FireEMT2009

After talking to a very respected medic in the company, they taught me an easy way to calculate a dopamine drip for a patient as long as you are using the standard 1600mcg/ml bag (double the drips for a 800mcg/ml bag). For every 5kg you add 1 drop. so a patient weighing 100kg would get 20gtt/min at 5mcg/kg/min. (I worked the math out myself and it works perfectly). Just thought someone might appreciate that sometime or another, I know I did.

I agree with everyone else, relax. And always remember use common sense on ever answer.

OK, before we get too advanced, I'd like to hear from some of our newer BLS/ILS providers..... then chbare/Squint can come school us all

Called for interfacility transfer

66 y/o male longstanding history of COPD, persistant smoker, CHF, non-med compliant.

Meds: Dosen't matter.... He has not filled prescriptions in years. (ventolin/spiriva/Prednisone/Metorolol/Lasix few others I can't remember but all related to CHF and COPD)

HxCC: Pt presented to ER 2 days ago with shortness of breath. Worked up for pulmonary embilism with spiral CT - Negative

WBC count slightly elevated at 15. No other abnormal blood values

ECG normal, no chest pains.

Over the last 12 hrs pt has turned quite cyanotic, he is becoming disoriented and combative at times.

On arrival: you find him semifowlers in no obvious distress. He is blue as a smurf. There is a simple mask at 4lt on his obeise belly. He tracks you as you enter the room, but is disoriented.

There is a 22G in his right hand and a hydrocortisone infusion just finishing.

He has also had Cephalexin about an hour ago.

Vitals: HR96 BP 148/90 Respitory rate 18 non-laboured, Sp02 96%, Temp 35.9C,

What else would you like?

BTW this is from memory, so there may be a few thing I forget.

1800th Post!!!!

Well lets start from the beginning,

Airway- Open patient? Audible sounds (stridor, gurlging, wheezing)?

Breathing- Respiraton rate? Breath Sounds? capnography?

Circulation- Pulse quality (strong, weak, irregular, thready, regular?)

Labs showing any imbalances of electrolytes anything?

Any other history of heart problems except for CHF?

If they did an echo did they find anything?

Has he been this cyanotic the whole time?

Is this mental status normal for him? Has it deteriorated since his arrival?

Any trauma or other medical history?

Any food or drug allergies?

Is he on oxygen now? if so how much and by which device?

What is his blood sugar (strange yes, but I like to cover all bases especially with a severly cyanotic patient)

Is the amount of cyanosis normal for him?

Congrats on the 1800th post!

I am sure you did... But elevating the legs/lwr torso can help, as well as turning the pt's head 30degrees, Too far and it flattens, too little and the skin is too loose.

Other than that..... well, go IO

We did the tilt the patient but it did not improve anything but I will look more into the 30 degree thing through. Thanks!

Really not being a smartass brother, but I don't know what any of those caths are...

Some people seem really good at knowing the names of the caths, or the types of ambulances and such. I'm more of a "That's my ambulance? Does it have something in it that pokes into veins? Some O2 tanks, a couple of small ones and a big one? Yeah? Awesome, lets roll..." kind of guy. Likely a weakness, but it is what it is.

If you can explain I'll certainly give you my thoughts, though there are many, probably most, that are more qualified to do so than I am.

Dwayne

jelcos do not have any sort of safety device on it...the other brands all have either retractable needle or a plastic safety piece which caps the needle.

I'm with Dwayne. I don't know the names of the various brands of angiocaths, but I do know starting an EJ is easier WITHOUT a protective version. Problem is, in many places you have no choice. I'm old school- I simply do not like those protect catheters. That said, it's certainly not impossible, but often trickier simply because of the angle and surrounding anatomy and structures. One thing you should have is a longer catheter- it makes accessing the vein easier

Its easier to show you a picture so here is the Nexiva closed system I was talking about:

The needles the other hospital must not be a jelco but it is the one that the needle retracts into the barrell like this:

For the EJ I used the first picture one, except in a 20 gauge not a 22.

Hello all,

As many of you know I have had many concerns and questions about EJs. Well in my last clinical rotation of my paramedic program I was given the chance to do an EJ in front of my OMD. The hospital I was at uses the Nexiva closed system IV catheters if you are familiar with it. The other hospital in the area uses the protectacath (Jelco) needles. The hosptial I was in that uses the nexiva keeps a couple of the Jelcos around just in case and for large bore IVs due to not having the nexivas in 14s or 16s but I digress.

