DwayneEMTP

When I went to paramedic school, AAS Paramedic medicine, I had a 50hr per week committment to work. Of course, I'm married to an angel, so that helps, but still. About an hour, hour fifteen depending on traffic to school, one hour, or two depending on where I did clinicals.

If you choose to go to any decent program it's going to kick your ass, simple as that. There was a time that I worked 50hrs per week, did 48hrs of clinicals at night, 25hrs of week of school per week, and still studied several hours per day. Every...single...day. I don't really remember much about those times...but it is doable, but I'll tell you this right now...in no universe would I ever consider doing it again. There were times, and I swear that this is true, that it made me feel physically ill to open any of my text books.

Oh, hell. The reason for this post. I almost didn't get to start medic school the year I did as the out of state fees were prohibitive. (We'd just moved to the state for personal reasons). But the program director called a few days after the program started and offered me money that was earmarked for the fire depts. I guess most schools have tons of money for the hosemonkeys, and most often all or part of it goes unused. So if your progam guy is offering you free paramedic school, it could be that something like that is in play.

Yeah, MikeEMT makes the most valid point. You truly can not be dumb enough to fail it three times if you've made any effort to learn the material.

That is not a sneaky way to call you stupid, but instead to validate Mike's point. If you've failed it three times, and have made an effort to learn the material, something else is happening and you need to figure out what it is. Taking the test again without doing so is kind of like hoping that your patients B/P will stop falling while you sit without intervening in his arterial bleed.

I'm mean, c'mon Brother, look around you at some of the people that have passed it...are you intimidated by their knowledge? Probably not, with many of them. It's vital that you don't tell yourself, "I can't believe that I'm so stupid!!" We believe it when we talk to ourselves like that.

Time to let the brains here pick away at your test prep, anxiety levels, test taking skills and see if they can find the gremlin...

Low though it might be, wanna share what would suspect to be above it? :-)

Or is hypothermia your entire working diagnosis at this point?

Mike, you've worked in systems that allow lavage for an overdose yet still push charcoal with a long down time?

Triemal, why RSI?

What was her resperation rate, did I miss that?

In answer to your question I would try and orally intubate her first, and then, nasally afterwards.

Does anyone else think that putting her on her side would have been the FIRST intervention?

Would Epi be a superior infusion in this patient when compared to Dopamine?

What is the temp of the home? Is she truly hypothermic or just feel clammy because of retarded skin perfusion?

I don't have the bandwidth to search now, but the deviated pupils, it seems like I might remember that that implies a possible CVA, and/or traumatic brain injury. (Same thing? My meaning is injury initiated inside vs one that's initiated from the outside, but I'm not sure that I've used the proper terminology.)

I had a patient a lot like this once. My first nasal intubation. Bottles of mom's drugs all over, antidepressants, b/p meds, Valium, Percocet, Vodka and Tequila, all empty. I had no idea what to do, so I intubated him and drove him the few mins to the ER. Turned out he was unresponsive secondary to a CVA and had no dangerous levels of drugs in his system. (Theorized that he flushed mom's meds, threw the bottles around to freak everyone out, got shitfaced drunk and had a stroke.) It was also interesting on this call that I didn't push Narcan, only because I didn't really know what to do with the soup of drugs and didn't want to add another one to the mix, but the ER doc told me that he sees, on some occasions, Narcan work on patients with only alcohol onboard.

Ok, that's all of my nonsense for now...

Edit: Holy shit. As soon as I hit submit I thought..."Wait, unresponsive, deviated pupils, bradychardia,...This is a herniation, right???" (The hypothermia even makes sense to me, though I'm not sure if it should, if the brain stem is being compressed.) What is the triad?? Ok, now I really wish that I could Google it, not only so that I could see whether or not I'm being a complete moron, but also so that I could pretend that I know off of the top of my head what the hell I'm supposed to do about it....

In that spirit, this would be my treatment, right, wrong, or indiffernet....I'm going with massive brain injury. The pacing seemed to have taken, so I'm going to leave it in place, but assuming that I can maintain capture I'm going to bump it up to 80bpm, going to try and bring the B/P up as high as I can (Though, I can't remember if this is contraindicated due to increased cerebral swelling) to try and get my brain perfusion back, bag without hyperventilation and go emergent to the hospital and hope that the ER doc doesn't tear me an asshole that you fly Haley's comet through....

My logic...If it's a herniation then we've almost certainly already lost this battle. But if we're going to win then I have to try and force some blood through the pressure that's high enough to force the giant brain out through the tiny little skull butthole. (Foramun magnum? God...I've been in the jungle to long)

I'm going to up my heart rate on the misguided assumption that though my pressure is way too low to push blood into this brain, if it is pushing any, maybe I can circulate this 'little bit' more often. (Probably I'm only increasing the rate of herniation, but, this is what I'm going to do still.) If this battle isn't already lost, though I can't really see how it isn't, then tossing a Hail Mary to try and save any bits of brain that I can seems like my only decent option. And I can't imagine that either intervention won't be good for the other organs as well...should she now be a donor.

