks because of the inherent challenge in being the only ALS provider available. I don't know how your services are or how you guys run your calls, but I very rarely make a patient code green (code I by most of the country's standards?). The way my protocols read, I'm free to make them a yellow if I think they require paramedic evaluation, and I can pretty easily justify making any patient a yellow (code II?) and in fact do make most of them a yellow unless I can be certain of what's going on with them today and don't have any suspicion of their conditioning worsening. At the service where I'm doing my internship, I've gotten on average between five and ten calls per day, and out of them I've probably only made a dozen or so code green. In my system, all yellows get a monitor and IV, and it's rare that I don't at least have a look at their heart (which automatically makes them a yellow if I put them on the monitor). Unfortunately, I never worked as an EMT before going to paramedic school (which has come back to make my internship much more difficult than it could have been), and I'm a big fan of working as an EMT before going to paramedic school because seeing the people in my class who did have that experience versus myself, I can see where they've got a leg up on me. At the same time, it also means I'm very ALS oriented in the sense that I'm all about seeing what their heart's doing and having IV access, though I tend to be conservative in my treatments themselves. So for me, it's easy to justify myself and say "I want to put them on the monitor and I want to have IV access, though I don't plan on giving them any meds or fluids unless something changes", but on the other hand, I have gotten almost no exposure to working with an EMT and the dynamics inherent in that kind of system.

Hi everyone. So, I'm curious. Throughout my internship, which is coming to an end soon, I've worked with my preceptor and his partner who are both paramedics in a large service that runs dual paramedic trucks. They do hire EMTs part time if you're in paramedic school (I work part time for them as well, sort of) and are about to hire several EMTs full time. But so far, my only interaction with a BLS crew has been during an ALS intercept for a BLS only truck coming in from the next county over. I've never worked with an EMT before in an ALS capacity, and pretty much all of my exposure has been in a dual paramedic setting, so I'm curious as to what kind of staffing your services maintain, and your own experiences working on paramedic/EMT and dual paramedic trucks. What are the benefits/cons to each model? Do you have a preference?

Lung sounds clear and equal bilaterally. He states he's been compliant with all of his medications. Sorry, I thought non-diagnostic was a more universal term, apparently not! No ST elevation/depression, T-wave inversion or other signs indicative of ischemia or infarct. No heart blocks noted but there are some signs of left ventricular hypertrophy. You got your line, after a 250cc bolus he's up to 120/80 with some improvement in color but no definitive change in rate. He continues to have periodic episodes of regular sinus rhythm rate of 70 that last a few seconds. Decrease in weakness, increase in SpO2 to 98 on 10 LPM via NRB. Atropine brings his rate up to 100, which completely relieves his weakness and gets his color back to normal, next blood pressure is 130/90. Repeat 12-lead is still non-diagnostic with no signs of ischemia/infarct or block. 4-lead is now a junctional tachycardia. Thoughts on a diagnosis?

Why don't we try 1 g/kg of mannitol and see what that does? It'll reduce the ICP and increase the CPP, and if we have that art line and can get a MAP and if we can still keep an eye on the ICP (I assume they local ER doc put an ICP monitor in, though technically the patient doesn't meet the criteria for ICP monitoring, but since we got one earlier I'm assuming one's in place) we can get a CPP as well and have a better idea of where we stand. Ideally I'd like to get that ICP down to <20 mmHg and keep that CPP >60 mmHg, and maintain the patient's BP <160 systolic, which it's skirting the line right now so I'll leave it be.

Patient's complaining of general malaise and some weakness/dizziness. No respiratory distress, no chest pain/discomfort. No nausea/vomiting, diarrhea/melena or abdominal pain. Patient denies any recent medication changes/additions/discontinuations and states he's taken his medications today. Patient also states he has been getting over the flu recently, no meds taken for it. PMH: AMI (heart attack at 21 and at 33), IDDM, HTN Meds: nitro, ASA, carvedilol, simvastatin, HCTZ, Klor-Con, insulin Allergies: PCN Vitals HR 35 BP: 110/70 with +orthostatic changes (90/60 sitting accompanied by near-syncope) BGL: 110 RR: 20 NL SpO2: 92 RA 4-lead: junctional rhythm rate of 35 with brief (<10 sec) moments of regular sinus rhythm 12-lead: non-diagnostic With exertion patient's skin becomes paler and mottled, especially in the face and extremities. No change in mentation, only complaints with sitting the patient up/exertion is generalized weakness. Treatment?

What kind of clinical opportunities are available? (Locations, how busy the hospitals are, opportunities to intubate, average number of skills performed per student during clinicals, average number of intubations per student, support from the local medical community, etc.) What are the hourly requirements for clinicals and field internship? What additional resources does the program have available to prepare the students for passing the NREMT (or the equivalent in your country)? (I.e. emscat.com, etc.) How many lab assistants are available? What kind of teaching experience do they have? Is the program accredited? And if so, what sort of standing/ranking does it have? What kind of pre-FI training is available to actual field work? (That is, simulated scenarios on a more massive scale than lab, involving full equipment and possibly actual ambulances.)