Doczilla

I agree with dopamine. 'zilla

Norepi (levophed) Strong alpha agonist with some beta effects. Some folks will say this is the DOC for septic shock after fluid resuscitation. My first line for shock with a low CVP. Dopamine. As Dust said, it's a good all around pressor. Inotropic and chronotropic at low-mid doses, vasoconstrictor at higher doses. Good choice for cardiogenic shock. May be considered in septic shock because there is some depressed inotropy with sepsis (more prevalent in kids). Important to note that it works by stimulating release of norepi, and may not work if the patient's norepi stores are low. Epi. Popular drug in kids. DOC in multiphasic anaphylaxis when the patient needs to be sustained on something. Not a big fan of this in adults otherwise. Okay for sepsis and other forms of shock. Some evidence to support its use in massive pulmonary embolus. Phenylephrine (Neosynephrine). Pure vasoconstrictor. Good for shock states from vasodilation such as spinal shock. Also used frequently in septic shock. Vasopressin. Vasoconstrictor. I don't use this very much, to be honest. Other good choices which are cheaper. Dobutamine. Pure inotrope. Doesn't really increase BP. Good for the pt. in CHF who has a normal BP. Otherwise, I don't use it much. Milrinone. Phosphodiesterase inhibitor. Essentially does the same thing as dobutamine but doesn't require a beta receptor to work. No evidence supporting its use over dobutamine, and much more expensive. I never use this except in beta blocker overdose. Glucagoon. Not routinely used as a pressor except for beta blocker or calcium channel blocker overdose. That's about the only time I whip this out, and usually at very large doses. So in summary I use: Cardiogenic shock: dopamine Dopamine not working: add norepi Sepsis or suspected sepsis: norepi Spinal shock: norepi or phenylephrine Anaphylaxis: epi Kids: epi Beta blocker or calcium channel blocker OD: glucagon +/- milrinone Most important to remember: FLUID! 'zilla

Some civilian organizations (law enforcement in particular) will permit the wearing of earned military skill badges such as jump wings, EOD badges, CMBs, etc. This tends to be more common on dress uniforms. Ribbons? No. Some police departments have adopted ribbons for particular achievements, and it's easy to use those already manufactured by and available through the military. Because of the confusion that sometimes ensues, there are now cop ribbons specifically designed and manufactured for police to wear on their uniforms. I think it's somewhat questionable to wear a SF tab or Ranger tab on a civilian work uniform, as well as most military decorations. This does not equate to a miniaturized enamel pin that indicates affiliation with a particular military unit, such as a division patch, small SF tab, or something else. I think that's fine. For formal dress (black tie), many retired vets will wear a miniaturized set of decorations on their lapel. That's fine if small and tasteful. 'zilla

The best part about THIS is the comments from readers. Now off to train my wombat army. 'zilla

No, simply because rolling someone is necessary in the provision of care. The back must be assessed, the patient must be backboarded, and the pelvis should be wrapped in some sort of sling or pelvic immobilization device. None of these can be accomplished without rolling the patient. It's highly unlikely that rolling them would cause any harm other than the pain of doing it. 'zilla

Yes. That's not to say you should be cruelly inattentive to stabilization, but manual stabilization will do until they are backboarded. If you have a pelvic sling or TPOD or something, apply that at the same time as backboarding. Let nothing keep you from hauling ass to the hospital. 'zilla

You can provide manual stabilization on the femur fx while you look at the back and simultaneously place the backboard. Don't spend too much time immobilizing the leg. You need to scoop and scoot. 'zilla

MAKE.......IT.........STOP............. 'zilla

That's an EXTREMELY important one. I'll add other anti-thrombotic drugs: aspirin, plavix (clopidigrel), aggrenox (dipyridamole). 'zilla

Look for patterns in generic names. Classes of drugs often have similar generic names. Some common ones: Blood pressure meds: Furosemide, torsemide: loop diuretics. HCTZ, thiazide: diuretic, thiazide type Anything ending in -pril is an ACE inhibitor (lisinopril, enalapril). Anything ending in -sartan is an angiotensin receptor antagonist (losartan, irbesartan). Anything ending in -olol is a beta blocker (metoprolol, atenolol, nadolol, acebutolol, pindolol). Also add carvedilol and labetalol. Hydralazine Metformin, glipizide, glyburide, glimepiride: diabetic meds. Insulin, obviously. Others to know: digoxin (lanoxin, Digitek) prednisone, prednisolone (steroids) Potassium chloride SSRIs and other antidepressants: (brand names, too tired to look up the right generic ones) paxil, prozac, zoloft, celexa, lexapro, effexor, wellbutrin. Tricyclic antidepressants: amitriptylene, nortriptylene, desiprimine Benzodiazepine sedatives: diazepam, temazepam, flumazepam, triazolam, etc. Those are some of the most common ones. Dosage is not so important to know, but general mechanism of action is. Start there. 'zilla

