kristo

Well, of course AEDs at every house would increase survival. Early defibrillation is proven to increase survival, so better accessibility obviously would. Another thing we could do would be to implant defibrillators into everyone. That would probably decrease mortality from AMIs significantly. So, who's going to pay? A sidenote: My dad actually has one of those implanted defibrillators. Amazing thing. He goes to his cardiologist every three months for a checkup. The cardiologist checks his bloodwork and actually downloads data from the device, looking over the last 3 months of cardiac activity. Really cool.

A short explanation: The vertebral artery is a branch of the subclavian, which ascends through the transverse foramina from C6 (if I remember correctly) to C2. It then goes posteriorly, then pierces the posterior atlantooccipital membrane and enters the skull through the foramen magnum. This placement obviously makes it pretty vulnerable in neck injuries. Now, inside the skull, the vertebral arteries on each side join to form the basilar artery. The basilar artery then branches into the bilateral posterior cerebral arteries (PICA). Those arteries, ie. the vertebral, basilar, and PICA, provide blood supply for the brainstem (medulla oblongata, pons, and mesencephalon (midbrain)) and the cerebellum. Now, we actually can live without the cerebellum (although we would not have well coordinated motor function), but in the brainstem are the nuclei of the cranial nerves, which appear as columns that run caudorostrally through the brainstem. In this case, the tear in the vertebral artery will have caused ischaemia in the medulla oblongata, where, among others, the dorsal motor nucleus of the vagus nerve resides. That nucleus handles regulation of respiratory and cardiac function. The basilar artery gives pontine brances, which supply the pons, where more cranial nerve nuclei reside. In short, this is bad, mmkay... To the best of my knowledge, the circle of Willis, which is a large anastomosis of arteries from the internal carotid and basilar arteries, can compensate for some lack of perfusion from either end, but definately not a lot.

This is the same way on my end of the ocean. Medical students, regardless of which year, and even newly graduated doctors look at it this way. They like their ambulance drivers, they respect them in a way, but not as medical providers. More like quick drivers who can stay calm themselves, calm other people down, get safely up on a glacier and back down (certain areas). The medical expertise on ambulances in serious calls, however, should be in the hands of the doctor. I remember a conversation I had with a friend of mine, who's had his MD for a year now. He'd been working as a doctor during the summer for two years (i.e. after 4th and 5th years, and some weekends during 6th year), and the topic of EMTs (meaning any certification level of ambulance driver) came up. I said something to the effect that EMTs should have the capability to interpret answers to the typical questions, like which meds the patient is on, pertinent medical history, etc. He was a bit surprised and said...it's not the EMT's job to ask questions like that, it's the job of the doctor... That about sums it up. EMS is such an underrepresented profession, even many people who work with them have no idea what they do. A major part of the problem is the large portion of the EMS profession who don't know what they (should) do. Happy being (not so) glorified taxi drivers. Another interesting trivia - in some rural areas of Iceland, the hospital janitors double as ambulance drivers. I actually happened to see an advertisement for such a position just under a year ago. :roll: Of course, in rural areas, a lot of the time, a doctor rides with the ambulance, so it's not as bad as it sounds.

Might I suggest a beginner's physiology book to cover at least the first two terms? Also, there was a thread a while back about alpha and beta receptors which spun off a nice conversation on cell receptors, their importance in physiology, and their agonists/antagonists. Edit: Probably spoiling you rotten here, but I went and dug up the thread I mentioned above: http://www.emtcity.com/phpBB2/viewtopic.php?t=10546

NREMT-B is, or at least used to be, a very weird test. I took it in 2004. I took the Washington state exam 2 days prior and I remember having to memorize different things for the two different tests, i.e. if I would get the very same question, I would have to answer differently depending on which test I was taking. In my experience, passing the written NREMT-B is more about learning how to answer the NREMT-B written rather than actually studying the material. Use the question banks, there are plenty out there. Just remember that your grade is almost completely random. I was in the high 90s in my EMT-B grade, took the NREMT, almost failed (got 77% - needed 75% to pass). My OB/Gyn part actually went better than cardio. :roll: After EMT-B, I finished college in nightschool and then went to medical school. I will finish my second year this spring and I am actually doing very well. I'm not saying this to brag, but to assure you that how you do on that test doesn't say anything about how good a student you are. It's just about saying what the NREMT wants to hear.

