FireEMT2009

Hello all. I am an EMTB in Va. I am getting ready to start EMTI class in September. Happy to be here. Any advice on the EMTI?

First off hello to a fellow virginian.

EMT-I is not what exactly I would aim for considering national registry and most states are eliminationg it. Once the new standards talke place you can take Advanced EMT or Paramedic. Va will still be recognizing Intermediate for a period of time but will be eliminating it as well, so you will have to take over 100 hours of extra training to become a Paramedic or you will be thrown backwards to a AEMT which has less skills and scope of practice than the current I certification. If you get it it will help you in Paramedic. My suggestion, if you go through I, dont stop there continue through to P. Trust me I am going from B-P and I am glad i am able to bypass I but would still have liked to have the knowledge because going from B-P is difficult cause you have to learn the I and P material all at one time, it can get really complicated. Take it as you will from a guy who is about finished with Paramedic school. Good Luck! Here is a good tip, learn to study, apply material, and gather rationale. Know your anatomy and physiology inside and out, left and right, forwards and backwards. If not you will have an extremely difficult time.

FireEMT2009

Ok "calm" the heart ?

http://circ.ahajourn.../IV-58.full.pdf

This from the "bible" here they have removed lydocaine in its entirety .. and man this stuff is expensive I should have bought shares.

Antiarrhythmics

VF and Pulseless VT

Amiodarone

Mr. Tniuqs,

"Calming" the heart is the best way for me to explain the power of the antidysrhythmics without going into the mechanism of action of the drug. When I think of ventricular rhythms I think of the heart beating so fast that it starts to just full out shake and cannot slow itself down where the amiodarone or lidocaine can "calm" the heart slowing it down and causing the ventriclesx to pump correctly and causing a perfusable rhythm and pulse; producing ROSC. I am sorry if my wording of choice offended or upset you.

I took ACLS last summer, and when I took it then lidocaine was still considered an antidysrhytmic drug choice.

Your link above did not work but I found this on the AHA ACLS page: http://circ.ahajournals.org/content/122/18_suppl_3/S729.full, it says if amiodarone is unavailable lidocaine may be considered, which means that it is still a vialbe option for a VF/VT patient. I am not trying to be snappy, arrogant, or cocky with my above remark, but giving evidence to support my claim that lidocaine can still be used in VF/VT rhythms. So this contradicts you saying lidocaine has been taken out entirely. It hasn't if the AHA has said that it can still be considered if amiodarone is unavailabe. Thanks for the comment.

FireEMT2009

We carry and use Lidocaine. If I remember correctly from paramedic school, and this was 2 years ago so its possible that it has changed since then, Amiodarone has a proven increase of ROSC over Lidocaine; however neither increases the rates of hospital discharge following their use.

I had one code "save' with the use of Lidocaine. I think it had to do more with great timing than anything I or my partner did. V-fib on arrival, defibx2, little Lido. So I think in some situations Lidocaine has the potential to work.

Ms. Medicgirl,

I am very surprised and interested in the fact that you only have lidocaine available for the ventricular arrhythmias. I would like to hear your opinion on lidocaine. How do you like using it? Do you have complaints or precautions that I should use if I decide to use it? We have both drugs in our drug box available for us to use, so its a medic's preference on which one they use. Thanks in advance.

FireEMT2009

Excellent answer. Truly.

Now your transport time is 30 minutes. What do you think?

It's 60 minutes now? Same answer?

I have a little trouble with your opinion that this patient isn't critical. I had this exact patient, only with a penis, showed Hi, only I was able to easily obtain access and run a ton of fluids. Labs showed a BGL of 1500 at the ER and he died before the next morning.

And though Beiber may not have meant me, I do think that folks take I/Os, and EJs, way to seriously. Some patients need fluid or meds, others will simply benefit physically, mentally or emotionally from fluids or meds..to deny any of these folks any of these things because you (general you) are afraid of more aggressive access should get you fired. Or, as I've proved at least once...giving it to them may get you fired too.

But I think that your logic is awesome. A couple of pieces of advice, meant friendly as I'm already a fan. Could you break your posts up into smaller paragraphs? It makes them much easier to read...easier on the eyes, and much more likely to generate responses. In my opinion.