Dust's comments about tactical medicine are regarding those who think that because they went to a SWAT call-out once, they are suddenly an 18D. His comments are grounded in his experience in real tactical medicine in combat environments. And they are important at a time when everyone and their mother wants to call themselves a "tactical medic" after a 5 day course. Like SWAT "operators" after a 5 day basic SWAT course. I don't expect that Webster's Dictionary really knows the first thing about "tactical anything." The fact that the dictionary definition of "tactical" appeared in this thread is laughable. Giving nerve agent antidotes makes you a tactical medic? Give me a freakin' break. NREMT, it is clear that you really haven't heard anything that anyone has said here. It sounds like you are trying to get support for your notion that as a member of a DMAT team, you are a "tactical medic". Failing to gain that support, you are making the argument on your own to others who know far more about the topic than you do. 'zilla

I'll paste something from a previous post I made on tactical medical providers, because I'm too tired to type it all out again. Understand this: there is far more to being a SWAT medic than stopping bleeding. ...The vast majority of what I do as a SWAT medic is not trauma care, but symptomatic management, injury and disease prevention, and evaluating and treating injuries and illnesses other than those sustained in the stack. The medic is the "medical conscience" of the team, and I frequently provide input on work/rest cycles, hydration, nutrition, etc. I help them figure out work or training restrictions for the SWAT members who have injuries and illnesses. I often review medical care provided by another physician, particularly when relevant to injuries that impact mission readiness. I'm more approachable than their doc in a white coat, and can advise them about specialists to see and make relevant phone calls to arrange follow-up visits. I have never had to provide trauma care in the zone, but have had to listen to lung sounds of plenty of chuckleheads complaining of asthma after the flash-bang goes off and cuffs go on. I do "sick call" kind of stuff, and provide medical evaluation and management on minor illnesses, rashes, and injuries. And I'm the one that remembers to bring the big cooler full of ice and water bottles. This is the uncommon image of the tactical medic, but is far more accurate. Paramedic school did absolutely nothing to prepare me for it. And no amount of training for the officers would prepare them for it... If you are wondering how often I need to provide on scene medical care, it is just about every call out and training. And I can do a hell of a lot more than the paramedic behind the APC. NREMT, the thing that is missing from your assertion that DMATs are tactical is the hostile nature of the tactical environment. 'zilla

I deploy at the back of the stack with our SWAT team, and know many civilian medics who do as well. Tactical medics are those who provide medical care in environments that are expected to be hostile, with the possible addition of being remote and/or austere. This does not include medics who simply work EMS in bad neighborhoods. It means people who provide that care in situations EXPECTING to be shot at. What NREMT-Basic is describing is disaster medicine, not tactical medicine. The fact that you do not wear body armor illustrates the fact that you don't expect to be shot at. Hazmat does not qualify one as tactical, though it is possible that hazardous materials may factor into a tactical scenario. Hazmat by itself is not tactical. 'zilla

For US medical schools, there are about 45-50,000 applicants for ~16,000 positions. Many though are repeat applicants from previous years. Of those that are accepted, there is a 90% pass rate. I don't really forsee a bridge program from paramedic to physician. The material needed to successfully matriculate as a physician is so extensive that the small amount of time spent in paramedic school wouldn't in the end make much difference. The anatomy and physiology, pharmacology, pathophysiology, etc. that a paramedic learns is very rudimentary compared to what is expected in medical school. That's not to say that a physician can just do a paramedic's job. Paramedics have certain skills that are desirable in physicians, such as self-reliance and the ability to prioritize and perform care in environments where help is relatively scarce and treatments are limited. Physicians only obtain training in prehospital care while in residency (only ER residency). It would make more sense to make the physician work with EMS, than to bridge the medic to physician. 'zilla

Just Dust! :boxing: :laughing3:

Sorry, let me clarify that. The flight RNs can do anything on standing orders through protocols without requesting permission, but require contact with the MD at some point during the transport. What I meant to say was that they are not independently licensed to perform the various procedures on their own without protocols and a medical director. I think we're saying the same thing. 'zilla

