FireEMT2009

Hey guys,

After working with patients for a while now I have a question.

I have noticed that some people have blatent EJ veins but some of the patients that I have thought about attempting the EJ, I have had issues trying to locate and find it even though I know where it should sit anatomically.

Does anyone have any tips to find an EJ for the non-obvious EJ patients?

Thanks in advance,

FireEMT2009

In VA, you must have a NREMT-P certification to receive your initial reciprocity to get your certification. Once you have the state cert, you can let your NREMT-P lapse, it is not required for recert in VA. Your state license will last 3 years, but the CE hours are the same hours, NREMT to VA, so there is really no reason to let your NREMT lapse. There is no Virginia EMT-P exam, you must have NREMT to become a paramedic. The state now has started requiring ALL levels of EMS to obtain their NREMT certification in order to become an EMT in VA. This is a new standard that was put in place this year.

Has he ever had pain like this before?

Does the pain go anywhere apart from in his chest?

What type of pain is it? sharp? stabbing? cramping?

How bad is the pain?

He has never had this type of pain before.

It says it does radiate a little on each side, but is substernal.

He said it feels like a strong pressure and that he can't breathe.

He describes the pain as a 8/10

Does anything make the pain better or worse?

What is his past medical history like?

Does he have any family history of heart disease?

When did he last eat?

Ix - obs and 12 lead ECG including V4R, right sided or posterior leads as appropriate?

Does physical exam reveal anything? lung sounds? heart sounds? JVP?

PDx - myocardial ischaemia until proven otherwise

DDx - MSK pain, spontaneous pneumothorax, trauma, PE, chest infection, pneumomediastinum, AAA, acute ventricular aneurysm, acute valve rupture, pericarditis/myocarditis, epigastric pain, GERD

He hasn't done anything he called as soon as it started really hurting, He said it started a couple of days ago, but has gotten worse over the time period. He had a gravy biscuit for breakfast (It's now 11:30.) His father had one heart attack. 12 lead reveals no ST elevation/depression or T wave depression, Posterior and Right sided are performed with the same result.

Lung sounds are clear, heart sounds are noted with S1 and S2 with no gallop or murmurs. No JVD.

He states that he has had heartburn before, but this is not heartburn, this is presenting differently.

What else would you like to do for assessment?

Pt HX , eval , vitals, orthostatic BP, quick 12 lead while stretcher/ stair chair is being brought in

325 mg ASA if no contraindications , O2, IV access, NTG if indicated,& not taking the magic blue boner pill, put his butt on the stretcher, get in the office and start heading towards definitive care while doing all the above. We have a thirty minute ride to small hospital and hour plus to cath lab if determined by diagnostic review and evaluation.

Today with the weather might take a couple hours due to whiteout conditions just to get to the local hospital.

If your in the big city with a cardiac center on almost every street corner. stay in the house and play with all the toys as your transport time is only three minutes.

You have IV access with blood drawn (if per your protocols), 12 lead performed without ST or T wave depression or elevation. Vitals remain stable throughout the orthostatics. VItals are as follows: B/P= 182/110 HR= 120, SpO2= 98 RA, ETCO2= 40. No contraindications to ASA or NTG. Both given without any relief, but now he has a headache.

What do you want to do next now that your transporting?

pericardit......awww screw it.

Quite possibly, continue assessing.

Erectile dysfunction pills are not a contraindication to GTN here, just a warning that it is prudent to give a reduced dose i.e. 0.4 mg SL instead of the usual 0.8 mg

If there was no very strong evidence as to an alternate, non cardiac cause I would give him aspirin.

Entonox +/- morphine as required for analgesia.

Serial 12 leads

Transport to the hospital

As listed above, 12 leads show no abnormalities. You have administered Morphine and the patient states that his pain has decreased from an 8/10 to a 6/10. What's next?

Well, I have been looking into furthering my education, and I understand that some of the stuff we do as Paramedics, mimics what an RT does. And not to mention, the airway/respiratory/circulation system has always amazed me and I would like to continue my knowledge.

My question to ya'll is, would my experience as a Paramedic assist me in RT school? and what ya'lls opinion on transferring from NREMT-P to RRT?

Thanks for any opinions,

FireEMT2009

Dispatch: Caller states that his father is experiencing chest pain.

You arrive to find a 30 year old male meeting you at the door saying his father is having terrible chest pain please hurry!

Your patient is a 54 year old male patient. You find your patient sitting in his recliner holding his chest, the patient appears anxious. He says he has never had this chest pain before but needs you do something, he thinks he is having a heart attack. Who's on first?

