vs-eh?

http://www.emtcity.com/phpBB2/viewtopic.ph...b757646dc#82517 I felt that this needed its own thread. This kind of action boggles my mind. Uglymedic, how can you possibly think that what you did on this call was correct in anyway? Honestly. A conscious, breathing patient who is maintaining their own airway AND TALKING TO YOU says they are choking ON A F*CKING ANT! You tried your awesome q-tip technique (which is sketchy in itself) and then decided "Oh well....next step is laryngealscopy and Magill's right?" JESUS. H. CHRIST Hmmmm... Let's see...Correct me if I'm wrong but perhaps encouraging the patient to continue to try and cough it up, ummmmm maybe drinking/gargling with some water? Salt water? Listerine? Pop? Anything? Man... Honestly...How did you even do this? Told the patient to lie down and scoped them? Conscious and talking to you? Did your partner not perhaps suggest an alternative? Your patient went along with all of this? Laryngealscopy carries it's own cardiovascular, iatrogenic, etc...risks.... My faith in EMS is destroyed. Uglymedic, report your action to your medical director and see what they say.

WHAT THE FACK!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! That is the last straw. My faith in EMS is absolutely destroyed. Especially American EMS...If others are reading that and say "What is the problem?" I pity you...Tell me where you work uglymedic so I can forward this to your medical director. I don't believe this...I hope you are joking...And if you're not, you are an absolute and total idiot.

Should probably be in the Canada forum but... Some other guy recently posted a similar question here - http://www.emtcity.com/phpBB2/viewtopic.php?t=5874 My response... 1. Please link your program. Is it considered ALS or BLS? 2. Are you currently involved in this program? If so, how far in? If you have not started yet, and are set to work in Canada, it may be easier to just take a program in Canada instead of going through a shit load of equivalency. 3. Here are some links... http://www.ontarioparamedic.ca/ http://www.paramedic.ca/ A link to my program (this is for BLS/PCP) http://postsecondary.humber.ca/07651.htm A link to an ACP/ALS program (you need your PCP first obviously) http://www.conestogac.on.ca/jsp/cecatf/health/acp.jsp An Ontario perspective... 1. You will need to do equivalency - likely following CMA/MOH guidelines and hope that your program jives. 2. If you only get PCP equivalency you will have a very VERY difficult time finding work currently. If you get ACP equiv. it will be much easier. 3. Areas to live in Ontario? Depends if you want urban, rural, or a mix of both. Cost of living in Toronto is basically the highest (outside Vancouver) in Canada. However most Greater Toronto Area Services will be difficult to get in. Urban centers expect 3-8 calls / 12 hours...Rural shutouts can be a regular occurrence. 4. Salary - PCP = $26-32 dollars an hour...ACP is $28-37... All services are unionized and municipal. Generally good health care plans, benefits, etc... 5. No clue of immigration. But I would imagine it wouldn't be difficult considering we are all commonwealth no?