On this side of the pond, the RN's independent scope of practice does not include many of the medications and procedures necessary for the prehospital environment. Our flight service (all RN) has a medical director and protocols and requires online medical direction. 'zilla

I have never ultrasounded a coronary artery before. 2D cardiac echo is pretty much a standard here prior to discharge after ACS rule-out. We don't have a cardiac observation unit, so our chest pain patients get admitted and get the echo with the stress test. CT coronary angiography is gaining fairly wide acceptance. The recommendations are now coming out supporting its use in acute coronary syndromes. We haven't gotten up to speed on it yet here, but it seems like just a matter of time. Cardiac MRI/MRA is pretty slick according to the radiologists. We don't have the technology here. I don't know that there is a recommendation yet on it's utility for acute coronary syndromes, and I don't know that we have yet defined it. For that matter, getting a stat MRI here takes an act of Congress. You can pretty much only get it for cauda equina syndrome. 'zilla

The Flight RN. EMS is ultimately not a democracy. 'zilla

Only 30-50% of acute MIs show EKG changes. EKG is good to "rule in" or confirm the suspected diagnosis, but is notoriously insensitive. You need cardiac enzymes and a stress test to rule it out. 'zilla

I thought I could be a paramedic, but then they realized that I was pure evil. 'zilla

Where are you? Are you in the U.S.? If so, then high school grades and coursework do not matter in any way for medical school. Being a nurse or paramedic gives you a grounding in performing interviews and exams on patients. It also helps in certain small ways like running codes and starting IVs, but these are a very small part of what a physician, even an ER physician, does. By the time you graduate residency, it will be hard to distinguish you from your classmates who lack that experience prior to med school. If you want to be a doctor, be a doctor. You're already in paramedic school, so I wouldn't give that up. Get the experience you want as a paramedic and go on to medical school. Being an RN too is overkill. It won't really add much to your skillset that being a paramedic won't, and it's a whole lot more schooling. What do you hope to gain by being an RN as well? Why an AAS in prehospital care? Again, this won't help your application. Get a 4 year degree (in anything), just make sure you get a year each of physics (with lab), chem (with lab), o chem (with lab), bio (with lab), english, and math like statistics or calculus. Concentrate your efforts on your premedical coursework. It's fine to major in whatever you want (just do it well). There are some considerations for those with relevant medical experience, but that will get you only so far. When it comes right down to it, nobody will care what experience you've had if your grades aren't good. You'll miss the cutoffs that each school sets for entrance grades and scores and nobody will get the chance to look at your resume and see your experience. Everything else is just a waste of time, effort, and money. 'zilla

Half my med school class had EMT-B certification, but almost none of them actually used it. I knew many more that got it and joined up with the collegiate squad but ran very little, all in a vain attempt to try to pad their med school application with "relevant experience". It's hogwash. Unless becoming an EMT really touches you and you can relate that in your essay and your interview, nobody in med school will care. Nobody on the admissions committee has any real idea what an EMT does anyway. And no, you don't have to stop once you're an MD. You just don't have to call for orders anymore. 'zilla

"Let him keep seizing"? Give me a &%$# break. That would be negligent, and is certainly not an appropriate approach to the patient. He wouldn't let that fly in his ER, particularly with such an easy way of treating it. 5mg is an appropriate dose for any patient over 110 pounds. And if it didn't reverse with flumazenil, then other causes of the patient's coma need to be considered. Some docs are just a$$wipes. Surprisingly few ER docs consider themselves to be mentors or even remotely connected to EMS, even among residency trained ER docs. This is despite residency requirements for EMS activities, encouragement from faculty, and receptiveness by EMS squads. Either they get it, or they don't. 'zilla

He may be smarter than you think. Aiming center of mass gives you a much better chance of hitting something. By making the aim point someone's head, it will be much more difficult to get on target. Add that bit of stress to the overwhelming stress of shooting at someone who is shooting back at you, and chances of getting on target are even smaller. And people who need to be told that police officers wear body armor probably aren't the best marksmen to begin with. If anything, his comment will decrease the chance that a thug will be able to make a hit on a cop. Not only is the military type vest impractical for street use, it's hot, heavy, and expensive. The coverage provided by the IBA is excellent, and it is very well engineered. Hard body armor for level IV threats is most certainly overkill. Unless you are on a SWAT team. A vest appropriate for EMS: Level II, which is appropriate to the threat posed by most handgun rounds that you are likely to encounter (essentially police caliber). Woven kevlar or twaron, not laminate Hard trauma plate in the front Concealable carrier so you wear it all the time regardless if you "think" you won't need it. 'zilla