We had a patient that had been stuck numerous times and could not gain peripheral IV access. So I asked my OMD if he would allow me to do an EJ (It is a doc only skill in that hosptial). The doctor came and attended my EJ. During the proccess we could not "see" the EJ but it could be palpated and a slight buldge appeared (dehydration/hypovolemic). I stuck at the site with the nexiva and never got flash, after about a minute of searching the needle was withdrawn and peripheral access was finally obtained elsewhere.

I have heard that the nexiva needles are not the best for doing EJs, has anyone ever heard of that before and if so do you know why they aren't the best IVs for it? And can anyone give me any EJ IV cannulation tips as well. I occluded the base of the vein so that it would stick up more during the procedure.

Any advice is welcomed with a clear and open mind. Thanks!

FireEMT2009

Mike,

I apologize that came out completely different than what I meant. I treat kids as just that, kids. I completely understand that pedi assessments are different than adult assessments and have learned that with scenarios in our lab setting. I meant as in ABCs are always first just like adults, except that kids are alot harder to manage compared to adults.

I apoligize for my mistyping. I am working on learning the dosages, memorizing i have come to realization, that it only stays long enough for the next test or the next couple weeks but not the next couple of month or years depending on when I need them. I work hard to memorize, understand, and fliter out the drugs of which I am administering, whether adults or pediatrics. Thank ya'll for the advice.

I will continue to keep ya'll updated on my progress and continue working hard throughout the rest of my time in medic school. Its better to learn your mistakes in the lab setting than the real deal.

Thanks for the great advice so far,

FireEMT2009

Hello everyone,

I made a topic about this a couple of months ago and just thought I would give you an update and have some questions that I would like some insight on that I can get nowhere but here.

First off, Peds seems alot like an adult assessments, ABCs come first (DUH) and that the browslow tape is your BEST friend on peds patients. I would also say that it seems to be clicking with me very easily and am truly enjoying my class before PALS.

I test out in April and will be taking the NREMT-P and I know there is no browslow tape allowed on the wiritten. The questions I have are:

When you are dealing with drugs that aren't on the browslow tape (i.e. albuterol, diphenhydramine, phenergan, odansetron, etc.) how do you remember all the drug dosages? I understand that 99% of all the drugs that are used on peds in a critical situation are on the browslow tape. I am just looking for some great insight that I know this site can offer me.

I also have found that the "generic" (i use this term loosely in this situation) is 0.1mg/kg.

Thanks for all the answers that I hope to come. And in case I haven't said this before, thanks for all the help and advice ya'll have given me so far in my education.

FireEMT2009

ABCs do always come first. Define respiration. Compare that to ventilation. What's the difference between the two? How does that difference apply to what you're trying to say?

Ventilation is the act of moving air in and out of the lungs from the outside in or vice versa.

Respiration is the act of the transferring of oxygen molecules to carbon dioxide molecules which is what happens at the aveoli-capillary level.

I need to fix my signature cause I can not truly cause respiration due to having no control over a person's respirations. I can cause them to ventilate. I will correct it ASAP. Thanks Mike!

FireEMT2009

Yeah man, I get that. But you need to be really careful about that. Medics, in my experience, are really bad about coming up with tons of 'logical' reasons for not using valuable tools that they are simply afraid to use.

Don't limit yourself on hearsay. You're going to need to step away from the pack now. Decide to make your own path, or you'll be another one of the sheep that make the ERs think that we're all a bunch of yahoo wannabes.

Also, watch your presentation, ok? I really love your spirit, but part of it's getting lost in your poor presentation. Write, proof read, spell check, reread and then post, ok? That's really important not just here, but for your professional life in general.

There is something about you that makes me really glad that you're here. Good on you for having the balls to participate.

Dwayne

Yea, I have realized in my time here precepting for school that using other medics advice is helpful but at the same time might steer me down the wrong path, especially when they try to pick my brain and I end up getting in my own way too much.... Had that happen a bunch of times but thats an obstacle im working to overcome and a thread for a different day.

I try and get a ED doc or whatever specialty doc I can talk to's advice so that I can better think and rationale things. My OMD for my school comes in every month and challenges us on drugs making us give him rationale why things work the way they do and why they don't work on some things. I really learn alot from that and him overall.,

I appreciate the constructive criticism. I am trying to improve my forum rapport through breaking up my posts and communicating more fluidly.

Why did this have you confused? Seriously. Talk this out with us. It'll be good practice for when you're in the ambulance and need to think things through. What about the contractions threw you?

I'm with Dwayne on this one. You need to start marching to your own drum, so to speak. While most of the medics with whom you're working probably aren't going to steer you wrong, you need to be able to answer questions for yourself. Please trust me when I tell you that, "Because <insert senior medic's name here> said so" is NOT a valid answer to anything.