Also, having the balls to post a case review before you have 20 posts? Yeah man, I'm confident that I'm going to remain a fan.

Also, you're not a hosemonkey here, so sir isn't necessary. Every now and then Babs says it, and it friggin' rocks! But it sounds to me that you've earned your place here. There's no hazing, there's no 'noob' hoops to jump through. All are judged on their heart. commitment and logic. Good on your for the respect, but take it brother, don't ask for it. I'm grateful that you're here. Many here like Paramedic Mike and Herbie are so old they won't remember that you were nice to them anyway.

Thanks for participating..

Dwayne

Dwayne,

Thank you for enjoying my posts, our instructors told us that they would make sure we were not goonaj be the "cookbook" medics that know what drugs to push, they wanted us to know why we push it and what it does. They require logic for all of our treatments and the rationale behind it. If I had a longer transpsort that was about 30 minutes I would have probably done the EJ and gave fluids but being so close to the hosptial I let the docs handle it.

I was brought up that anyone that was older or more experienced than me gets sir or mam no matter what, until told otherwise.

I think I probbly should have been more specific than using just the word "critical" in the after thought of yours and biebers posting. The patient was not in shock, she was perfusing well, vitals were good, and she remained conscious throughout transport. If she started going down hill or starting decompensating from the hyperglycemia I would have went the IO route. I believe that if my patient requires an IV and I am unable to obtain one I will use the IO without fear. I wanted to be aggressive, but you can only do so much treatment in 10 or so minutes of transport time for this scenario.

First of all, you are the first person to ever call me "Mr." Bieber, which is hilarious in and of itself. =P

Secondly, and don't take this like I'm trying to criticize you or anything 'cause I've only been a paramedic for six months, but why aren't you a fan of using IO's unless they're absolutely necessary?

I completely agree with the first thing you said about the patient being one hundred percent critical. While we may only see the beginning of DKA, once it's just getting bad enough for them to call 911 for help, the truth is patient's with these high sugars have already bought themselves a stay in the ICU, and the lab chemistries that get out of wack by hyperglycemia can have very serious, life-threatening and life-changing consequences.

I also did mean you, and agree that IO's and EJ's are taken way too seriously. It's a tool, one that in the wrong hands can have serious consequences, at the same time, it's one of those things where you have to way the risks and benefits and I think that the risks are sometimes overhyped due to the simple idea of drilling a hole into someone's bone. Yes, like any invasive procedure, it can have dire and even life-threatening consequences. At the same time, I don't believe it's SO dangerous that you should feel you like you have to have a code blue to whip it out. Use it when you need it, and learn to recognize when you need it (and when I come across that patient that I need to do an IO on, I'll be sure to share it with everyone to let you know my experience!).

Take care.

-Bieber

Bieber,

As i stated above with Dwyane, respect is given to anybody who has more experience or is older. I think the IO and EJs are great tools and options to have and can make a huge difference when used properly. Looking back on the scenario I think that the situation was treated as best as possible with the situation and transport time that I was given. I am still learning and still a little fearful of some of the skills I have been given although I practice them regularly to keep up my skills. I appreciate your comments and showing that I shoud be a little more specific with the wording of my posts.

FireEMT2009

Let me put this back on you since you apparently have covered this in depth. What does the current evidence suggest? Does either agent lead to increased survival to discharge?

Take care,

chbare.

Mr. Chbare,

The current evidence that I have seen and that our emergency pharmacist instructor says is that amiodarone is better and increase chances of ROSC. I am a big fan of amiodarone myself but will use lidocaine if needed. I just wanted to get a couple opinions. Amiodarone and Lidocaine both have their pros and cons in terms of ease of usage. I just like hearing other peoples opinions on things that puts old school (lidocaine) and new school (amiodarone) and see where the population lies.

It was foretold in Mobile Intensive Care Officer class in 1992 that drugs in cardiac arrest are of little benefit and somehow the idea never caught on

Mr. Kiwi,

I guess some research is keeping the ball moving for cardiac arrest drugs in order for AHA to continue pushing forward with them.

Amiodarone has been shown to improve ROSC but not improve overall survival rates

Due to the time of my registration and training skill levels, its only ever been Amioderone that I have used, but then bear in mind, that it has only recently been incorporated into the resuscitation guidelines for the event of ROSC.

