JakeEMTP

http://www.jppt.org/...JPPTv8n1ms7.pdf

Seeing as this thread is morphing into treating asthma, can you explain the actions of mag sulfate, especially in the paediatric population.

cheers

First, my bad for forgetting we were talking about a paediatric. I went back and read the OP. While the benefits of MgSO2 probably will never been seen in the field, why do it right? Pre-hospital medicine. I do believe it does benefit the pt. The same can be said for administering Solumedrol in the field. It takes hours for it to work and yet it is probably every EMS systems protocol. The Mag works great when the standard nebulized treatments are helping but not to the extent we would like to see. Only when this is the case will I hang the mag drip. It's another one of the medications that is nice to have but don't use all the time. CPAP is another "tool" for the the treatment of the Asthmatic pt. Do I have to explain this too?

http://www.medscape....warticle/498382

http://jama.ama-assn...62/9/1210.short

I couldn't find a lot of studies to support the use of mag in paediatrics, there aren't an abundance of studies to support either side.

I did find this one though.

http://emj.bmj.com/c.../24/12/823.full

3) Protocols I work under, which may be different where (collectively) YOU work, state to the effect of "even if it is the same med, issued by the same doctor, on the same day, to both spouses (or domestic partners) from the same pharmacy, you cannot give the medicines of one person to another person, or suffer the consequences of the authorities".

Dunno Richard, I'd have a really tough time standing around with my thumb up my ass while somebody dies, when I could have helped them. I think I'd rather face the wrath of the authorities and be able to sleep at night.

Regardless of what the protocol states, it s ethically wrong to fade to black and do nothing. It is against everything I have been educated to do and my own personal values. If you kept this pt. alive long enough so they could be tended to by ALS (I hate using that term!) by using something as simple as a MDI, then you've done your job. The authorities can blow me.

This is a great thread!! I wouldnt give the patient someone elses medication, for all the reasons mentioned above.

Mathew asked how oxygen could make it worse. ( sorry havent figured out the whole quote thing). If they are in acute and severe respiratory distress, 15 liters of oxygen by non rebreather can actually shut thier respiratory drive down. I've seen it happen...now you have a respiratory arrest on your hands.

In the short term, it will help some but they need the nebulized meds to actually help stop the attack. Our protocol is nebulized Albuterol/Ipatropium. Consider Epi 1:1000 0.3cc sq. Contact Med Control for additiional Albuterol/Ipatropium. Monitor respiratory status continuously and be prepared to deal with respiratory and cardiac arrest.

No Mag. Sulfate in your protocol 39?

I don't think there is any easy answer. Repetition is the best teacher. If you know your treatment plans (I'm guessing protocols/standing orders), then just do it! Assess the pt. and treat them accordingly. When I precept, I will on occasion question the student's treatment during the call, but usually after. Not trying to question their abilities, but just their thought process. What I would like to see them do is respond quickly with a well thought out response.

Your progamme director is right in telling you to step up. Obviously the feed back from your preceptors has led to his conversation with you. The time to gain confidence is now while you have another medic with you.

Your inability to want to take charge is nothing new. I'm sure all the providers on this site went through it at one time or another when they were being precepted. That being said, all of them also grabbed the bull by the horns and ran with it. If they didn't, they wouldn't be working for very long. Sometimes decisions need to made quickly when it comes to treating pt.'s. Go with what you have been educated to do and treat the pt. Someday, you will be out on your own and won't have a preceptor to help you. You need to step up now. Don't be afraid of making mistakes, that is why your preceptor is there, to make sure you don't.

I'm not trying to bust your chops, and you still have until April, and by then you should be good to go with the testing w/o fear.

Good luck man! Keep us posted on your progress!

No I wouldn't immediately use someone else's medication, although I won't lie, I might consider it if an ambulance is going to take some time and the pt.'s condition worsens (which it will). A true asthma attack is nothing to play around with. Although Ugly is right about the "R's", most asthmatics have had albuterol or ipatropium before. Before the pt.'s airway closes completely, I'd have to consider using someone else's inhaler if it was in date.

I also wouldn't wait for that miracle drug O2 to work before calling for an ambulance. For a true Asthma attack, O2 is not going to cut it and the pt. needs and ambulance.

Based on the condition you describe the pt, I see no valid reason to not to medicate the pt prior to cardioversion. Shocking a conscious patient [without meds on board], unless they REALLY, REALLY need it RIGHT NOW, is just plain mean, IMHO. Of course, I wasn't there, so probably shouldn't pass judgement without knowing more about the situation.

I was just thinking, the nurse probably had to wait for orders to medicate the pt. from the puppet master (j/k Doc's and nurses) and decided to go ahead and cardiovert w/o it, which in and of itself would require orders I'm sure.

I've only seen the situation described by the OP once. Depending on the circumstances, the cardioversion w/o premedicating may very well have been warranted. I don't know, I wasn't there.

Again, show of hands, how many of you have a black supervisor or better yet, Chief ? I hear crickets again. The only way a black medic can get promoted is if he/she is a medic in the military.