I have two "lines". For the people who do the "I've been having those occasional digestion problems, blah, blah, blah, I went to this gastroenterologist, he doesn't seem to be sure what it is and wants to do blah blah blah. What do you think it is?", I explain that I am currently working very hard to get to the clinical years of my studies, and my goal over the next few years is to get where I will be advanced enough for that gastroenterologist to teach me how to diagnose and treat GI stuff. If he can't figure out what it is, chances are I can't either. For most people who ask me medical questions, I tell them it's probably AIDS, and that an amputation will most probably be necessary. Then I tell them to go see their doctor.

What I meant was a staffed kitchen that cooks and delivers meals to the units at a set time. The system I suggested, ie. have the employees pay for the food and the agency for the kitchen would simply take whatever the cooking division pays for the ingredients for the meals and divide the cost between those employees who use this service. The agency would pay other costs of running the kitchen, ie. equipment, staff salaries, etc.

Since we're talking logistics. If this is going to be a medium to large sized agency, it should have a kitchen with some chefs and deliver food packs to the stations or units. No junk food. Wholesome, hot, real, cooked meals. I'd prefer it if the agency simply provided the food, but some other arrangement could be made. For example, the staff could pay for the food, but the agency would pay for the kitchen, including staffing, delivery, etc. A large kitchen like this should be able to get food wholesale, so the cost of the materials (the part the employees pay) could be kept at a minimum. At least one hot meal per 12 hour shift and some sandwiches for snacks. Good, wholesome meals make better AND happier employees.

How about having mobile medical command? An ambulance staffed with 2 paramedics and one doctor. The doc provides online medical command, but has the option to come to the scene and even accompany the transporting ambulance. Maybe dispatch could even dispatch the doctor to calls fitting certain criteria. This would probably improve the quality of medical direction, as the doctor would be more in touch with medical care in the field. Also, the option to get a doctor on scene could improve patient care.

Well, I don't think a fine would be the right way to punish the government - those are our common funds. Individuals within the government could be punished, though. I agree with you, the example you provided should not call for punitive damages - my comment was just a general wondering on frivolous lawsuits. A lawyer friend of mine once explained to me why people get more money from lawsuits in America than Europe. The reason was that in America, damages included a fine, in a way, so the amount is decided not from the amount of damage (at least not directly), but from how much was needed to properly punish the offending party. So, if Bill Gates were to cause you harm, you would become a millionaire...if I would cause you the same harm, you could invite two more friends to your wedding. The problem with the victim getting all the damages, punitive and otherwise, is that it encourages frivolous lawsuits. We still need punitive damages, though, because otherwise the offenders probably wouldn't feel the need to avoid causing damage. This is something the whole world can agree on; we don't like lawyers.

Here's a thought. Maybe fewer people would engage in frivolous law suits in the US if the damages they got was just enough to cover the actual damage. I realize that sometimes a punishment is needed for the one who caused the damage, but we could easily do both. Give people proper damages for what happened - punish the company/city/whatever with a large fine. The fine would go to the government. If that man did what Dust implies, i.e. willingly created a situation where the FDNY could be sued for something whatever they would do - just for money, then that's fraud.

I agree, anatomy and physiology are separate things and, if covered in detail, should be taught as separate subjects. They do overlap, but not just with each other, but also biochemistry, cell biology, even pathology at times. I was, however, under the impression that this material was not covered in that much detail in college, so they combine the two. That's the way it's done in Icelandic colleges (LOL* 103 and 203). I guess it would make sense for colleges that focus on preparing students for further studies in health care to separate the two. * LOL (here) means "Líffæra- og lífeðlisfræði" (Anatomy and physiology), not "Lots of Laugh".