I had a recent patient that we found unresponsive. He was found by bystanders at a highly populated area so it is unlikely that he was down long. Everything about the patient is unknown except that the guy who sat close by him earlier reports he complained of back pain. Initial pulse is 30'ish. Breathing shallow. During transport he went into asystole. CPR initiated for about a minute and during the first pulse check we had a pulse back. Patient became tachycardic at about 130 before settling back into the most beautiful NSR ever. Nothing on 12 lead. Blood sugar was perfect. Patient started coming around and was combative. When we got to the ER he started becoming alert.

Test results showed a high ammonia level. The nurse told me it was over 100. I have done some research on ammonia levels but nothing that really shows how this patient coded and came back with just compressions. Anybody have any ideas? Maybe it had nothing to do with ammonia levels? The day after the event I learned his admitting diagnosis was hepatic encephalopathy...

I think I presented the pertinent info on how he presented but if there is something else that is important I'm happy to fill in the blanks. I just was completely confused by the way the call went.

Thanks for your input!

There was no AV-block. I don't know what MAS-syndrome is...12Ld was after the asystole.

Heart rate was 30 for maybe 4 minutes. I didn't give Atropine because I didn't have a line yet. I didn't get the line until the asystole was over.

I didn't smell the breath.

Thanks!

Medicgirl,

looking at your original posting compared to your posting just now about your patient being extremely bradycardic, why did you not start TCP? What where the vitals prior to coding? Looking at a pulse of 30ish, that is showing poor cardiac output. Why not place them on the TCP while you were working on the line? In this patient, since they were unresponsive and critical, why did you not start an IO? Not trying to armchair quarterback here, just trying to follow your rationale and train of thought.

What were the patient's pupils? How was the patient's blood pressure and Respiration rate prior to coding? Because a mix of hypertension, irregular respirations, and bradycardia would show me an increased ICP. I have seen hepatic encephalopathy before, but not in this severe of a case.

For me, I always try to see if you can see the chest rise and fall, and yes some patients might not have a very noticable chest rise and fall, or they might have some very thick/multi-layer clothing on. If you are sitting on the captain's chair or bench seat you can see respirations looking at the clavicle area, you should see some movement. Also, look at the stomach, some patient's stomach will rise and fall with their breathing. Just suggestions.

Hey guys,

I started a new post on this forum to ask about two books I am interested in buying. They are both to help me build on my 12 lead interpretation skills beyond identifying ST elevation and RBBB and LBBB. and Right and left sided deviation. As some of you know I am a new paramedic and 12 leads are my real weakness right now. So here are the two books I am looking at getting:

Rapid Interpretation of EKGs by Dale Dubin

and

The Only EKG Book You Will Ever Need? By Malcom Thaler

Pros to Each?

Cons to Each?

Do they Complement each other well?

Additional information and opinions on them.

I plan on buying both but am looking for which one I should by first.

Thanks

FireEMT2009

I started my first week as a paramedic this week. I had to begin precepting to be released to practice. In my agency they place us on a three person medic truck with one BLS provider and one other medic of the same (or higher) FTO with you. Here is my issue:

I know what I need to do and I know what to do but my brain seems to vapor lock shut and doesn't allow me to able to think, proccess and act as the medic I know I am and can be. I am pushing to get better but am being told to lead my team including my FTO on calls. I just can't seem to beat back my low confidence and the disconnect between my head and my hands and do and act as I need to. I seem to bumble around and act almost incompetent and I just become more and more aggrivated at my self and I am just completely frustrated to the point of not knowing where to turn.

So I am looking for advice for someone to help a new medic work especially when you have a FTO watching every move you make questioning you at all times. Any advice or opinions are greatly appreciated.

FireEMT2009

A paramedic is not defined by the skills they can do, but by their knowledge and the level of education they have attained which, as inadequate as it tends to be in the majority of the United States, is still substantial compared to that obtained of an EMT-Intermediate. Now, I wouldn't complain if we abolished the term "EMT" and renamed it "paramedic" and clarified the level of care as an addendum to the title (if only among ourselves)--i.e. Basic Paramedic, Intermediate Paramedic, Advanced Paramedic, etc--but as it stands, the way we distinguish the two is with the classical nomenclature of EMT(- , (A)EMT-I, and (EMT-)Paramedic.

Should there be noted differences between the two? Well, yes, because there ARE noted differences between the two. Sorry, man, an intermediate in your area may be able to perform all the same procedures as a paramedic, but they're not the same. I say this as someone who was once an EMT-B, an EMT-I and who is now a paramedic. The amount of education (at least around here, and granted, Kansas requires an Associates to become a paramedic but I don't believe we're light-years away from the rest of the country either) is on a completely different level.