No hyperventilation secondary to the rebound vasoconstriction arguments. And I'm happy with her SPO2 in the low - mid 90s. I don't know about steroids, but I'm not going to push them in this patient without medical control (and I'm assuing that as in most scenrious, at least my favorites, that MC isn't available) as it seems that I remember reading about this being contraindicated...but that's maybe just in spinal injuries..and maybe not even that...but I don't want to push something bad that I can't take back as long as I have that "bad tickle" about it..

Man, I've not participated in a scenario in a long while....Let the beatings begin... :-)

Thanks all.... Good points Mike...

MG, it's not my way to play on my gigs, though I know, or guess anyway, that you were teasing. Even though, believe it or not, since leaving for my first remote gig Babs said, "I know that men are men, and you may find that there are things that you need to do while being away for such long stretches. If you need to, that's ok...just be careful and don't ever tell me, ok?" Awesome, right??

Unfortunately, though there have been many times that I really, really, 'wanted' to do something to fill some lonely nights, and no remote medic, even those that look like me, are ever shy of invitations, I've never 'needed' too...and my bullshit conscience won't allow me to blur the lines of such a generous permission. So, nothing to hide so far.

Plus, man, one of the ways to get killed here, without police involvement, is to steal/kill a man's pig(s), kill a man's wontak (one talk, tribesman/woman, someone that speaks the same local dialect)or to make inappropriate comments advancements to a married woman. So having sex with a local woman, and many are highly motivated to misrepresent their relationship status to force 'compensation'...Yeah, man...not happening to this horny ol' white boy.

Thanks all for your help on this. I'd had kind of a general feeling for the facts, but I like that so many smart people chimed in. So many in high risk behaviors (We know a "swinger" couple that say the same) say, "Oh yeah, we get tested all the time..", people that should know better, that I thought that maybe it was me that misunderstood the risks.

Hey all,

In my current gig there is a ton of high risk behavior where HIV exposure is concenrned. I was recently talking to an expat that participates regularly in such behavor. (unprotected sex with locals, sometimes multiple partners in a night.) When I asked him if he wasn't worried about the exposure he said, "Nah, I get tested all the time" I've no idea how often that is, but I'm guessing yearly. I'm not sure how regular testing makes you more responsible, but whatever.

That got me to wondering, how long between exposure and contraction of HIV to the time of a positive test? (I know it can vary, but a general rule?) And how long from contraction to the ability to infect others?

I'd thought that the internet would be loaded with this exact information, but after a few hours of searching I can't find this directly addressed anywhere.

Thanks for any information that you can provide. Also, please don't post links to long articles or vids as answers. Though I'm grateful for the time spent locating them, I can't view them here with my limited internet.

It appears that the OP is no longer participating...

I am pretty damned pretty, now that you mention it...

Man, I just can't say...I don't have any idea...

I'd probably just try and be as a greeable as possible, which we all know, probably means I'm going to get shot in the face...

It still kind of confuses me when I see some of the biggest supporters of this site saying what equates to, "Please don't support this site by coming here looking for answers. Please go, and tell all of your friends, not to bother us with common shit..."

What is up with that?

I remember having some of the exact same questions, and having them answered here. Had I known that there was a state EMS office, and had I known that that office was the right place to go for the questions that I had, then I'd probably have done so. But I didn't...so I came to the place that made the most sense to me...here.

Where is the joy in making sure that a new poster knows that they've been stupid by coming here before giving them the information that they've come for...proving that they weren't, in fact, stupid for doing so?? "Why the hell would you come here looking for that kind of information? Oh, by the way, here's that information.." What??

Doc - have you truly studied the bible in light of your own theological understanding? Have you compared beliefs? Have you read the Christian apologists? I respectfully submit that your study is incomplete and suggest that you don't know what you are talking about...

It's a difficult study to keep an open mind and read the true evidence.. It also requires a spiritual willingness to understand. I don't pretend to know everything.. and I am a far from perfect teacher. Perhaps you should seek out people who truly do know what they are talking about.

Christ said "seek and ye shall find" . In the infamous line of the "X files" the truth is out there. It's frustrating and sometimes difficult, but so worth the effort.

Unfortunately Girl, your statement makes Mike's point as it's no different from the many, many Christians that we've all encountered, "I know the truth because I've studied and considered harder than you have. If you don't also see my truth then you have no idea what you're talking about." I'm sorry to see you present your point in such a way.