Bullshit. It is the law of averages..I know very few medics who are black, and those who I do know are extremely talented. At the risk of you bringing up the "the education system is slanted against the black community" crap, if there are very few black medics, there's going to be an even lower percentage of black supervisors.

I work critical care transports now. But in the County we are based the local EMS system has 4 black shift supervisors and this is in the South. It can be done. One just have to apply themselves, get the same education as everyone else and excel at what they do, just like everyone else, to get ahead.

Stop looking for the easy way out. If we (us white folks) had to go to school and obtain an education, apply for a job and compete for it on an equal playing field, then so do you. Frankly, I would be pissed if I was passed over for a position when I scored higher, interviewed better and had higher qualifications, than the individual that was awarded the job because I was white. That's discrimination.

Interesting. I would hope to see this on EMS and Critical Care units. As you are well aware, most EMS advancements come from the military. This should be no exception.

I may have missed it in the reference, but what is the shelf life of Tranexamic Acid? I don't imagine you would use this everyday, but would be great to have on the unit. With this and quik clot (another thing we have thanks to our armed forces) a lot of folks would make it to surgery who otherwise would have bled out.

We fared pretty well here in Pawleys Island SC. We got lucky this time. I do have a lot of friends in NC and they have been w/o power since last night. I have a daughter @ MCAS Cherry Point and they just got hit. Lots of wind and rain and prepared for the flooding which is bound to come in a few days.

Good luck to you guys in the north. Irene sho' ain't pretty.

RSI is a great tool, but I struggle sometimes to justify it. I don't like to dick around on scene in an emergent situation. If I can manage the airway w/o RSI, I will. CPAP works great for the COPD'ers. I can be 5 or 6 minutes down the road towards the hospital instead of knocking the pt. down and tubing them. Have I done it? Sure I have. But just because I can doesn't mean I have to. Total pt. care. Be careful when contemplating intubating the COPD folks. Some, (read most) will never get off the vent. If you can manage the airway w/o a tube, do it.

Queen's "Another one bites the dust" is will also provide about 100cpm if you can remember. Not only the rate is important while doing CPR, the depth is equally important.

.

All of those things you pointed out have nothing to do with race (tractors, stoops, cannoli, etc). They just have to do with what part of the country you grew up in and that has nothing to do with race. Anyone that doesn't know what a cannoli is doesn't deserve the job anyways.

Anybody who has seen the movie "The Godfather" knows what a cannoli is.

I have refrained from posting on this topic. Quite frankly, I'm sick of reading this crap constantly from our poor misguided comrade. Every post is the same. "Y'all won't hire me 'cause I's black" or, "Society is always putin' down the black man". Blah, blah, blah.

If you don't expect to be coddled, then you won't feel you were passed over unfairly. Suck it up and study harder for the next time. Get over it. Take a litlle responability for yourself, I know, foriegn concept.

Hey man. There are several folks here who got into the EMS game later in life. Myself, I was 44 when I began my EMS career and I've been a paramedic for almost 4 of the last 6 years. Approaching my 51st birthday, I am now doing Critical Care transport. As much as I THOUGHT I knew as a medic, there is a lot more to this game.

I can't give you to much help on the tactical medic gig. It just wasn't my thing.

Welcome to the site bro'! There is a wealth of information here, yours for the asking.

Again thanks to all that have posted on here. It really does help.

Another question would be in any of the EMT-B classes you guys have had do they go over talking about coping with death and/or gruesome scenes? Just curious.

And i have seen dead bodies before, i've seen relatives in hospital beds pass away and at their funerals, they made me feel a little uneasy but for the most part it didn't bother me to much. But then again i wasn't interacting with them a whole lot either.

Thanks again

Kyle

To answer your question, I would have to say no, they don't. If they do it is a very short part of the class, but I don't remember anything of that sort. A semester of Psychology would be better to help you prepare and understand. If you do all you can to the best of abilities, you should be able to sleep at night w/o worrying. Like all my esteemed colleaques have said, sometimes people die despite your best efforts.

Having a patient under your care and dying is different than watching someone pass away in their sleep. A month or so ago, I had a pt. have a AAA in the back of the ambulance and die immediately. No real warning, just die. I was talking to the pt. minutes before and had just taken a set of V/S which were extremely vanilla. I just did what I had been educated to do and rode into the ED. At the time we didn't know it was a AAA, only that the pt. coded. I didn't fret about it, the outcome was not of my making and every possible intervention taken in the short time we were working the cardiac arrest (or so we thought) would've benefited the pt. had they responded.

Do not worry about working with deathly ill pt.'s. Sometimes the outcome is not ours to decide. I'm not religious, but sometimes I think someone else is making these decisions. With time in the field, you will become more comfortable.

Aren't administration sets pretty much universal? Of course, this would exclude 'brand speciffic' for infusion pumps...

As far as I know LS. 60, 15 and 10 gtt are the norm. We use the Alaris pumps where I'm doing critical care transports now and yeah, the IV tubing is brand specific as far as I know.

The reason in my mind for not reducing a dislocation is the possibility of fracture. Even ER docs don't reduce shoulder fractures without x-rays and we shouldn't be doing that either.