Like I said, I don't care if we rename all EMT's "paramedics" for ease of use and for the general public's sake, but to imply that there is no difference between two providers because they are allowed to do the same skills shows a complete lack of recognition for the fact that we are not what we can do--any monkey can perform the skills we do; hell, a child can intubate. We are what we know and what we have proven we know.

Not trying to be a dick, man, and if I misunderstood something you said then please let me know and I'll redact my reply, but the impression I'm getting from you is that you think the ability to do the same skills makes an EMT-I the same as a paramedic, which couldn't be further from the truth.

Hello, all sorry haven't been on here in a while. I actually am I new Paramedic myself. I just made the long transition from B to P. My bachelors program skipped Intermediate completely to better give us the patho and rationale critical thinking base we needed for our careers.

Anyway, I completely agree with everything being said. I have never been an intermediate nor plan on giving up my paramedic anytime soon that is why I posed this question. I have talked to people that have made the transition through all three and they have stated that it was a lot more pathophys and critical thinking than intermediate was. I posted this to see as what ya'll felt about it. I feel the field is changing in a lot of ways. We now have active lobbying going on in captial hill with "EMS on the Hill" as well as acceptance as a medical profession. I am just looking for good opinions. And Beiber as I said I converted straight from Basic to Paramedic so I never got to experience the joys of an Intermediate class.

Hello all,

I would like ya'lls advice on something that I have found to be somewhat immature and more of an ego thing then anything else, but yet it does annoy me. Here it is:

In my region there are intermediates and paramedics working throughout. In our protocols here there is not any differences between the two levels in range of skills. There are a couple drug differences where the P's do not have to call for the orders where an I would have to. The big debate with some people is the fact that an intermediate should not be considered a "medic" since they do not have a paramedic certification. In my opinion I do not believe that to be the case. They can intubate, push all the drugs in the drug box, etc.

What do ya'll think? do ya'll think that their should be noted differences between the two?

Just curious,

FireEMT2009

The topic came up between my partner and I today that our narratives are vastly different, and she seems to think that I'm including a lot of extra words and info, when it isn't needed. I have only been doing this for 4 months now, but I've been doing process documentation for the better part of 2 decades, so I thought I had a decent grasp on what was needed. So... for your entertainment and critique, here is a sample of a completely fictional narrative. I'm a Basic EMT, but I'll be starting medic classes in August, so I'm sure my narrative will be evolving even further after that. Feel free to pick it apart as needed.

Typical transport:

B582 dispatched non-emergent to (hospital) for pre-scheduled transport of pt to (other hospital) for rehabilitation services not available at (hospital). PT was admitted to (hospital) for rt knee replacement surgery, treated, and cleared for transport to (other hospital). PT requires ambulance transport due to unsteady gait, and pt is at risk for falling off stretcher. ATF 70 yo female pt laying semi-fowlers in hospital bed. Pt assessed, found to be AOX3. Pt denies cp, denies sob/dib. Pt states she currently has pain in her rt knee at the incision, which she rates 7/10. Nursing staff administered pain control medications approximately one hour ago. Pt denies any other pain at this time. Pt vitals checked (tech initials): BP120/70, P70, RR16, SPO2 99%RA. Pt is unable to stand due to surgery, pt moved from hospital bed to ambulance cot via draw sheet, secured to cot railsx2, strapsx5. Pt moved to ambulance, loaded, secured to floor rail. Pt transported to (other hospital) non-emergent, monitored for safety en route and vitals rechecked prn. Upon arrival at (other hospital), pt unloaded from ambulance, taken inside to rehab wing, and taken to her room. Pt moved from ambulance cot to hospital bed via draw sheet, positioned for comfort, and rails raised. Report and paperwork given to nursing staff. Care transferred to receiving facility. B582 cleared without incident. (tech signature)

Typical Emergency:

B582 dispatched priority one to (city) residence for chief complaint of altered mental status, possible diabetic emergency. B582 responded emergent to scene without incident. ATF 30 yo male pt seated on city easement with (city) PD on-scene and at the pt side. Pt appears AOx1, conscious and alert, but disoriented. Pt responds to his name, but answers questions incoherently. (tech initials) retrieved glucometer, checked level, BGL 20mg/dl. Pt given one tube of insta-glucose orally, pt condition immediately improved. Pt LOC increased to AOx3. Pt denies pain, denies sob/dib. Pt denies alcohol or drug usage. Pt states he is a diabetic and took his insulin without eating lunch. Pt agrees to examination by EMTs. Assisted pt in standing and walking to ambulance, helped into pt compartment, and seated on squad bench. Pt vitals checked (tech initials): BP100/50, P100, RR20. Pt agrees to go to (hospital). Pt moved to stretcher, positioned for comfort and secured railsx2, strapsx5. Pt transported priority 2 to (hospital). (Hospital) contacted via HEMS radio patch. Upon arrival, pt unloaded and taken to ER Pod C. Report given to nursing staff. Care transferred to receiving facility. B582 cleared without incident. (tech signature)