I am of the opinion, not directed at any post(er) in this thread, that an intelligent person that will disallow urban legend and superstition can't read the bible with a scientific mind and not have to bend way too many things to make them fit.

I'm kind of on board with Penn Jillette, "The easiest way to make an Athiest is to have them read the bible."

I wanted to be a Christian in the worst way. Everyone I know is Christian, including having several preachers in my family. I really wanted to be part of that club. But I found no possible way for me to get there through the bible. And continuing my education made that even less possible. I too often feel that there is "something else" but can't really identify it. But for me there has become no question that it's not possible for it to be Christianity if the Bible is our only source of information for defining that.

How to verify my 'something else?' I can't within a scientific context, but I've kind of lost the need to do so as my something seems more in line with the Buddhist phylosophy...it mostly focuses on myself, without a need to convert anyone, or judge anyone. As it harms no one I find no need to nail down the exact justifications for doing so. It seems like if I stay in a place of "good energy" that my life works pretty well, 'bad energy', less well, though of course there are a million more ways to explain why my life might work better while making decisions based on a positive attitude rather than a negative one. I've just sort of run out of steam at the half century mark for spending the rest of my life studying psychology and philosophy... :-)

Man, what a great question and an amazing group of people to discuss it!

Short anwer. I had doubts regarding my Christian upbringing prior to college level education, but found it impossible to continue within that belief system after being exposed to science based principles.

I'm sorry...there is no place in EMS for Lefties....

:-)

As said before, by Kate and Mike I think, it's too hard to say. Asking what to do with this guy is kind of like saying, "What would you do with a drunk patient?"

How drunk is he?

Only drunk?

Is he an angry drunk?

Weepy drunk?

Drunk enough to get in his own way?

Etc, etc...

(Not saying that it's a stupid question, just that there are a ton of variables to be considered.)

But I do agree that it sounds like this guy doesn't want to hurt anyone. He could have done that when you came in the door. He has other wants/needs and no other way that he can see to get people to listen to him. Or he's living out some sort of psychotic fantasy..or...

We had a woman once pull out a knife thinking that intimidating us was the best way to get us to work harder on her arrested father. Before she finished her threat I rammed into her with the jump bag between she and I...smashed her hard enough to push her through the drywall into the wall insulation, she went out cold and the police took care of her from there.

I think that that was the right approach in that case. She probably just wanted to be dramatic and wave her knife...But, I wasn't in the mood, nor had the time to entertain her..And in that situation I had the upper hand as on TV everyone always runs from the crazy woman with the knife..she didn't really have a place in her had for an alternative. But, a knife certainly isn't a gun...

Thanks Mobes...

Grrrr...can't see the vids...Can someone paraphrase?

Sorry to disappoint you mate but most had received at least 1mg of Remifentanil (syringe driver obviously still running), 1.5-2mg (per kg) of Propfol, and about .5 (per kg) of Rocuronium (and a lot of oxygen ) ... You can consider them apnoeic. No visual guidance. As I said, I was shocked. It works though. I usually visualized the vocal cords while intubating nasally, simply to get the hang of that. I very rarely had to touch the Magill foreceps, normally the tube slips in easily. I still remember my very first attempt, got the tube in but broke the cuff. That never happened again.

What is the relaxed state of the apiglottus? Isn't it closed? And if the resting state is closed, can someone explain to me how we're getting all of these blind tubes down all of these apneic patients through a closed epiglottus (epiglotti (?))without doing any type of damage to the airway?

Anyone ever notice that we never get that many "hellos" when a new member named, say, Bob, joins? Curious...

Welcome Ash...jump in, you'll have a blast...

I'm not trying to bust your chops, as this sounds like an amazing trip, but how do you plan to manage worst case scenario without IV fluids and/or significant pain management at the EMT-B level with a minimum evac time of 6 hrs?

I did my clinicals with AMR years back in Colorado Springs and found everything about the way that they ran their business to be inspiring. Smart medics, liberal guidelines, hardcare continuing education, really good managerial support for the street level providers. There were some yahoos that worked there, like anywhere, but in general it was an amazing experience and if I didn't work remote would be proud to work for them in a second.

I'm constantly confused by those that say, "They're all about profit!" How long do you believe that they would be in business if prifit was important to them? At what point did becoming a mega successful business, creating a gazillion jobs, in and of itself make a company evil?

In the Springs you need to put up or shut up. If you're a whacker medic that will come to light and you get booted. If you're a good medic/Basic, and/or want to be a good medic/Basic, then that is a good place to be.

While certainly not best, 'blind' nasal intubation still remains common practice. I've done one of my clinical rotations in the anaesthesia department of a maxillo-facial surgery unit where most ETIs were done nasally. I was shocked (on my first day) to see the senior anaesthetist simply 'shove' the tube down the patients nose without even touching the laryngoscope (and stethoscope for that matter). Still, I haven't seen any of his intubation attempts fail... Some of the other consultants used the same technique. Trick is not to tilt the head backwards, basically get it into a Jackson kind of position.