What happens if it's not a dislocation but a humeral head neck fracture with that presentation? Try to put that one back in place and you are not going to be successful and more than likely sued big time.

I've never seen a doctor reduce a shoulder dislocation without an x-ray first. Never. But I'm sure others have.

Exactly why I haven't done it Ruff. Like ERDoc said, if and only if, there appeared to be vascular compromise, I might attempt it. As Bones would say " Damn it Jim! I'm only a Paramedic!"

When I worked in NC, we were allowed to attempt one (1) realignment. I never did though and to be honest, I really didn't see that many dislocations. Many fx's however.

As far as splinting, I would usually allow the pt. to self splint. Then place a triangle bandage (just unrolled, not unfolded) around the wrist and tie it behind the neck. A roll of kerlex just so the knot wasn't resting on the pt.'s neck. This would allow for some support in the event the pt. lost his grip due to a bump in the road or whatever. Pain mgmt sometimes (ok, most times) would cause the pt. to drop his hand or loosen his grip. Adapt, improvise and overcome.

Hey scratrat,

I just recently did the NR Paramedic for my move to SC. The skill stations were a joke. I was talking to the proctor for the exam and an examiner friend I know who was there. They informed me on the "QT", that it has been their experience that the "random" basic skill 99 times out of 100 is, wait for it, the KED.

The other skill stations haven't changed, ever. Static Cardiology, Dynamic Cardiology, Adult (ETT and Combitube) airway and pediatric station which is airway and an IO, Trauma assessment, IV and medication administration and 2 Oral Stations. The Oral stations, which weren't hard by any stretch of the imagination, are my nemesis, I got through them all though on the first try. I think, because I haven't checked, all the stations are on Youtube, or so I have been told. You can download the check off sheets from the NR site and review them if you need to, but I shouldn't think you'll need it. Although, they will show you what they are looking for.

Good luck man! (As if you need any)

Jim

FMC164! You're so sadistic!

I know, it's a female thing. LOL.

I have seen electric razors on some ambulances. I don't know how well they work, I don't use one myself. Agree with Dwayne. The one's we have work pretty well. Also, the 12-Lead guru Bob Page says using an alcohol prep will help the electrodes stick. I dunno though, never tried it. As I stated, our razors work pretty well. Don't use the alcohol AFTER shaving the chest though! Well, FireMedicChick164 might.

Hey Dwayne! What's up bro"?

I guess I wasn't to clear, but I was trying to get the OP to realise that getting a set of V/S post 1st nitro and pre 2nd administration is paramount. If they had, perhaps they might have held off on the second dose. Sure, with an initial BP of 160 over something, I might have given the nitro w/o a line. By the V/S after the second nitro though, it appears we might have a inferior MI here. The pt. is compensating, time to shit or get off the pot.

The good thing I guess, is ALS (you know how I hate that!) is on the way.

One of the reasons I hate SL Nitro is, once it's administered there's no reversing it. I much prefer a nitro drip. At least you can stop it! That is for a different discussion though. I don't want to hijack our new member's first post.

^^^^^^^^^ Medic mills have made fortunes doing just that.

Yeah, we weren't trying to bust your balls. Just some overall opinions and concerns. Quite frankly, if you can't interpret a 12-lead, there isn't much point in adding this to your scope unless of course you have the ability to transmit to the hospital. Acquiring a 12-lead is easy, reading it and correctly interpreting it are quite another.

Good luck with your class and keep the questions coming. There is no such thing as a stupid question here and this site is an excellent resource for you. There are some really smart and experienced providers on here.

Yeah, not I big fan of giving Nitro w/o a 12-lead and a patent IV. I realize it might be above your scope of practice and that is not your fault, it is the systems. Did you take a set of V/S before administrating the second Nitro? You've gone to far brother. W/o a patent line, Nitro should NEVER be given. How do you reverse the low BP now? Better start bagging, call 911 and get the AED, your pt. is about to code.!

Volunteers should be just as responsible as paid personnel. Just because we don't get paid doesn't mean our behavior should deviate from professional or the scope of practice. Where I live we volunteers set the bar for our service.

We live with the same scenarios and the same work related situation so volunteers should take care of ourselves as well, probably more because we are damaging our health for free.

I think that was Mikes point. As a volunteer, you don't have to respond to every call, where a paid crew does. If you're tired, don't go on the call. If you're paid and on shift, you should be rested and able to answer the calls w/o being exhausted and a possible hazard.

With Bushy on this. I prefer to start IV's in the lower inside forearms if possible, especially on trauma pt.'s. My mrs., who is a circulating nurse in the OR, says most trauma surgeons prefer not to have IV's in the AC's because of the way pt.'s must sometimes be manipulated. Having an IV in a "fold" (for lack of a better term, hey, I just got up) can interfere with the flow of fluids sometimes due to the position some pt.'s must be placed.

For me, I like to start them in the forearm because it doesn't hurt the pt. as much and it is easier for me to keep an eye on it. The vein's are usually pretty straight and will hold a 18/16 in most cases.