678 Responding

http://www.state.nj.us/health/ems/document...tudy_report.pdf Well, here it is. The long awaited review and recommended changes for EMS in NJ. Hopefully something positive comes out of this rather than being another wasted and futile attempt at fixing the system. What do you all think?

Asys, Do you know what they ended up doing in the ER after you brought the patient in? I'm sure they started antibiotics, but i'm wondering if you had any idea what their initial treatment for the cardiogenic shock was. Good case though, nice one to debate about.

Oh no, by all means if you can get the drip started prior to getting in the ER, thats awesome. I'm just saying that since he is so close to the hospital, that by the time he gets his assessment done, and gets on the road which I trust is very quick due to the severity of the patient and gets orders for an infusion, setting it up, I can only imagine that he'll be hitting the "Run" button on the pump as he rolls the stretcher into the ER. So, why do that when they're going to switch over everything to their own stuff in 2 minutes anyway. I'm just trying to keep time along with practicality in mind.

Exactly what I was thinking about, but I had something else in mind. Dobutamine (as I am being taught in class) is more of a contractility increasing drug (inotropic and dromotropic), with little to no alpha effect so you're not squeezing an empty tank, but trying to make the pump more efficient, along the same lines of Digitalis. Levophed isnt what id want, as that really isnt the problem here since that is nothing but alpha effect and doesnt work where we want it to. Adrenaline or Epinephrine infusing is out of the question as this would sky rocket the heart rate, decreasing ventricular filling and making the problem even worse. I would be cautious with fluid boluses since the heart is already overloaded, and more fluid would put it into even further failure. Trying to increase the force of contraction of the heart in my personal opinion (opinion only) would be the best course of action. There is enough fluid, it just needs to be circulated better. If you increase the force of contraction, the pump becomes more efficient thus increasing the blood pressure to a more comfortable level without increasing heart rate or oxygen demand all that much. My reasoning behind this is that the low BP and rales are due to poor circulation and LV failure, so we most likely have enough fluid, just not enough "umph" from the pumper. Thats just my $.02 Have a nice day.

After all basic interventions have been applied I would have done some ALS if I had time without delaying transport to the hospital. I don't think dopamine would have hurt. The patient has a pump problem, and I dont see why it wouldnt have helped the patient. If you had it, I would have opted to go for dobutamine due to it's mostly inotropic effect, and less chronotropic effect of dopamine since the patient is already tachy and dont want to increase myocardial oxygen demand by increasing the heart rate anymore. But, my personal opinion is that even though the patient has endocarditis, its complicated with cardiogenic shock (according to your assessment) and that needs to be treated immediately. If you're less than 5 minutes from the hospital, I dont think starting a dopamine or dobutamine infusion is going to fix the patient that tremendously since you'll be rolling into the ER just as you hang it. Nice case though.

AZCEP, thanks for the response. They arent advocating much use of Verapamil here anymore, and I hear that term "Verapakill" quite often from the medics as it can have some pretty nasty side effects. Nothing from my school. just street talk. As for the Beta blockers, I meant to say Receptor, not channel. Had a long day. hehehe. Thanks again for the input!

She was dehydrated, so they started a fluid bolis on her. This didnt seem to change the heart rate all. We dont focus on conversion either, only rate control. Calcium channel blockers are great for rate control, as they affect the slow conduction, and are very close to Beta channels, so they have the same effect. Less force of contraction and slower heart rate. We dont use verapakill anymore, its not as cardiac specific, as cardizem is a much better choice for rate control. The patient would thow an abbarant beat every once in a while, so it hardly effects the rate and BP at all. Now that I look back at the picture, I think she might have been dehydrated, the heart tries to compensate, and in being in a chronic a-fibb, went into a RVR. I wasnt there long enough to see what happened to her or what the final result was. I do know that she was admitted though for the high BGL. I was just curious as to why some people prefer a Beta channel blocker for A-fibb/flutter with RVR over a Calcium blocker, as we are being taught to use drugs like Cardizem for this type of patient rather than Lopressor. Thanks everyone for your input.

Ahh, no hard feelings man. Kinda hard to gauge sarcasm over the net sometimes. Even when it was meant to sound serious As for that Busbulance... way cool. Now THATS mass casualty preparedness. 8)

I agree with Asysin. It is what it is. But who cares, really. To petty over something this small is like pouring a cup of water in the ocean; something stupid and insignificant while you still have a bigger, more significant problem to deal with. Like...... THE TOPIC AT HAND. Thank You.