Most people's religious beliefs do not effect them as professionals. While we do have a freedom of religion, and you are entitled to think and act in this way (faith first), I believe that if that faith in any way stops you from doing the right thing, professionally (eg. blood transfusions) you are not fit to perform your duties in that job. The most professional thing to do would be to inform your boss of the fact and either request a position within the hospital/whatever where you will not be faced with this dilemma or to resign. That said, what I have observed in these matters is that health care providers try as much as possible to be considerate of their patient's religious opinions. Examples of this include female doctors for muslim females, adjusting to various rituals at the end of life, and avoiding blood transfusions if they can. If a procedure that hurts somebody's religious feelings is unavoidable, an adult patient can refuse it. Children, however, cannot give informed consent, and parents are not allowed to abuse them by refusing necessary treatment. Staff can have whatever religious beliefs they want, but they are expected to perform their duties and uphold the same standard of care, regardless of religion.

My advice would be to finish the classes you enroll in and start a paramedic program in August, rather than May. While I agree with most here that you should further your EMS education as soon as possible, I also think that it is important to finish those courses beforehand. Your future will not be significantly altered by this 3 month delay. Believe me. Also, it sounds like you have a rather hectic schedule. From what I've heard, paramedic school won't improve your life in that aspect. If you finish your courses in June, you have two months until paramedic school where you have "only" work. Hang out with your friends. Read non-medical books. Take a trip to Iceland. In short: enjoy yourself, get some rest from school. On which courses to take, do as much as you can. All of the courses you listed will help you, both in paramedic school and in your life as a health care professional. Additionally, I'd recommend some physiology. Maybe that's included in your anatomy courses? There was a reference to a course called "Human Physiology 3"?

Today I finished the hardest test I've ever taken in my life: Anatomy final exam. Four painstaking hours of oral/practical testing in a dissecting lab. Just theoretical histology took a whole hour - after I had already identified the tissue samples I got and pointed all the relevant things out in the microscope...I really thought he was going to fail me a couple of times (examiners can and will simply ask students to leave if they make a serious mistake on the exam, i.e. immediately fail them). Embryology was great, gross anatomy also went really well. So, everything I've studied in gross anatomy, histology and embrylogy for the last whole year (2 semesters) put to the test. Every tissue sample, everything ever mentioned in lectures, seminars, or in any known books on the subject...everything is fair game. Around 80% fail their first chance. At least 60% will never pass. Actually, out of the 54 people scheduled to take the test yesterday and today, 39 postponed it to a later date. Recently, I haven't been sleeping (almost at all), zero appetite, for the last 1-2 days I occasionally wanted to throw up (never did, though)...and finally, it's over. Passed on my first try (even though I scheduled my test in the second week out of six), and with a grade high enough to be eligible for research at the department, if I choose to do so (which I won't, I want to go into clinical work, not research). Sorry if I sound a little too pleased with myself, but after all this hard work, I feel that I deserve it.

What I was taught was to listen in the middle of the brachial area. This was, of course, long before I knew there was something called the brachial artery, let alone that it crossed an area called the "cubital fossa" in a characteristic place. Now, off the top of my head, the difference between the palpated and auscultated systolic blood pressure might simply be due to different indicators being used. When you auscultate, you hear when the pressure in the artery is enough to push blood through during systole, but create a very turbulent flow, hitting the wall of the artery. When you stop hearing the sound, that means that even pressure during diastole is enough to push blood in the artery, and the flow is no longer turbulent. When you palpate, you are checking for the presence of a palpable pulsation. The appearance of turbulent flow just distal to the constriction (i.e. the BP cuff) and the appearance of a palpable pulsation of blood, say, in the radial artery, will probably not be at the same point.