Some doctors I have worked with have still asked for Lignocaine as that is what they know and have had successes with. I can only comment on giving Amioderone as a standard. All medications have factors which enhance or limit their success. How long the patient has been down, the time of admin, state of the myocardium, hypoxia, sensitivities to the medication, precipitating factors to the arrest *H's and T's etc* and the outcomes with studies have shown favor to amioderone hence the current recomendations for it.

Are meds of little benefit in Cardiac arrest? Who knows, are all cardiac arrests the same? No. So perhaps the statement of that "all meds in cardiac arrest management have little or no effect" is contradicted. But then the date of that statement is also the time we did alright chest compressions and three stacked shocks and only had monophasic defibrillators and intracardiac medications lol.

Times change, meds change and so do protocols. Be interested to see other replies on this thread.

Scotty

Mr. Scotty

I agree that today it seems amiodarone is being pushed much harder for usage than lidocaine. I know everyone in my class choose amiodarone everytime we did a megacode for our ACLS class.

I think that either choosing to work with lidocaine or amiodarone is a personal choice, lidocaine has been around for a long time and has shown an increase in ROSC, and amiodarone is newer and has shown increase in ROSC as well. Either way your patient could not go wrong with you choosing either drug for their condition. H&Ts are a priority during cardiac arrest, and if they aren't fixed the arrhythmia won't be fixed either so its a cycle.

And as you said not every cardiac arrest is the same, you play that game and have to learn to play it well enough to increase your patients survvival rate.

Thank you everybody for your comments and I will be gladly watching this topic over the next couple days to see how many other comments it gathers.

FireEMT2009

I have almost completed my paramedic school and we have covered pharm and cardiology 20 times over. The big question I have is which do you perfer when treating VF or pulseless VT, Amiodarone or Lidocaine? I know that both has the potential to calm the heart down and help it beat regularly. I was just wondering ya'll's opinion on it, from a student to a veteran. Thanks for responses.

FireEMT2009

Mr. Bushy,

I completely agree, the IO was not warranted in this scenario. I would have liked to have had at least an IV in place and some fluids in and lowered the pressure a little bit. I talked to my OMD and he said a liter of NS can lower the BGL by a good 100 g/dl. It also would have hurried her care up a little bit as well. Oh well, what can you do? Thank you for your comment and advice.

FireEMT2009

Mr. Herbie,

I only had about a 10 minute transport time. The patient was as stable as could be even though she was lethargic. To me she did not meet the criteria for it, if she had worsened and started going down hill I would have started either an EJ or the IO. Thanks for the response.

Mr. Bieber,

I am not huge on using IOs unless absolutely nessecary., My patient was as stable as she could be and showed no signs of deterieration in the sligthest. I did not attempt any other methods of venous access. The transport time was about 10 minutes as I stated above. I figured that since we had a short transport time what little fluid I could have administered would not make much of a dent. I left it up to the ER docs on this one. I just thought it was an interesting scenario and just wanted to see what other experienced medics would have done in the same situation. My preceptor told me that they pick her up regularly with the same problem and can never get an IV line on her. Thank you for your response.

FireEMT2009.

We are called to a residence for a 40 (ish) y/o female not acting funny. Upon arrival she is found asleep on the bed. We awoke her and she stayed lethargic throughout the call. I have gotten vitals and they are all in normal range. Her BGL is read as HI. We transport her, as we get her to stand up with assistance she begins to puke but states that no ETOH or drugs were used today. She has IDDM although hasn't eaten today nor taken her insulin. I am unable to start a line due to lack of veins. She stays lethargic and altered level of consciousness. We transported to the hospital and did EKG monitoring and found no etoptic reasoning within the EKG. I told some of my fellow classmates about it and those that I asked stated that they would have tried to start an IO. To me this patiennt was not in the criteria nor the critical condition to conduct an IO. I thought about an EJ but she would keep turning her head randomly and say something slurred and become lethargic again. She did not meet any other stroke criteria, except for the slurred speech. My field impression of this was HHNC or starting DKA. I was wondering if I was correct in making the decision to not start an IO. My only thought that kept me from attempting an EJ is the fact that her head jerking motion could cause it to blow thorugh the extrernal jugular and possibly go into the carotid artery which is a major problem. So from all the medics out there, how would you have handled this call?