Southern Florida my man, can't beat it. lol

I couldn't tell you exactly for sure what states they do 9-1-1 in. There are others in here that work for them that could answer that question better. The nice thing about AMR is that you can work for them in one state, do one thing, and transfer to another state or different job title without a glitch because its all the same company, just for the info. Try not to limit yourself to just one company, even though they are the biggest. What I would do is pick a particular part of the country you would like to live. Do some research, and see who runs the EMS systems in that area. For example, AMR is in Hawaii, and I belive does 911. But also, in Honolulu they have their own city EMS system. Cities like San Francisco, LA, Philadelphia and NYC. are fire based. Here in NJ, we are hospital based, and have a tiered system. (You ride in Medic chase trucks, and ride in with the BLS ambulance) Look around, see whats the most attractive, do some research and jump into it. If there is anything else you'd like to know, let us know.

Hahaha, this is great. I have to agree 10000000% with all of this. Burn the First Grade Council to the ground!!!! As for holding people accountable, isn't that what everyone else does? I mean, if someone pokes themselves in the eye with a spoon, we don't give them a spoon again, right? hehehe. But as they say, you cant cure stupid. Please please, keep on going people. I'm just waiting for the FAC jolly volley people to come on here and start whining. I'm biting the bullet for a little bit, then plan on leaving the state some way or another. There are just way too many corrupt, medically conservative minded, politically motivated, self absorbed free loading pricks in this cursed state for anything that would benefit people in a good way to get done. But like I said, keep on going people.

IF you want to go to Florida, most of the ALS systems down there are run by the fire departments. That means that more than likely you'll be made to cross train in fire fighting as well if you go that route. AMR around me, which is the Philadelphia area doesn't do 9-1-1 emergency responses, only transports. As i've heard from others, thats pretty much how it is in FL also, most of the emergency calls are handled by the fire departments as AMR does a lot of non-emergent transports, but this isn't everywhere. They're big, they cover from Hawaii to Connecticut, and as stated before, your experience will differ from place to place. Also, pay varies on what part of the country you are in. You'll be making less in FL then lets say in the north east. Medics are in need, but there are way too many EMTs. For example, in NJ, where I live, for a population of about 9 million people, there are over 22,000 EMTs, but only about 1,500 medics. Just to put it in perspective. As for the U.S. being ahead of MOST of the countries in EMS, I have to agree and disagree. For the most part, id much rather be sick here than any other place, but they are definitely NOT the most educated and advanced. For example, the Netherlands, requires a Bachelors degree in Nursing with specialty in Cardiac or Anesthesia, several years experience and then go through a 2 year pre-hospital education program. Pretty intense, where as many medics in the U.S. can be out the door in as little as 6 months to as long as 2 years. SO thats a pretty grey area. If you need anymore info, just let me know. Take Care.

Well, I was in the ER the other night doing a clinical rotation, and we had a 80 Y.O. lady come in with a rapid a-fib around 130-150, occasional PVC's and abbarent beats, asymptomatic, BP around 130/90. She does have a hx of a-fib. The reason why she came into the ER was because she said her BGL had been above 500 for the past few days and can't seem to get it to go down. So I do an accucheck and its 486. Confirmed. So, the resident does his evail, orders 5 Units of Insulin IV, and 5mg of Lopressor IV. I was a little taken back, since we were always taught to use a calcium channel blocker first for an uncontrolled a-fibb rather than a beta blocker, as also states our pre-hospital protocols. So the 5mg is pushed, and it doesn't even touch her. Her rate is still the same, and BP is untouched, se he tries it a second and a third time. Still nothing. He eventually stops trying, and her rate is around 120-130 now, BP still the same. I asked the resident why he used Lopressor instead of Cardizem for this patient, and he couldn't give me a straight answer. He tried to say something about "other underlying pathological conditions" etc etc. but I wasn't buying it. I still feel this lady should have been given Cardizem instead of the Lopressor. Does anyone else have a possible reason why he did this, what are your protocols for this, and whether or not I would have been wrong for giving Cardizem if this were my pt. in the field. Do you feel the calcium channel blocker would have had much of a different effect than the beta blocker in this case? Thanks!!

Yeah, thats Pine Hill, covers Clementon too. I haven't been there for quite a while though. I've been too busy with school.