...my parents went away on a weeks vacation, and...They left the keys to the brand new porsche, would they mind? Hmmm..well, of course not... So, I had an interesting set and thought I'd share my tale of 3 patients. Sit back and enjoy. Hold all comments to yourselves because I don't care what you think. THIS IS LONG SO GIVE YOURSELF 7mins and ummmm 31secs of time... Patient 1... Called the a NH on a DELTA for a man in his 70's, unresponsive, diff. breathing "like sleep apnea" as per NH. LOL...so I'm thinking "sleep apnea"? He's probably pulseless and agonal... So we get there...Man is unresponsive and in cheyne stokes resps (look it up if you don't know) which I had never seen before. He is pale, cool (tympanic 34C and cool to touch) and diaphoretic. He was last seen ~30mins prior with zero c/o and normal mentation (GCS 15 apparently though normally abrasive). He was generally well x several days. I don't remember specific medical conditions, though he had recent hip surgery including an MI during the operation. Vitals - Pulse 70's, BP - 62/40, sat 97% RA, BS was normal (don't recall), chest was clear with no adventia. NSR on the monitor (no 12 lead), pupils PEARL at like 3? Meds - Don't recall specifically but no antibiotics and no beta-blockers/anti-dysrthymics... This patient is a DNR... So I'm thinking maybe sepsis (hypotension with no compensation, and he probably had been sick for a few days) and increased ICP (query CVA with the cheyne stokes maybe bleed affecting pons/medulla). inferior MI with R vent. involvement could be on there too I guess. So NPA, NRB, monitor, IV (he had about 700ml prior to hospital arrival with zero HR/BP change). I was going to ask for dopamine but given his DNR I decided no...I also decided no PAI (he was becoming more rousable during our tx with some purposeful movement) always considering the DNR. Patient 2... Called for an ECHO. Male, mid-40's collapse in a mall, unresponsive, shallow breathing, mall security had a PAD with one "no shock". Noted - EMS was called there for this guy ~30-45 mins prior because mall security "didn't think he looked good". Paramedics arrived, and he basically told them to F-off, and was threatening to sue for hastling him. All they got was name and DOB. He refused all assessment. Crew actually attended the call to back us up and said he was GCS of 15, CAOx3, with no noted mental deficits or distress. Witness - Buddy was walking with a walker and just fell backwards smacking his head. Unresponsive post fall with shallow breathing. No noted seizure activity, no obvious distress prior. So we get there, buddy is being attended to by mall security with a PAD on him. Unresponsive, being ventilated with a face mask thing, no CPR in progress (and never was). He is breathing about 6 a minute a shallow, strong rad pulse (obviously never arrested, FR aren't taught pulse checks anymore?). So OPA/NPA and BVM tolerates everything good compliance, good a/e, initial ETCO2 like mid/high 50's with a good waveform. Vitally he is stable HR - NSR in the 80's, BP - 120/84, BS - normal, sating well, pupils like 2-3 slow, he had matted bloody hair to occiput difficult to qualify injury but nothing grossly unstable...So hmmm right? We had no PMHx besides some obvious neck problem (flexion/stiffness/and bandaging for chaffing obvious chronic issue...great tube eh? Go go lighted stylet). So whatever differentials are pretty big but head injury/CVA/seizure or narcotic OD (likely polypharm given vitals). Seizure would seem odd given his tolerance for the airways and vents for ~10mins. CVA vitals are unusual... So a/w and breathing are good, no need for a tube this instant, IV is started, and c-spine is underway. I am standing there already prep'd for intubation and have some drugs out just in case. I give him pre-intubation lidocaine due to query head injury as the issue. Shortly after doing that, he starts biting/gagging on the OPA and fighting the bag. Take out OPA and he starts coming around to about a GCS...oh....8ish? By the time we got to the hospital he was GCS 8-9. He kept saying "sit me up" and not answering any questions, also he wouldn't move his arms/legs though it was obvious he had pain sensation... Patient 3 (The weirdest one)... Called for an ECHO again at a residence. This time for a choking...Now, anyone who has worked in EMS for a bit, especially urban, knows that 99% of "chokings" are BS. They are either resolved prior to arrival, a person coughing and talking who just needs a little coercion, or the "I took a vitamin 20mins ago and it seems to be stuck in my throat..." As they are gabbing away about there 6 grandkids and such...Very very rarely do they require BLS and ALS intervention... East Indian Male, mid-80's...Less than 5 mins prior to arrival pt. had taken a bite of his dinner (roti). Less than 10 secs following that (with no warning) patient falls to the ground...no coughing, no seizure, no "universal choking hand sign", nothing...Pt/ had no c/o prior, generally well x several days, and no medical hx. That's right folks, mid-80's and NKA, NO MEDS, and NO SIGNIFICANT MED Hx (surgery on knee and gall bladder like 10+ years ago thats it) and a 50+ year smoker. For an east Indian male (high risk for coronary) that is good... So our arrival (right on top of this, like < 2 mins). Pt. conscious lying on floor, breathing, no real distress, no audible stridor/adventia. a/w was maintainable by pt. no tracheal sounds on auscultation, = a/e bilat A>B, is breathing somewhat shallow. Vitals - 98 on RA...but he desat to 94 soon after (recall smoker), HR - 150-160 atrial tach, BP - 190/100 L arm, 220/100 right arm, sating 98 now on a mask, BS - like 9 something...physical had a bit of abdo distention that the family said was unusual. Mentation - Patient did not speak english but would not talk to family when asked questions, he did have some movement in extremities but nothing fantastic...So whatever monitor, O2, IV (no luck, he had veins but no flash and no advancement, took the hospital a while once we were there too). CVA? MI? Meh... We sit this guy up and move him to the stairchair...Sit him down and he lets out this HUGE belch and out comes this 3/4 palm size piece of Roti. Lol, my partner and I are like huh? So here is our hypothesis... He may or may not have actually had a tracheal obstruction. For whatever reason it dislodged from the trachea prior to our arrival and rested either in the hypopharynx or (more likely) in the esophagus. He had some how managed to swallow a bunch of air (would equal the distention). This obstruction I guess could have been intruding on the posterior trachea cause a partial obstruction, but clinically, there was really nothing to suggest that out side of the hx. Certainly nothing to suggest BLS or ALS a/w intervention. But ya...once the roti was expelled, he started to perk up. Tachycardia resolved....BP fell...started talking to his family. By the time we got to the hospital, he was basically his old self as per family and hemodynamically stable. Weird eh? Tach and hypertension was some kind of laryngeal stimulation/hypoxia? Meh, who knows... We were laughing because we weren't getting any patients who "fit" on this set. It's good though, I like it... Comments? (Yes, I really really want those comments).

