musicislife

A few questions here for any NJ EMTs. First off, I can only see my transcript on nj ems user (i cannot access oemscert due to my number starting with a 6) and it only contains online courses i have taken. I have taken many more CEUs, but they have been on drill night at my squad and I did not get a certificate, just signed a CEU sheet. Does the state keep track? 

Secondly, there are requirements for all responders. I took a fire 1 course recently that included hazmat awareness, ICS 100 and 700. Does the hazmat awareness I took count (from IAFF, not NJSP)? is my pro board fire 1 cert enough to satisfy the hazmat awareness, and ICS?

How do you guys keep track of the required courses and CEU credits, in case an audit comes around, especially if required courses like CBRNE that I took provided no certificate of completion, just signing a CEU sheet?

but isn't this technically a vehicle accident? he was operating a moving vehicle? (devils advocate). Describe Moderate speed? how fast is moderate? 10 MPH? 20 MPH? 30?

He said he was just casually riding his bike home..I have tried to go as fast as I can on flat ground and only hit 20 mph. My best guess is 10 mph or less

Do you have a selective spinal immobilization protocol option?

This would allow you to do the spinal / neuro exam and properly rule out the need for full immobilization.

If you do then it could have been used.

If you don't , then do some research on the NEXUS study.

Many states now have the ability to make this determination, by following a protocol that was first developed by the wilderness medicine folks and then followed up by the NEXUS study.

We have been using it since the early 1990's

Ive done a lot of nexus research..however I doubt our great state of NJ is that progressive with EMS. I will have to look into NJOEMS

Well that would be your first clue she was a protocol monkey. Just bide your time working with her and then move on. I'll bet this isn't the only time she blindly follows protocol. But in her defense, it is protocol so she really didn't do anything wrong.

Now let me turn this around, had you have not boarded and collared this guy and if it was in protocols, would you be in violation and subject to discipline? Do you have the fortitude to go against protocol and buck the establishment? I'm pretty sure this medic on the call was not willing to do that.

So by your admitted judgement would you have broken protocol and not boarded the patient, thus invited a review of your call and possible disciplinary action?? Are you ready to face that music?

Think of me as your Medical director - tell me why with evidence backing up the why, WHY you did not board and collar this patient who sustained a bicycle crash when protocols state he should have been fully immobilized? Your job depends on your defense and whether you convince me.

well, our protocols do not specify MOI, except in the case of MVA or GSW i believe..they only specify signs/symptoms of spinal injury

anyway I found that PT had no neuro deficit, palpating the spine revealed no pain, and the pt was not complaining of head, neck, or back pain. he was fully alert and oriented, he was not intoxicated/under the influence of anything, nor did he show any signs of being under the influence, and had only minor injuries (3 small abrasions to knee and hands), and the PT stated his head did not even hit the ground (and there was no damage to his helmet).

from this i would say the likelihood of spinal injury is very, very low, as no signs or symptoms were present.

that would be my defense of my treatment plan.

Well it's the crew leaders call so let the protocol monkey go with it. Did you discuss his decision after the call?

yeah, her reasoning was simply because the bicycle crash.

Scenario was a teenage male hit a lip in the sidewalk and went flying off his bike (moderate speed, on flat ground) Helmet was intact, no neck or back pain on palpation, pupils unremarkable, grip and motor skills intact, vitals good, just abrasions to his knee and hands...it all just seemed like a kid who took a spill off his bike.

My planned course of action was to dress the wounds, and transport if the parents decided (which they did).

Leader of my crew decides full spinal immobilization.

Personally, I had no desire to backboard, because no part of this presentation screamed "spinal injury."

he had fallen off the bike and broke his fall with his hands/knees.

to me, the board seemed like overkill..but my decision was over-ruled by the leader of the crew. thoughts?

So I was wondering how you guys dealt with being the new EMT/medic..

it seems to me that it is difficult for me to voice an opinion sometimes (such as: "he doesn't need that board and collar")

anyone else have this experience?

luckily my on-call night crew is great, but in the daytime we get who we get, be it the most experienced member or the guy who rides one call per year

why don't you give us the whole pt report in the form of a report that you would make to the ER Doc.

Sounds like the makings of a serious hypertensive crisis with complications to me.

Possible cardiac or stroke potential , or as you say with abd pain a possible AAA.

Where was the abd pain focused? radiating? steady? dull? sharp? Duration.

was was the rebound of the abd on palpation?