Mind you, these guys had 10+ years of experience doing exactly that day in, day out. I'm fairly certain none would attempt it in a code situation.

Now the interesting question is, why was the jaw clenched??? Any kind of trismus would cease during arrest, possibly the clenched jaw was due to surgery or radiation therapy? To be honest, Spock is probably right.

Good points, but I am willing to bet that not a single one of these nasal intubations, unless assisted visually in another way, was done on apneic patients, right? There is good reason that we nasally intubate breathing patients only. I've done a half dozen nasal intubations now and it's not easy, it my experience and at my level of skill.

If you're looking for advice for you in particular, I can tell you that I talked at length with someone that rode with you, I won't say in what capacity, and they claimed that you're smart, kind, patient and inspiring as a provider....

Pissed me off...I want to be you! But I'm too fat...I just know it...

Kudos to you Brother, I hope that I could rate such a review someday...

So if you're going to force me into the right wing wacko category, make your argument Brother.

I'm not sure what crap you mean?

Make the argument that the guns being targeted are a logical agenda for this administration. There are massive amounts of data available. Why spend all of this time and effort on these guns instead of, say, beer, which kills, injures and victimizes hundreds of times more people every year. Why the guns? Why not beer? Or all alcohol? Or cigarettes? Or motorcycles?

It's way below you to start speaking of the "nonsense" of my argument and then make no attempt to defend it. If we're going to go all political, then surely you'll admit that if "hidden agendas" are the conservatives "nonsense" that making arguments based on emotion despite overwhelming evidence to the fallacy of their feel good ideas is certainly, as seen above, the liberals "nonsense" as well, right?

If you're referring to more than one the plural is physician assistants. A physician's assistant is a tech. Physician assistants are more than techs.

It's not semantics. I'm sure it's simply a misunderstanding.

I knew this was going to get you the grammar Nazi comment, but I actually thought it was really cool. It's been a while since I've read or written anything that'd (:-)) made me think in those terms. Thanks for taking the time to write it, in a productive and kind spirit. Pretty cool...

Busy, I would agree with you if the world had a more well defined definition of "paramedic."

Holding people accountable for their toothache means that everyone involved in the profession will be intelligent, professional and responsible enough to be sure that it is in fact just a toothache, and that the "ache" didn't in fact need professional attention.

This just isn't the case. Too many times people are being misdiagnosed and mistreated, yes, even in Australia. As long as that's the case then the 2am toothache needs to be transported if that's what they choose...right?

Asys, to me, the reason is simple. We can track those chemicals to illegal uses that are harming many, many people. Many of the illegal activities are creating dangerous environments for people, many of them children, that are not choosing to participate in the activity. That makes it bad, and in my opinion, actionable.

That's not the case with the guns that they want to ban. The list of weapons that are being attacked are simply not being used to harm many people. That is why I hate the ban. I don't love the weapons, but I hate the hidden govt agenda that is attacking them. I'm no conspiracy theorist, so have no real idea what their agenda is, only that saving people isn't it. If that was the case there are a ton of other, much more realistic and much more productive ways that they could be spending their time, right?

For me it's kind of like having weed illegal. We've got billions of dollars, maybe trillions, per year chasing and housing those that use and/or sell this nearly harmless herb. Every halfway informed and/or intelligent person knows that having it illegal in a world where alcohol is legal is ridiculous, and yet illegal it remains. I don't know why it's still illegal, but I'm completely confident that protecting people from marijuana isn't the reason. That the agenda is something completely different but 'protecting the innocent and weak' the excuse. I feel exactly the same way about the gun bans, as it has the same fishy, sneaky, illogical smell...(Though I'm not completely sure what illogic/sneaky smells like..)

A word of warning about the EMTB Registry testing. It's really, really important that you believe me when I say that everything on your test is going to go back to the A, B, Cs and scene safety/BSI.

The questions are worded in a way that makes it really easy to try and create a complicated question where there isn't one. On every question ask, "is the scene safe? Are they breathing? Is their heart beating? Do I need to do anything about any of those situations? Am I wearing gloves?" I promise you that you will rarely, and likely never, get past asking/answering those questions before your computer based testing is completed.

I choose to recert each time by retaking the NR test and each time I've come away (except for the first time) angry at the childish simplicity of the questions. It is almost unbearably attractive to try and make them into questions that would really separate those that have worked hard to become part of EMS from those that haven't, but that just simply isn't the case.

Read every single question as being as simple and straight forward as you can. Assume that every question is meant to test students that are, say, two weeks into class, and you will do fine....Trust me on this.