Wow. I thought our government-run nursing homes were bad. If a resident would not have a bowel movement for some days, it would be noticed, as this is one of the things checked upon shift change (every 8 hours). All bowel movements are registered, along with some rudimentary info like if there is diarrhea and an estimate on the amount (I = little, II = normal, III = a lot). If, at the start of a morning shift, a resident has not had a bowel movement for an unusual period of time (for that resident), a time will be agreed, after which, without sufficient bowel movement, they get Microlax or Dulcolax. :roll: In case you're not familiar with Microlax or Dulcolax, they're drugs that are given rectally to induce bowel movement, Microlax contains Natrii citras and Natrii laurylsulfoacetas, Dulcolax contains Bisacodylum INN. I don't know what they are, physiologically. I think they must act as a local stimulator for the enteric nervous system to induce mass peristalsis in the rectum, as that is usually the result...

What you're basically asking is if dispatchers should be downgraded to switchboard operators? Never having been a dispatcher myself, I can't really say I speak from experience, but it seems to me that apart from the process of taking the call, extracting basic information from the caller, deciding an appropriate response and dispatching it, the dispatcher has a vital role in calming the (often very upset) caller down just using his/her voice over the phone, extracting more information, giving instructions (like chest compressions or whatever), etc. I think you may be overestimating the bullshit (for lack of a better term) filter dispatchers provide between the caller and the responder.

Ahh, true. The AED would have to be very close. Still means that the AEDs in the public swimming pools are a good idea... :wink: Interesting. Didn't know that. Thanks for the info.

I was under the impression that hypoxia led to ventricular fibrillation? Let's say an infant's problem is initially airway or breathing related, that's fixed by the responder, but the hypoxia has led to ventricular fibrillation...that being a shockable rhythm, one would assume that defibrillation was indicated. Maybe it's just that I shouldn't post before my morning coffee, but this sounds fairly logical to me...

I thought the very same when I first saw this thread. :-)

Well, the pressor center is also very active at the same time because of the brain ischemia, causing vasoconstriction, increased cardiac output, etc. The pressor and depressor centers are basically competing.

The short answer here is simply yes. For those who don't know, what we're basically talking about here is the so-called Cushing's reflex, which occurs when the intracranial pressure rises and compresses intracranial blood vessels (we're mostly talking veins here, arteries are more muscular and don't compress that easily). The body's natural response to this is to raise blood pressure to forcefully push the blood up to the brain (ischemia in the brain triggers the pressor center to stimulate the heart through the sympathetic nervous system). Now, the baroreceptor in the carotid sinus will detect this sudden raise in blood pressure and respond by lowering heart rate (parasympathetic reflex from the depressor center through the vagus nerve). What you will commonly see in those patients is extremely high blood pressure (220+ in systolic BP is common in those cases), but low heart rate (bradycardia). This is the commonly accepted model of how this works, and is known as the Cushing's reflex. Another model is what the OP described, physical intracranial pressure on the vagus nerve. If I remember correctly, this model is described as Cushing's response (as opposed to reflex, the word "reflex" indicating that it as a pressor/depressor center thing, where the "response" does not). I think most physiologists agree that what happens is a little of both.

A valuable resource that has proved very useful and even essential at times. Losing a good resource is never good. And I'm actually just another schoolboy, so they're not my patients, as such, but I still appreciate your trust.

Healthcare professionals should look and act professionally when around patients or even the general public. This inspires trust and enhances the comfort their presence offers to people who need it (i.e. the patients). That said, there's a time and a place for teaching professional appearance. We have lectures/seminars/labs to teach us theory and clinicals to teach us the practical stuff, which includes the proper look and behaviour around patients. This means that I dress comfortably in school, except in labs, where I have to wear a white coat, and during oral/practical exams, where I dress like an oncologist delivering bad news, i.e. black dress pants, white shirt, black tie. When the time comes for clinicals, I will do the whole "look professional" thing.