In my limited spectrum of knowledge here I only have a few things that I do in my narrative that made it through my paramedic program and was never asked for clarification. You have a great meat and potatoes now just add some gravy and sides and you will be good to go. The rules I follow are:

I never use abbreviations, every career has different terms for different abbreviations, so I follow the cop rule, abbreviate nothing.

When I say my patient is alert and oriented times 3, I always put to what they were oriented to such as: Patient is alert and oriented to person, place, and time, but could not identify what event had taken place. That way its there in case it ever gets called to court.

I always try to include my SAMPLE, OPQRST at the bottom of my narrative for emergent and non-emergent if possible. So it looks like this:

Narrative

S

A

M

P

L

E

O

P

Q

R

S

T

Name, EMT-B/I/P

That way if it ever shows up in court, you have your Objective and Subjective assessment in there.

I always make sure that whoever I recieve or give report from, I always include where I left the patient, who was in the room and what relation/ level of care provider they are, RN, MD, DO, wife, mother, husband, etc. I document all names whether it seems insignificant or not it might be useful later. I also will note whoever gives medication, the amount (1 half tube of oral glucose, 1 tube of oral glucose, etc. that way there is no confusion later.

Also, especially while precepting for your medic ask to see your preceptors way of narratives and pick up good points and learn to mix them into yours.

On every patient I will always give my ABCs such as:

Patient was found sitting in the chair, Patient is alert and oriented to person, place, time, and event. Patient's airway is open and patent without intervention. Patient's breathing and circulation are life sustaining without intervention. Patient is breathing 16 times per minute, equal and bilateral chest movement noted, lung sounds clear. Patient is not experiencing any labored or difficulty breathing or showing any signs of respiratory distress or failure. Patient's pulse is 76 strong, regular, radially. Patient's skin is warm and pink with nothing remarkable. etc.

Just my two cents.

Yea that is one of the big pluses that I was thinking of when I had the theory hit me, especially when you get someone bagging with a critical patient that gets caught up in the action taking place or gets anxious and looses rhythm and rate of his ventilations.

Anything else you would like to add Kiwi?

I have been thinking about the usage of transport ventilators in 911 response. Not just for the normal vent patients but for patients that are intubated in the field, using them to free up manpower to help with critical patients instead of keeping someone constantly bagging the patient. (Of course this would fall under the proper traning for usage, maintanence, pathophys, etc.)

My theory is that it might help free an extra set of hands in the back of a truck and allow the ALS provider to use his BLS/ALS partner in another part of patient care while the ventilator does the ventilations, while under constant capnography, SpO2, etc. monitoring to ensure effectiveness of ventilations.

I am just curious on what ya'll's thinking is on this topic. All opinions and advice are welcome. I am excited to see where this thread will lead and what new ideas, or education will come out of it.

FireEMT2009

Thanks!

Hey everyone,

Sorry for the delay I have been busy at work. I passed all of my practicals first time round an am an "unofficial" paramedic. It's not official until the National Registry gets the paperwork. Either way I'm glad its over with.

FireEMT2009

Actually, hardly anyone ever searches before they post. It's human nature to not search before posting. Everyone thinks that their post is the first that has ever been asked. So don''t beat yourself up.

What Dwayne was sayin is that if you did search you would have found that there was a lot of stuff out there already about this.

But hell, 80 questions and it cut you off, you thought you failed and in reality you passed. I see a pattern in the registry here. Those who seem to get cut off at 80 seem to pass. Those who keep going, seem to fail.

But kudos, congrats, way to go, awesome job, now, stop studying, don't even crack a book, if you don't know the right sequence to do something then you won't learn it in two days.

Just relax, spend some time with friends, eat your last meal, and then go take the registry test. Even if you fail a station or two, just relax and go retest again and pass it. You obviously know it. Just don't get too stressed.

Honestly, I think we place too much stress and emphasis on this one test. Just go in and take it. Breathe in, breathe out, wax on, wax off, Do the Mr. Miyagi dance, Daniel San.

Thanks for the advice. I am definately more relaxed now that the written is done. I know the practicals in my sleep it is just getting the written out of my way so I can have my confidence a little higher for my final stage.