History of past events?

sorry I should have given a better report...

the pain was in her LLQ and she described it as a come and go cramp, and the whole event began about 15 min prior to our arrival, when she went syncopal..she was diaphoretic and warm, with no prior medical history and no history of a similar event. The pain would last about 10 minutes at a time. There was no rebound tenderness or radiation on the pain

the reason I am asking is because the medic seemed to brush my report off about the tachycardia (130bpm) and the hypertension. I guess I am trying to figure out why she brushed that report of, thinking maybe she knew something I didn't

Ok. So at this point who are you going to trust more? Yourself? Especially after having verified that your concern about her BP was founded in reality... specifically that the patient's BP was, in fact, high? Or the medic who seemed to brush you off?

What other differentials did you come up with regarding this patient? Any follow up availa

i was also thinking a bowel obstruction, especially judging by the come and go nature of the pain and tachycardia...we don't get follow ups unless it is a CPR save

Normal ranges for blood pressure are pretty easily searchable. Pressure ranges and stages of high blood pressure are also pretty easily searchable. What has your research shown? You thought this was a high pressure and reported it as such. Surely you had something that made you think so. What was it?

Have you asked the medic in question why she said what she said?

my research from AHA says that BP is the lower end of a hypertensive crisis..but the medic said otherwise. She also left before I could ask after we transferred the PT. I was concerned because the LOC, hypertension, abdominal pain, seemed like dissecting AAA.

I gave a report to a medic that the BP was a high, saying that it was 184/110..she said it was not high...what is considered "high"? no history involved here, just syncope and abdominal cramps.

Patient in motor vehicle crash, neck/back pain severe. Board and collared. States feeling dizzy after being boarded. Any (general) idea what could be the cause of this?

Hi,

So i have been tasked with interviewing a healthcare professional (besides an EMT-B, since i am one) for a health care class that I am taking. I am interested in being a paramedic, so I would like to interview one. I also need your first name and your years experience as a paramedic. Thanks for your time!

1. What is the function/description of your discipline?

2. What educational and professional credentials are required for the discipline?

3. What kind of settings/environment do people in your field work in?

4. What personality traits and/or characteristics must an individual have to be “cut-out” for this discipline?

5. What drew you to this particular discipline?

Typically with psych patients we have one cop ride in the back and the other ride in the patrol car behind. We usually don't mention we are going to the county psych ward unless they directly ask. The key is to keep these people as calm as possible. Nothing is worse than a crazy guy in the back who gets a little too upset with you. Also, consider restraints if the patient gets too rowdy. Something about EDPs, they seem to like me.

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The kid might have looked at the paper cup and said " seriously?"

Yea typically I estimate it. I guess I don't see a difference if he is an 8 and I guess a 9. Usually the assessments that are involved in the gcs end up being done anyway, just not as part of a formal gcs. My only exception is if I know we are using a helicopte, because that is usually a bad trauma.

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I'll wager a bet the CC is the one with all the whacker lights on his vehicle. It is NJ after all. :-}

Thanks for the replies. I'm so used to using my squads abbreviations. Cc means crew chief, the emt in charge

Having a rather heated discussion with my CC about this one..

We had a 4 y/o male, pretty large for his age, with an apparent asthma attack. His SpO2 was 89%, I decided to use an Pediatric NRB on the PT. He tolerated it just fine, and his SpO2 increased. My CC got upset about that at the end of the call and said I should have used o2 blow by with a paper cup and o2 tubing. Which do you guys think is more beneficial in these situations? Blow by or NRB? It seems to me based on his presentation and response to treatment that the NRB worked just fine.

Yes? Yes what?

yes that was a joke. I did not use quick clot on a paper cut. However, it does burn according to patients we have used it on

Alright children, lets play nice.

thank you

1) Ab is not a universal abbreviation for abdomen. You should never use abbreviations in your narrative unless they are on an approved list by your agency and even then it is a huge risk to take.

2) O2 by po??

3) It's great that lung sounds were assessed but what did you hear? Did you just listen without critically thinking through what they would be classified as? Same with cap refill and skin condition. What did you assess them to be? Writing down that you looked at those things is great, but meaningless as to the condition of the actual patient.

4) If you are going to write patient states, put the statement in quotations.

5) Again, put down the information you gathered from the history and vitals. You're giving half information here and that will get you into trouble.

6) What does that even mean?

7) I would put down the real name of the hospital and use proper grammar with capitalization.

Here's how I would write that report.

C: BLS Unit 208 dispatched to a 20 y/o female c/o abdominal pain. Upon arrival, found patient in fetal position being attended to by (state who was actually there). H: S- symptoms listed here (diaphoretic? flushed? what are YOU observing about the patient). A-allergies M-medications patient is on P- past medical hx, has this happened before? L- last oral intake (pretty important with abdominal pain assessment) E- what was the patient doing leading up to this pain starting? Was she just sitting around? Was she playing football?