No no, I won't get all pissed off, I like to hear other peoples opinions from all views. No matter where you go, you're going to get the same bull shit, no matter what. Politics ALWAYS seems to find a way to wiggle itself into everything. As for the First Grade Council, I have to agree. You know their motto "75 years of standing in the way of progress." They should be disbanded and everyone thrown in jail for negligence to the citizens of NJ for supporting sub-standard volly squads. The tiered system would work (I believe) if everyone would truly understand the way it's supposed to operate. Unfortunately, easier said than done. You must also take into account the gross incompetence from your jolly volly squads that gets FAC support, with (if you're lucky) one EMT because they don't want to swallow their pride and become a paid, professional service. The system is screwed up and flawed because people don't want to allow it to work the way it should. But don't forget, the ALS services here I feel offers a greater quality of prehospital care compared to some other systems (ex. Philly). If I may, where in NJ were you? Did you work for Virtua or Atlanticare? I'm currently in school, and want to get your opinion on these services if you care to share to help me choose when i'm done. Florida is looking awfully attractive also. Thanks!!

A DNR not signed by a Doctor is INVALID and hence, is not to be followed. Now, like you said, you called your doctor, explained your situation and was told to not attempt resuscitation. THAT IS valid. A verbal order from a doctor is as good as any written order. If I were the EMT in this situation, since they do not have ONLINE medical command, I would begin resuscitation efforts, and when the medics arrived, they would contact their medical command and get orders to cease efforts. So you did the right. I would have done it the same way.

I think i'm going to have to agree with the whole oxygenation/heart rate treatment together. He is having such a rapid A-fib due to the hypoxia. Why not treat both at the same time? I think he his having the edema from the blood backing up due to decreased cardiac output. I would throw him on Sp02, ETCO2, CPAP, and try to get his oxygen saturation up as high as I can while trying to keep CO2 under control. I also think the use of albuterol might excasorbate the situation, causing more myocardial oxygen demand, making everything worse. But does the risk outweigh the benefits? How about 125mg of solu-medrol? Atrovent would be good too, but I dont think it's going to do much. Also, since this is an obvious unstable A-Fib, if the oxygenation doesn't help bring the rate down, either use Diltiazem .25 mg/kg, if that doesn't do anything, sedation and cardioversion is going to be needed. Regardless of whether or not he's on blood thinners, if you don't control the rate, he's going to eventually die. Chances are, since he has chronic a-fib he's probably on a blood thinner like coumadin already, but if he does throw a clot, you can always treat that afterwards. But I also agree, if you try to convert or control this rhythm without massive re-oxgenation, you're going to be wasting your time because you will have no response from drug therapy, and a not so nice V-fib or Asystole from electrical therapy because the cells don't have enough energy to repolarize after a "reset". Tricky topic. Good one though, keep it coming.

Where is this video? They said it was posted on a website, but I can't seem to find it. I wanna see some ass kicking damnit!! hahahah

Haha, you guys rock. You know, i've always had an issue with the same thing before, now its crystal clear. Thanks Dwayne for posting the question, and dust, azcep for giving such a clear concise explanation. Awesome.

Ok, this is how it works. I'm a PA medic student but intend to work in NJ. Ill get to this in a second. My program has 545 hours of didactic time (Classroom). We are then required to do a minimum of 372 hours of clinical experiences (ER, OR, OB, Cardiac, ICU, etc). Then we are required to do an additional 240 (PA) to 500 (NJ) hours of street experience. Add it all up, it comes out to 1,417 hours TOTAL for NJ and 1,157 for PA including clinicals in and out of hospital that I am required to have at a MINIMUM. More might be needed for whatever reason. This program takes 13 months Full Time to complete at 3 days a week, 8 hour days; OR Part Time 18 months at 3 days a week 4 hour days. This is all without an Associates Degree. If you want to do the Associates Degree program, its a little more didactic time. You can take college classes in conjunction with the medic class, as long as you are able to handle everything. Sometimes an intense medic program is just as difficult if not more difficult than most "college" classes. This is what I am doing myself, as the A.A.S. option doesn't come out until next year, so I am taking college classes at another school at the same time so that when I am done, I will have my college degree in Paramedicine. Hope this helps. If you have anymore questions, let me know!! Stay safe.

Seatbelt people, SEATBELT!! Ughh. So frustrating.

I think you're in luck, because AtlantiCare I believe is heading up a new Medic program, so you wouldnt have to go all the way to Blackwood (where I am) which is a hike, or even philly for that matter.

Need to be a little more specific, all of us viewed it as care in new jersey. Never even heard of the company.

Yeah, a lot of them are people that were once medics or EMT's whose cards had lapsed and didn't renew them and continued working. Another one that cracks me up is how many people that were medics and EMT's and turn in fake cards, or medics that turn in fake ACLS and PAL credentials. Ever hear of CEU's and taking the required classes? Just proves that we aren't immune from stupid, retarded people either, and we bitch about them everyday.