Don't hate me... STAT holiday not worked (i.e. falls on my normal days off) = 12 hours of pay STAT holiday worked = 12 hours of pay + double time for the day. Yes, I get triple time for working a STAT, about $96 an hour on those days and I'm not at the highest pay. We can also choose to to take 12 hours of that time in lieu time and get cash for the rest. Also if you are scheduled to work on a STAT during what would be your normal shift, you can book it off and still get 12 hours pay. Ex. - Your normal work sched. has you working on Xmas. You can request it off and you will still get paid 12 hours as would anyone who would have been off normally. There is no "penalty" other than loosing out on 24 more hours pay for that shift. Ah.....The joys of working in a large unionized municipal service.

This is what you need to have on you on the job... - Stethoscope - Pen - Shears - Pocket drug reference - Gloves - Pen light (admittedly I rarely carry one) - Eye protection (especially if you are doing advanced airway management, but admittedly I don't carry this). Optional that I carry... - Cell phone (in pocket) - Standing orders (Most carry this, you should have it memorized but sometimes you may need a quick ref. on more obscure orders) That is it. Anyone who carries much more than this is carrying too much. Knife? Window punch? Hemostat? Nope, you don't need it. I work in a heavy urban area, one that is busier than 99.9% of the areas people here work and I have NEVER needed anything more than that. Nor have I thought - "Man, I really could have used a hemostat here". Did someone here say they used their knife to puncture tires at an MCI? WOW...

:shock: :shock: :shock: :shock: Ummm...remind me never to go to Indiana! Points on the transfer... - This patient only had a saline drip and nothing else and was given sepsis as a dx and is hemodynamically unstable. No pressors, inotropes, antibiotics? Nothing, but bolusing an 80 year old heart? - This 80 YEAR OLD PATIENT is being treated for his hemodynamic instability only by running IV's WIDE OPEN? Continuously bolusing an 80 year old heart is not such a good idea, especially when they are being suctioned pretty dynamically and likely are showing some signs of CHF (though I'm not saying only)... - You had to BAG this patient for what? 20-30 mins? LOL!!!!! No vents or anything? Jesus...How are you maintaining an FiO2 of 0.5???? Pray-tell? - You should not have done this transfer by yourself and have had at least another paramedic with you, if not an RN or RT or MD. Or any combo of that. - You SHOULD NOT have taken this transfer with what you have stated happened in hospital. YOU SHOULD HAVE asked for more help, asked why other interventions weren't happening, and (I hate to say this) why the patient wasn't flown. This would have been a Critical Care transfer here, either by land or air. Period. That or had an RN/RT/MD with a crew. I would like to hear more. You put yourself at professional risk with this one my friend.

In Ontario, everyone is supposed to have a provincial ambulance photo ID card. It is issued by the Ministry of Health and (as far as I know) is a valid piece of provincial identification (akin to a drivers license). The card generally has your name, and your photo, it also what is called an OASIS number that all Ontario paramedics have assigned to them. There is no identifier of what service to belong to (outside of a number in the corner). There is also no personal information on the card. It has a magnetic strip that I assume people could access, but I have never had it swiped, nor has anyone that I know of... I say supposed to because I wasn't given one into well into 2+ years of service. You are supposed to carry it with you at all times while on duty and it must be surrendered upon completion of service in ambulance. Technically I have to show this every time I do a call at our international airport. I have only done one or 2 calls at the airport and was never asked. It expires at the beginning of the year, we'll see how long it takes to get a new one... Most larger services that I know of also have a service specific ID. Your "paramedic level"/position in the service, name, employee number. We use it to swipe on and off, in our automated book-on process. Works pretty well. I'd say 95%+ of people do not wear their ID's, but simply have them on them. As far as I know you do not have to wear it, just be able to produce it. We, and most other large services I assume would not have an issue of false representation or people questioning who we are. There are not a tonne of overlapping ambulance services because basically all only cover their regional area. All are municipal services, their are no "private" services that operate 911 in Ontario. It would be akin (for lack of a better example) to FDNY doing ALL 911 and emergency work in the city, and are the only service that can say go L+S or to differ calls to. It is a different system here, I would wager there are approx. 30? ambulance services in the entire province. I would also wager that a moderate to larger American cities have that many ambulance services that could respond to 911 calls.