There is a time and place for questions. There is a time and place for doing your own research. Please don't be complacent with an answer just because a senior medic said so. Or, for that matter, because one of us said so.

I also agree with him on presentation. Spelling and grammar count.

With all that being said, why would you, or wouldn't you, start an EJ on a patient needing IV access?

Also, I'm curious. Your sig has this phrase:

There's something wrong with this statement. Can you tell me what it is?

The contractures through me due to the fact that I have started IVs in the ACs of patients and as soon as they bend their arm, BAM its occluded and It no longer runs fluid. I was confused because I figured no matter where on the hand or AC I can start the IV it would be occluded by the contractures. I have not had much luck with forearm veins but did get a nice stick today on the back side of one.

I would start an EJ on a patient needing IV access. The patient in this scenario was not extremely hypovolemic, but could have definately used some fluids to help replenish some of the fluids he had lost over the time frame of his sickness. I have been told EJs are always for last resorts by every medic I have worked with in the field that is why I am hesitant. Also I have never started one bbefore so it is alien to me right now.

I would perfer to use the response I gave to Dwayne about listening to other people as the response to your question instead of retyping it all over again.

About my status, It is meant to be seen as I can make someone breath, whether by face mask, ET tube, LMA, combi-tube, king airway, etc. I have always had the motto that is set as my signature and that is why I placed it there. I should update the wording of it cause apparently I did not proof-read that very well either. ABCs always come first and you can't have one without hte one prior and all three has to be present to have life. Hopefully that clears it up. If not please tell me how to better correct it. Thanks Dwayne and Mike.

FireEMT2009

normally I would have started an IV in this patient but the contractures had me confused about where to start said IV. I have no actual status saying that the EJs are only used for Codes and Traumas, it is jjust hearsay but i am relatively nnew and am taking it from the medics i precept through.

And Defib,

Epi could possibly cause the baby to go into cardiac arrest. You are trying to increase the contractility, rate, and oxygen deficit of an already overworked, overstressed, and under oxygen fed heart. Epi is the exact opposite, and epi will cause vasoconstriction instead of vasodilation. Epi is definately not the drug of choice of this little guy. I would stay away from those type of drugs especially since epi has a high oxygen demand.

With this child you will more than likely never acheive near 100% O2 because the heart isn't pumping blood adequately so no matter how much oxygen you push into this baby it will only raise it someone what.

Romney, What is the normal O2 sat for this baby?

My initial smart ass answer is- you get the IV WHEREVER you can, but for rapid fluid replacement, obviously you need something bigger than a 24 gauge in a finger,

The foot is often overlooked- and certainly not ideal, but better than nothing. A couple of other often overlooked locations are the underside of the forearms and upper arms and in a contracted patient, they may actually be easier to get at than a traditional site. Obviously EJ and IO are other options if allowed in your system.

EJs are allowed for traumas and codes, IOs are only for the most critical patients. That is our setups here in my area. I was thinking that the back of the arms would be a good place. I am a paramedic student in a place where we are only 5-10 minutes from a hospital so we have very short transport times.

edited to make an addition to of my sentences to make it understandable.

I truly have no idea how I would treat this child prehosptially. I would have to treat the symptoms as they appear. I am completely lost. I would definately want to call the child's cardiologist and get him to tell me what I need to do. Med control on this one. Is my treatment plan missing something or am I just way off into left field?

Had the parents been giving their child their meds religiously like they are suppose to? What made them call 911? this is extremely strange to me since the parents couldn't handle the situation on their own so they called us for a reason. What's the CC via parent's report?

After googling it and reading it on pubmed health it is where the left side of the heart is not matured enought ot support the demands of daily life. The cyanosis you are seeing is normal for a child with this condition because the left side cannot produce the pressure needed to deliver oxygenated blood to the body. Therefore the right side has to do it all, which will cause failure overtime.

The Noorwood surgery that you posted originally is where the surgeons form a new "aorta" by fusing togeter the pulmonary veins with the coronary veins and attaching them to the old hypoplastic aorta.

Since the patient can only stay alive by keeping the ductus arteriousum open so that oxygenated blood can pass through the heart. has the parent given the patient their medication today or the last couple of days? If not then you need to get them to the children's hospital ASAP. The child needs the children's hospital because they are specially trained for this and more than likely will have the pediatric cardiologist that is the doctor for this patient.