I would have startred the EJ and given fluid to try and break down her BGL while keeping check on her lung sounds, which were clear during the transport.

Mr. Mike,

I am 20 sir. Is there a reason why you ask?

Mr. Mike,

I understand and will use every tool possible to help increasse my patient's care. I just want to be prepared in case of the obese pediatric patient (which is becoming more prevelent in todays society). I will gladly use the browslow tape as needed. But the problem with the browslow tape that I have encountered is that it is done on the "average" pediatric weight. I also realize that some of the drugs that we use are not on that list as well. I was not trying in any way, shape, or form to downgrade the browslow tape. I enjoy having that tool availabe at a moments notice, but some pediatric patients will far exceed the browslow tape measuring dosages. I was not trying to make any enemies or hurt any feelings with my post. If i ruffled your feathers I apologized immensly. I was looking for tips for taking the National Registry. Thank you for your comments.

Mr. Dwayne,

I am very passionate about providing the best possible care to my patients,. I have been a firefighter for almost 4 years now and I am a true believer in the phrase "Whoever applies the first bandage holds that person's life in their hands.", as it is written in the PHTLS book. I also understand not every call will be life and death. I have pushed numerous drugs whether pediatric or adult in clinical and field internship. Our school's program does clinical and externship hours while we are in class that way we can put our information from textbook and theory into actual use and practice and it really makes a difference. I know in my community there is no paid staff we are all volunteers. So to me if you are a volunteer you shoud still give the best patient care as any paid person. ( Not trying to open up that bag of worms by any means). I hope after I graduate to work as a career firefighter/paramedic. I appreciate your comments. I hope to be involved very much within the forums to gain as much information as possible.

Mr. Lone Star,

I appreciate your courtesy and your response. I hope to learn alot from ya'lls vast majority of skill and experience. I understand some of the knee jerk reactions after reading the fourms for a long time. I will maintain proffessional courtesy and respect at all times. Thanks for the reply.

FireEMT2009

We start our final didatetic portion of our paramedic program, it starts in about 4 weeks. i have a good grasp on pharmacology and adult drug dosages and how the drugs work. I am more concerned with the pediatric patients due to the drug dosages are different and that my math skills lack on the fly. I can use a calculator or pen in paper to do the math but it is hard to doing math in my head to the exact expectations that are needed for paramedics. I feel confident working on adults but kids are my worst nightmare. I know we have the browslow tape but I dont want to do anything in my paramedic career that is half ***. I have worked too hard to get this far and do something half way. Is there any tips the experienced medics, students, instructors, etc. that can help me with pediatrics. I am also worried about the national registry. I know that we have been told that the CBT is no joke and is extremely difficult. I have passed all my paramedic classes with As and Bs. I just want to succeed and do my best out in the field. I have a very solid stand on paramedics knowing why they do things and why they give the drugs we give and the rationale behind that. In my school we have been pushed to have rationale in case anything is to happen and needs to be explained either to a doctor or a jury if it calls for. Any tips would be greatly appreciated and by all means taken with a posiitive attitude. If this is a little too long or too much information, I apologize. This is my first forum here and I am always looking for ways to extend my knowledge of medicine above and beyond just what we have to know. Thanks in advance. Stay safe ya'll!

Hello, I have been looking at this site for almost a year now and have been very interested. I am in paramedic school now at will finish my last didatetic class this fall and will have a test prep this spring and test out in May. I enjoy so being a EMT. We do our clinical and internships during the didaetic portion and I love being a paramedic. I have been a firefighter since I was 16 and an EMT since I was 17. I will graduate with my bachelors in Emergency Services Firefigher/Paramedic. I look forward to being able to talk to you and give you my advice and experience what little it may be. If I step over the line please forgive me, I am new to forums.

I'm in paramedic school now and only a semester away from finishing the last medic class. We use the books and they have a lot of good references and information that brings thinking and discussions about. Ms. Aehlart has a great Airway section over 100 pages dedicated just to it. The Medical, Trauma, Patient assessment section is also good too. We did not use the pharm section, we used a seperate textbook. There is some information that seems to contradict itself, but it is few and far between. It is a great tool for reference and review on stuff that you have forgotten. I had to do that a couple times so far when I couldn't remember a random syndrome.