God you are an awesome individual.

Bravo! =D> I recommend picking up this book... http://www.amazon.com/gp/product/078174764...6271944?ie=UTF8 I did and I read it prior to my OR rotations. I wanted, on an elevated level, to be able to discuss principals of advanced airway management and pharm. intervention outside of my traditional education. You know what? The doc's raised an eyebrow and gave a little smile of interest when I was discussing things with them. I didn't do my OR rotation in a teaching hospital, and I was the first to be educated in the OR at that hospital. I didn't want to let my school, the docs, or myself down. My clinical hospital (and I assume all OR's) don't use the traditional EMS BVM (self inflating), they use a Flow-inflating bag (Anesthesia Bag). Lemme tell you, after the doc sedates, anesthetizes, and paralyzes a patient, they are going to want to see you do good BVM vents. (the cornerstone of airway management). The flow-inlating bag, requires a GOOD SEAL and GOOD BLS MANUAL AIRWAY MANAGEMENT or else it ummm, won't inflate... They don't see that, don't expecting to be intubating a patient. They also have the luxury of monitoring tidal volume with this, etc... You will initially be intubating patients that doc's see as facile patients...Grade 1-2 airways, edentulous patients, etc... Know what those things mean too... There is no way you can possible get any type of decent education rushing around in your one day of ORdom and hoping to tube every patient. Baby steps.

Well, you SHOULD be doing a minimum number of IV's and intubations in hospital. If you don't meet these minimums you don't finish your hospital practicum and move on to field preceptorship until you do. Obviously you are going to be educated in advanced airway management and IV therapy, fluid/electrolyte/acid base/etc...prior to actually doing the procedure. I hope anyway... I have mentioned this before but...Most CMA accredited programs (and as a general rule of thumb for all programs) for ACP's require at least 20 IV starts and a minimum 70% success rate. Most people get 50+. Also for intubations, most require 6 days minimum (48 hours) in the OR with an anesthetist (you could potentially do an intubation in the ER too) and get a minimum of 20 intubations, with the last 3 in a row successful. You are given 2 attempts, following that it is unsuccessful. Again, I did around 30 tubes in the OR, with some getting as many as 50. You don't meet these minimums of clinical hospital practice? You go back and stay there until you do. Having one day to "practice" intubation on "real patients" is ridiculous. Most of the procedures that anesthetists do are elective/non-emergent surgeries. I wouldn't want some one day OR paramedic rolling into my hospital and accidentally chipping a tooth (a major concern) or lacerating vocal cords in their rushed desire to "practice".

That is actually what concerns me most...

WHAT OTHER ORAL AIRWAY ARE YOU INSERTING AS AN EMT-BASIC? NO IT MEANS YOUR FINGERS, MANIPULATE THE EPIGLOTTIS AND DIGITALY INTUBATE THE PATIENT! GOD! HOW DO PEOPLE NOT UNDERSTAND AFTER EVEN THE GROSSLY INADEQUATE EDUCATION THAT YOU RECIEVE THAT AN ORAL AIRWAY IS AN OPA? +1 for the -19325425 that EMT-B's have on this forum for education...Why can't I give NTG though... I have heard this test is a joke and a half...How do people fail this? Man, I wish I could write the NREMT-P.

We are doing this study (which is blind incidently, so you don't actually know what you are giving the patient). Here are the standing orders (as I recall)... Age >= 15 and/or >=50kg Blunt or penetrating trauma with SBP <70mmHg or SBP 71-90 with a HR > 108 (I think). OR Blunt trauma with a GCS <= 8 prior to any sedation... CONTRAINDICATIONS... - Isolated penetrating head trauma (I think it was just penetrating) - Incident happened > 4 hours prior to arrival - pt. has received > 2L of any fluid prior - known pregnancy - drowning - pt. is a known prisoner I don't recall any specific information you have to give to the patient prior to enrolling them. But let's be honest a patient who is eligible is either going to be unconscious anyway or certainly not in a solid mindset to consent. So unless they are a prisoner, they can be enrolled without consent. Also because it is "blind" they technically may not be receiving any type of "new fluid" and may simply be getting NS.