Sorry Brother, my post really wasn't meant as a "Did you search first, stupid?" reply. But after all the times it's been said I wasn't sure how to phrase it so that that would be obvious.

I agree with you completely. There is very often a little life left in the dead horse, but sometimes you'll miss some of the best/better posts if you don't look back because people don't repost them. That was the spirit intended...

Your testing date is past now, right? (Back in PNG so can't remember what your date is)...how did you do? How did you feel about the test?

Dwayne,

I took it today first thing this morning. It cut off at 80 and I knew as soon as it cut off that I had failed it completely. The only thing that gave me hope was that I had the last question right. After a mind numbing 7 and a half hours they finally released the test results and I had passed. So now the only thing left to do is take my practical on Saturday. Thanks for all support it is much appreciated.

I will search prior to posting next time to verify no duplicate posts.

FireEMT2009

Will do Dwayne. Thanks. And yeah I have seen and heard on many occasions that this subject had been beaten more than a dead horse in the desert. I thought maybe someone might have some different tips, never hurts to try but does get annoying after seeing it over and over and over again.

It's offical, I take my NREMT-P written test this Thursday and my practicals this Saturday. Any tips for a student who has never taken the NREMT exams before? Any test taking pointers? Thanks for all the continued sharing of knowledge and support. I have learned alot over my short time being here.

Yea we had to write oral station scenarios for my test prep class for NREMT-P and I wrote the one I gave on here. I hope yall thought it was as interesting as I thought it was. I had a lot of aggrevated medic students trying to figure it out.

Ok then... any exopthalmos? He's got a thyroid storm of some sort occurring. Could have been triggered by any number of things... boyo needs some Lugol's and supportive care at this point. Fluids, cooling, quiet environment, punt to higher level provider than me...

It would explain the increased metabolism (can't get full), hyperthermia, flushed skin, agitation, and diarrhea.

Wendy

CO EMT-B

No eye buldging noted.

Yes this is an abnormal case of thyroid storm. His upper respiratory tract infection caused excess levels of thyroid hormones T3 and T4 to be released over the last couple of days which is why his metabolism, diarrhea, and hunger has increased so much. His heart has gone into A-Fib with RVR due to the increase in hormone. He is heading to cardiovascular collapse in a quick fashion. He needs to be cooled down. The classic symptoms here would be: Hot dry red skin, wide pulse pressures (Note wide BP), minor rapid respirations, fast heart rate, and diarrhea and excessive hunger.

Infections are a big cause to set off thyroid storms.

What part of the country are we in? Any known tick, mosquito or other insect bites?

Southeast USA. You ask the patient and he says that he has not been bitten or noticed any difference in his bodily appearance, such as a rash.

whats the family history?

Family history- HTN appearance and older age and some history of diabetes. Thats it.

You said it was a professionally cleaned house... recently cleaned? Exposure to cleaning agents? Just a thought.

I'm curious... could this be an atypical presentation of Stevens-Johnson Syndrome? The flushed red skin fits, and if he's got the rare zebra of a lesion on the myocardium, that could account for the chest pain... SJS is associated with antibiotic use, including 'cillins... may be he hasn't reached the peeling skin part yet. (Oh, and I didn't google that, we've recently studied SJS in my nursing pharmacology course.)

The diarrhea could be accounted for as a simple side effect of antibiotic use.

*Puzzlement*

Wendy

CO EMT-B

Glad I have intrigued so many of you.

House stays spotless cleaned once a week but the cleaner makes sure that adequate ventilation is being used at all times during the cleaning process to filter out the fumes and she cleans up all residues.

I have the answer to this, but am not ready to give it just yet. I would like to see what else is coming down the pipes.

What does his nasal mucosa look like.

No trail marks noted? (including feet)

Im still not ready to rule out drug abuse

Has the house had any recent work done.(cleaning of course) was this because of some kind of plumping or recent water damage?

any petechiae?

Normal nasal and mucous membranes. No track marks noted. No recent work done. The mother always wants her house clean so she has someone come in and clean it for her. No petechiae. Sorry.

This sure sounds like the red as a beet, mad as a hatter, dry as a bone, hot as a hare syndrome.

Does sound like it but not giving any clues just yet.

I inserted my foot in my mouth. He did have abnormal lab values. His T3 and T4 are elevated. I apologize for the mistake.

Diabeetus?

BGL is 103mg/dl No past medical history.

Any travel history, sick contacts, history of the same?

Except for area soccer games none. He has a upper respiratory tract infection that is being treated with the medications from the previous posts bbut other than that thats all the medical history he has. He plays soccer and is in great physical condition.

Nope, no, and nope.

And its never Lupus!

Nope, no, and nope.

And its never Lupus!