A: Review of systems- Skin condition, mental status, location and OPQRST of pain, vital signs, bowel sounds, lung sounds, any data you actually collected should be listed.

R: Oxygen initiated at ____lpm via _____ by _____________(person who actually initiated care). Patient placed onto stretcher for transport in position of comfort. Oxygen continued at ____lpm via _____ with onboard oxygen. Any other treatments/interventions you performed.

T: (Mode of transport) ex. Transported with patient on stretcher, emergent to Valley Emergency Department. Report given to Kristen, RN and patient placed in room 2B.

It is important to be as detailed as possible. Like I said earlier, if you didn't write it, you didn't do it. Just saying you listened to lung sounds is not enough. Any attorney will look at that and say "what were the lung sounds? Did she have bilateral rhonchi that you failed to document and report?" The point of the narrative is to help YOU in the event a call goes to court. In 5 years will you really remember what her lung sounds were? Or her vital signs? Highly doubt it.

Hope this helps!

BLS Unit 208 dispatched to a 20 y/o female c/o abdominal pain x 30 min. Upon arrival, found patient in fetal position being attended to by P.O 423. PT diaphoretic, pale. NKA. Meds: Wellbutrin. Regular menstrual period. PT ate plain bagel and drank 1 glass of water 2 hours PTA. PT stated she was watching TV. Skin: Pale, cool, diaphoretic, AAOx4, sharp pain in LLQ, 10/10, denied radiation, constant for 30 min, sudden onset, vital signs assessed(see below), lung clear and equal in all fields, PT denies possibility of pregnancy. Denied again when asked a second time en route. Oxygen initiated at 15 lpm via NRB by P.O 423. Patient placed onto stretcher for transport in position of comfort. Oxygen continued at 15 lpm via NRB with onboard oxygen. No changes en route. Transported with patient on stretcher, emergent to Valley Emergency Department. Report given to Kristen, RN and patient placed in room 2B.

P.O 423 when written on reports in my area means Police Officer then his call sign. PTA means prior to arrival, standard in my squad. How is this?

Similar to winning awards for being the navigator and lookouts on the titanic. :-}

By CPR calls I'm guessing you mean cardiorespiratory arrests? Or were they having chest pain and got CPR?

full cardiorespiratory arrests. One had chest pain and dropped mid-sentence, according to my friend who was on the call.

We use the DCHART format:

D: Dispatch information

C: Chief complaint

H: History (SAMPLE & OPQRST)

A: Assessment: Physical exam, Labs & Vital Signs

R: Rx: Treatment rendered and patient response

T: Significant notes during transport

Field impression at the end

I have copied a fairly recent PCR that I did with some of the data removed or changed for obvious reasons:

D: Dispatched to the scene of a 76 year old male or female with weakness

C: 84 y/o male or female found sitting in chair at home with family at his/her side, pt reports “I think I feel alright,” family reports he/she has been very weak and breathing fast and they cannot get him/her out of his/her chair to get into the car to take him/her to the hospital, Pt contact made at 09:50

H: S: generalized weakness, tachypnoea

A: NKA/NKDA

M: Jalyn 0.5 mg PO q D, Megase oral PO Q day, mirtazapine 7.5 mg PO Q day, tamsuiosin 0.4 mg PO Q HS, temazepam 30 mg PO Q HS, Trazadone 50 mg PO Q HS, hydrocodone/APAP 5/325 PO PRN, lisinopril 1.25 mg PO Q D

PmHx: HTN, BPH, Fall resulting in intracranial haemorrhage in December 2012

L: Last HS

E: Family reports that the patient has recently been discharged from rehab following a fall resulting in a TBI but has been progressively weak and unable to perform ADS’s with s/s that have worsened over the past couple of days

O: Last HS

P: Denies pain or discomfort

Q: Denies pain or discomfort

R: Denies pain or discomfort

S: Denies pain or discomfort

T: As defined above

A: HEENT: Sitting upright in chair, AO times 4 with movement in all extremities, atraumatic to exam, airway patent and self maintained with increased respiratory rate, pupils pinpoint and minimally reactive bilaterally, neck midline with flat jugular veins, Pt able to swallow without difficulty and smile w/o indication of facial droop, speech slow but non-slurred

Cx: Atraumatic, unlaboured respirations, no accessory muscle use, clear lung sounds in all lobes, no c/o dyspnoea, no overt s/s of respiratory distress, but rapid and deep respirations at a rate of 24 noted with regular rhythm, irregular, faint heart tones noted at an elevated rate of 112-118, firm, round mass with a diameter of approximately 5 cm noted to lower right anterior chest wall, Pt reports “I have had that forever”