I would go with a sense of urgency to the pediatric hosptial. I would keep constant checks on their vitals and ekg. The ekg will probably be pretty funky due to the changes the heart has had to go through to continue to supply the body with oxygen. The low O2 saturation we are noticing is not going to be uncommon due to the lack of the left side to properly send oxygenated blod throughout the body. Therefore the pulse ox monitoring would be near useless.

I would place the patient on blow by oxygen right now and transport urgently while monitoring their vitals and continue getting the history from mom on the way to the peds hosptial.

It is always best to start distal and work your way in. Even with contractures, you may still find good veins in the hand, forearm and upper arm. You need to practice finding veins by feel instead of using vision, Do this:

Put a tourniquet on your partner's arm, blindfold yourself with a triangle bandage or just close your eyes, and see how many veins you can find by "FEEL ONLY". Once you get good at that, you will find veins on 99% of patients that others can not find.

Nurses will freak out, but i have used feet/leg veins when I had to, but then after they miss the next 3 sticks and put in a central line, they are glad i gave them something to use until the central line was in. Vein anatomy is generally the same in all people, so if you know where the veins are supposed to be, and learn to use your fingers instead of eyes, you should be great at IVs.

99% of the time I will feel for veins more than relying on sight.

Wouldn't the contractures inhibit the ability of the IV to flow due to compressing the veins?

Forearm, possibly. I`d also take a look at the foot.

I checked the foot and did not see any suitable places for venous access. I was looking at the forearm because the contractures would not occulde the IV sites.

You are treating a patient with constant contractures bilaterally at the elbow and wrist levels. Both of which would occuld IV sites. You need to start a line and give some fluid due to hypovolemia. I was thinking of the forearm are the upper arm/ shoulder area. Where would ya'll stick? I had a patient like this and was just getting an opinion from more experienced medics. Thanks

FireEMT2009

As a student you belong in this conversation as much, or even more so, arguably, than anyone else. Good on you for having the balls to jump in.

A couple of questions Mr. student man... :-)

Mobey mentioned that his rationale for intubation was patient exhaustion. And I completely agree with that now, after his explanation, so assisted ventilations at a minimum would seem manatory, right?

I also thought that bagging was a viable option, and bagging in a neb treatment even more so. But lets assume the transport time is 5 minutes. Do still feel the same? How about 30 minutes? 60 minutes?

Does your feeling on maintaing this patients ventilation status change in each scenario? What might the issues be should you choose to bag in each instance instead of intubate?

I haven't noticed you posting for a bit...good to see you here!

A friendly note to you, and others...simply for the ease of reading, paragraphs help. I sometimes, and I know others do as well, simply pass up posts that are in a giant block. Though sometimes you end up breaking parahraphs in illogical places, reading in pieces is much easier online.

Dwayne

Edited to correct spelling errors only.

For all the times:

Attempt to sedate the patient with versed, ativan, whatever sedative you have available and with an OPA and BVM with nebulizer. If the sedatives work as I would hope them to then I would attempt to reintubate and continue my neb treatments. As long as you have an OPA and BVM you have an airway of some sort.

I hope you are not planning on using versed alone for RSI, are you stating that you will just use it for those who fight the tube, after intubation ?

RSI needs sedative/anesthetics and paralytics. I would use it as a sedative assisted intubation to help the gag reflex and to ease the patient's suffering on the tube. I would use the versed or whatever sedative you have available at your disposal to help facilitate better airway management for my patients.

What part of VA you in ?

SW Virginia for college. Southern VA on the border of NC originally. Why?

Thats pretty cool, enjoy your rotations .. i miss class but would never do it again.

Solu Medrol is a standard but can take an inordinate amount of time to take effect at times. Does not stop me form giving it though.. also the nebs by BVM is a great thing to remember. However i lost track of what i was thinking early in the thread and was treating CHF/Pulmonary edema instead of COPD... lol

Sometimes not as easy to formulate a treatment plan when it isnt literally in front of you.

Yea i test for my paramedic in April so I am working on my last clinical rotations this semester and will finish up my field run time next semester. The sooner you give the corticosteroid the sooner it will work so it can only help your patient in the long run. And yea not having a "living breathing patient" in front of you makes our field decision alot harder than it already is.

FireEMT,

Great addition to the threat, thanks for including it. your absolutely correct with alternative treatments as well as your thoughts on the intubation. Of course you will have to stay with in your local protocols and if you have all of those at your disposal i want the number to your service... LOL

But do not discount your input because you are a student. even those of us with yrs under our belt need reminded of things from time to time... Keep posting and taking part.