Sorry, when you see the same thing and hear the same story for the hundredth time, it tends to get a little old. I can only be so "professional" when I'm handed an envelope and have a back turned to me without even saying a word. I can only take so much lip service and "oh's and ah's" when trying to explain a current patients situation that me and my partner could ascertain after 30 secs with the patient and looking at their history. When all my questions or my partners get the "I'm not sure" or the numerous almost script like answers... So who is a "paragod" and who is a "real" paramedic? Honestly, outside of this forum, I have never heard of the term paragod. Do people use this term commonly outside Ontario and in the US?

Whoa whoa whoa... I may bash NH staff but... - At minimum they usually have at least a 2-year college degree (or equivalent) here. - They dispatch 2 FD's (what does that mean like a fire truck and ambulance and stuff) and an ALS car for something "routine"? Sorry if anything that is BAD DISPATCHING and services looking to validate their expenses. So what like 10 people show up for some 80 year old's cellulitis in a NH? LOL...It reinforces my gongshow mentality of aspects of US EMS. No doubt crews go L+S to shite like this...

Succs is a different class of drug than the -croniums, as it is a DEPORALZIING NMB. It would make more sense (esp. for peds) to pre-treat with atropine (because of heightened vagal response period, regardless of laryngealscopy). I guess atropine could be the reversal (I don't remember) it kinda makes sense...

This is a spinoff of Godfather's blog post. I'm sorry, but the vast majority of my nursing home experience and their nurses is quite poor to lazy. When you call 911 for "your patient", I expect you to have some type of report with some type of flow to it. The vast majority of times when I unfortunately have to do a nursing home call, is me walking into a room where the patient is surprised to see me/unconscious and there is no nurse there waiting/or readily available to give me a report. I DO NOT want you to simply read off the doctors note's or the patients MARS sheet (I can do that myself). I expect you to have a little bit of insight into this pt. such as... - Their normal mental status - Their normal state of health - What has changed today - WHY 911 WAS CALLED! - etc... And don't shrug your shoulders and get all pissy when I GET PISSY because you obviously have zero clue about "your patient". I am not a mind reader, this patient is in your care 24 hours a day. Yes, I realize that you may have a lot of patients but I assume you generally see a "set" of patients and can at least form 3 sentences telling me what is wrong today other than reading notes and telling me "The doctor wanted them taken out". I do not want to hear... - This isn't my floor - This isn't my patient - I didn't call 911 - I just got back from vacation - It's my first day Do they teach people these phrases in school? Honestly I am tired of hearing them... Keep in mind that there are exceptions, but they are few and far between. It is honestly REFRESHING to walk into a patients room and have someone give me a nice formal report *AHHHHHHHHHH*. Keep in mind that most nurses in NH are not RN's (4 year university), but are RPN's (2 years college). Not that it should matter though...

They probably mean hyperkalemic induced arrests, which would normally be seen with dialysis patients. CaCl is used as a cardio-protective drug in these circumstances, I think having something to do with Phase 2 of the action potential. I don't remember specifically... Atropine is used pre-intubation for kids (under 10 usually as I recall) because they have a common vagal response to laryngealscopy. Pretreatment of atropine aids in reducing this effect. Ummm, perhaps you read it wrong, but I don't recall atropine as the reversal for vec, or any other NDNMB's. Vec (as I recall) blocks acetylcholine receptors with nicotinic and muscuric action and there for negates muscle contraction (mainly nicotinic) and causes paralysis. To counter this (reverse paralysis) you would want a drug that increases the concentration of acetylcholine at the pre-synaptic cleft, increases the concentration gradiatant on displacing the NDNMB. Drugs that do this are prostigmine and such... Prostigmine is a acetylcholenesterase inhitibor which negates the break down of ACh at the post-synapic cleft, cause a buildup and so forth... Spelling sucks and some of this may be a little off, I don't use any of the drugs listed for the purpose described and learned about this stuff like a year ago. Close enough though. EDIT - I did a quick search, it looks like atropine is used in conjuction with a -stigmine to facilitate recovery from RSI using NDNMB. I don't recall reading that in the Walls book though, and I'm not sure if that is standard practice.

cure

c u n t....yes I'm sorry....it is a terrible word....but I said it...move on with your life...

PINE!

vile

nile

fife...