Abd: Soft all quadrants, non tender to palpate, atraumatic to exam

Pelvis/GU: Pelvis stable and intact, full GU exam deferred, Pt reports that he/she has been having “difficulty going pee”

Ext: Movement in all extremities with weak bilateral hand-grips, atraumatic to exam, pale/cool/dry skin with decreased turgor, no indications of cyanosis or jaundice noted

Neck/Back: Atraumatic, midline w/o step offs, Pt denies any c/o

V/S: B/P- 60/40, P-118 & irregular, RR- 24 w/o overt indications of significant respiratory distress, SpO2-88% R/A, T-98 F, Wt~68 kg, Temp 97.1 F tympanic

Rx: 1) Pt contact and full assessment, placed on portable pulse oximeter and BGL of 265 mg/dl noted, Pt placed on supplemental Oxygen at 2 L/min via nasal cannula @ 09:50

2) Pt carried out of his/her room and down a small hallway via transfer sheet and placed onto the EMS str into semi Fowlers position by EMS crew, Pt reports “feeling like I’m going to faint” upon being picked up, Pt properly secured onto EMS str w/o incident @ 09:55

3) Loaded and properly secured in EMS unit for transport w/o incident, Placed on monitor for continuous SPO2 monitoring and cardiac monitoring in lead II with q 5 min v/s reassessments and XII lead acquisition and transmission to General Hospital ER w/o incident, sinus tachycardia with frequent unifocal PVC’s w/o overt ST changes or indications of BBB noted @ 10:00

4) 20 ga IV placed to L AC times one attempt using aseptic technique w/o incident along with BGL check (123 mg/dl), fluids up at 1,000 ml 0.9% NS at wide open rate for volume expansion @ 10:02

5) Radio report called to General Hospital ER w/o incident @ 10:05

6) Discussed possibility of Zofran administration for c/o nausea with EMS preceptor; however, she/he does not want to administer it at this time d/t "short ETA to the hospital", Repeat VS reassessment @ 10:10: B/P- 72/40, RR-22-24 and non-laboured, SPO2-96% 2 L NC, P-112 irregular, lung sounds remain clear after 500 ml of fluids have been administered, 1,000 ml challenge continued

T: Pt transported to General Hospital ER w/o incident or change in assessment or condition, bedside report and turnover to Dr Smith w/o incident @ 10:15

DDx:

1) Hypotension with possible tissue hypoperfusion

a) Possible infectious pathology (Consider urinary and respiratory sources as high priority systems to assess)

Possible toxicological etiology (Consider opiate toxicity with possible poly-pharmacy as a primary candidate)

2) Cannot rule out neurological event (TIA vs Stroke with possible increased ICP or intracranial mass effect)

3) Possible fluid volume deficit

4) Hypoxaemia with possible tissue hypoxia

5) Hypoglycaemia R/O with point of care BGL testing

Please note this may be based on a patient encounter but it is not an actual chart and presented here as a training tool.

you put that all in the narritive section? Our reports look something like this http://www.docstoc.com/docs/41480699/GENERIC-RUN-REPORT-Prehospital-Patient-Care-Chart-GENERIC-RUN-REPORT-Prehospital i dont have an actual blank one from my squad to scan in at the moment. However, this system looks pretty good

Please tell us you're joking.

yes.

I'm going to go out on a limb here and take a wild ass guess that you are in NJ.

Home of the first aid squad nation and whacker central.

Crappy protocols , petty squabbling and million $$ squad buildings with bars in the back room.

The last time I had to go to NJ to pick up our new ambulance at the PL custom Factory , we stayed at a Hilton inn not too far away. while we were sitting there having our morning coffee & breakfast there was a parade of vehicle that came screaming by with more lights than our new ambulance.

The best one of them was a rusty clapped out toyota supra with four different color doors and fender panels from the junk yard on it from the 80's that had a light bar on the roof, headlight flashers, tail and turn signal strobes and a rear window set of LED's.

The value of the car was way less than the cost of all the whacker lights bolted onto it.

Our salesman explained that it belonged to an asst chief of the local first aid squad and he was a proud EMT-B with the local service well known for trying to have the most lights in town.

Pretty crappy care doesn't matter if you have lots of lights on your junker.

being from NJ doesn't mean we deliver crappy care. Ill have you know this past year we had 10 CPR calls, and 10 CPR saves. Plus, we have the longest EMT training in the country that I know of. True, a lot of people around here don't give a hoot about care, but you don't know what I can do. To let you know, all the doctors in my area hospitals know me and have personally told me that they are relieved to see when im on the crew bringing a patient in, because they know that Im good at what I do. This opinion by the doctors extends to the majority of members on my squad. Im on one of the best rescue/EMS squads in the state, we win awards for our skills. Pretty crappy eh?