Race

We just got Versed here where I am in college for my rotations and our new protocols should be out in the next couple months. Luckly you can hook up a neb to a bvm without much problems as long as you have the T connector and the neb tube and connect it from the BVM to the mask. We do not have decadron here but we do have solumedrol. I am hoping to see that when the new standards for the scope of practice take full effect that it will open up new horizons for our protocols especially for these types of patients so our hands aren't tied up with this situation.

This might be a stupid medic student jumping into something he doesn't belong in but here is my thought on it.

The patient was resuscitated without the use of an ET tube or meds. Since COPD is a bronchodilation/inflammation response why not use the BVM already in place to start a neb treatment to get

her lungs back open while giving a corticosteroid such as decadron or solumedrol? The intubation giving versed, valium, or ativan would have given you the sedative properites needed to help the struggling on the tube and you could have used your BVM with a nebulizer and connected it to the tube and given a neb treatment with atrovent, albuterol, or combivent. It is hard to say what my response would have been to this call but I agree with you beiber a ET tube is a patent definate airway as long as it remains in place therefore if you knock out of her respiratory drive, what little she had via the note on your original post then that is what the tube is for. You can always breath for a patient if the drug knocks out the respiratory drive. You have an airway, breathing and circulation can be controlled by the EMT. Without an airway everything else is in vain. I think that if you had given her sedation and then intubated she would have probably done better. But this is a case of God knows what and opinions are flying. Either treatment, the ET tube or BVM is correct in my opinion as long as the proper stages of care are followed such as sedation assisted intubation or noninvasive intubation.

Just a medic students input if worth anything.

FireEMT2009

Firstresponder,

First off welcome to the city. I understand that it seems that everyone is out to tan your hide by their comments but it truly is not what it seems.

The reason they are being hard on you is because you practiced outside of your scope of practice and being in medic school I understand pharmacology and the human body and a mix of nitro and trauma is not a harmonious mix.

I would like to point out that I have been a firefighter for 4 years and an EMT for 3. I understand that you want to go help and save the world attitude, hell we all have had it. That attitude will give you a great drive in your EMS career and EMT school and I truly believe with proper training you will be a decent EMT.

Lawsuits, everyone is out for money, if this guy dies or has brain damage or something phyically or mentally wrong with him after this call due to your actions the family if not the patient will file a big lawsuit against you for doing something that is only done by trained personnel. And you will being paying them for the rest of your life. That being said, are you a certified first responder, or did you just place that as your credentials? I am not being sarcastic or smart ass just trying to figure out where your skill set starts from.

I understand that reading your EMT book earlier is a great way to prep yourself for class, but you still need proper instruction and training everything from C-Spine, to operations, to medication administration. Everything is done via building blocks. If you decide one day to become a medic you will understand how much of it is built upon your skills as an EMT.

In VA here you have to call medical control as a EMT-B to give any medication and you best know what it does, why you use it, what are the side effects, and what you can't use it with. Be careful with how aggressive you become, if you want to do some first responding, join a department and get some run time in with them as a observer and then work there through your EMT class ride time. It will help you become a better provider through the experience and street time that is ever so important.

Overall, learning the right way the first time is the best way, I would suggest next time to just listen into the call because I promise you that you will have some of these calls yourself where they are filled with adreniline or you will have a good samaratain come up and drive you crazy by their actions, its a part of this life.

Lastly, the people on this forum have 100s of years of experience combined and I trust their opinions and love to hear the inputs they have on my questions that I post, since I like you am still in school myself. Sit back and be able to let stuff roll of your back because somethings will be taken the wrong way by some people or it will not be meant like what it sounds like. Understand that the people here have more experience and knowledge than you do right now so they want to give you tough love so that when your an EMT you will fully understand why you shouldn't have done that. Its all for you and your patients best future.

I wish you luck on all of your EMS ventures and I hope to see you post further with better reports, updates on class, and other questions that we can help you with. We all want the best for you.

FireEMT2009

Well since he isnt seeming to be a psuedoseizure as of this point, I am now looking for possible factors that are treatable in the field. What ist he patient's temperature? If you have an I Stat what does his blood chemistry come back as, pH, electrolytes, etc. skin turgor, JVD, any other abnormal sign. Lets also get a 12 lead and get him exposed and see what we find. After that we will contenplate whether to load and go or stay and play for a little bit longer. I know we have 2 level I trauma centers within 20 minutes but what other resources do we have? Does he have a neurologist? If so can we get him on the line and get some better history of his epilepsy and contact our med control. Also while we are doing that go ahead and administer another 5mg of diazepam, seems like we are getting a little response in the severity and violence in the seizures with the administration. What do lung and heart sounds sound like? Trying to get all bases cleared here.

And what did the doctors give him this morning to stop his seizure? How much?