Punisher

As someone who has served as both a fire captain and as an EMS command officer, I agree with this. Personally some of the toughest and complicated decisions I have ever made are those as incident command on fire calls. The issue between the "two" groups- fire and EMS- boils down to an across the board failure to check egos at the door when it comes to working with one another. Neither group is more important than the other and we have far more in common than we often are willing to believe.

Care to back that assertion up with some scientific data?

In a tachycardic patient? Why? :shock: Obviously excessive vagal tone isn't the issue here, now if the patient were bradycardic, then yes by all means give atropine. But yes, as one of our medical director is fond of saying: PEA = "Push epi, a--hole."

Probably because hypovolemia is the most common cause of narrow complex tachycardia in an arrested patient. Most adult patients with cardiac disease severe enough to cause them to lose pulses are not going to present in an organized narrow complex rhythm. In fact, if I were presented with such a patient, my goals would be to rule out non-cardiac causes (hypovolemia, tension PTX, pericardial tamponade, vasodilation, etc) before I ever thought about treating the tachycardia with drugs or electricity. VERY rarely are you going to see a primary cardiac event present with SVT and arrest. In my experience (and I loathe relying upon anecdotal evidence but I don't have any hard data on this at hand at the moment), I've seen it one time. That patient spontaneously converted out of SVT during a pulse check about 40 seconds into CPR. If the patient had not been on a monitor at the time I would not have believed that he was actually in SVT- he went asystolic for about 10 seconds then dropped back into a sinus rhythm.

Only if there was some manner of abberant intraventricular conduction (left bundle branch block, etc) going on. I've only seen that twice in 10 years, once being in an emergency department, the other in a cath lab. I have seen multiple cases of SVT with rates well over 180 bpm (3 beats per second or roughly 3-4 beats per inch of EKG paper assuming a standard printing speed) and none of them were readily confused with VT when given more than a passing glance. That is why you NEVER, ever, under any circumstances treat a tachycardia of unknown origin from what is on the monitor....you always assess it from a strip. This can also be applied to any organized rhythm actually, but is most applicable when you're trying to differentiate between atrial flutter with 2:1 or 3:1 conduction and an AVNRT (AV nodal reentrant tachycardia- which is the more appropriate term for the dysrhythmia that most EMS personnel term SVT. SVT is correctly applied to any abnormally fast rhythm originating above the ventricles- including AVNRT, atrial fib w/ rapid ventricular response, atrial flutter with RVR, sinus tach, and some people lump in junctional tachycardias as well).

I look forward to seeing your protocols. I wasn't tearing you a new "anal cavity", just giving you a hard time. Trust me, I'm trying to be a kinder, gentler person. If there is anyone I was exceedingly brutal with over something on here during my previous tenure, I do apologize. There was a lot going on in my life that affected my attitude. Those issues have been taken care of now and I'm not going to tear into anyone unnecessarily. BTW, ego and confidence are basically the same thing, just the former is an extreme (and often misguided) expression of the latter.

No offense, but this doesn't seem to make a lot of sense.....at least in the case of overt hypovolemia. If they are in a physiologically appropriate rhythm (extreme sinus tach) as a compensatory mechanism, two things- one you are unlikely to "convert" them into a slower rhythm....except perhaps an IVR or asystole because of interrupting whatever low level of perfusion maybe occuring during the EMD. And yes, there is often some level of cardiac contraction involved with this- next time you are in the ED and they are coding someone in EMD, watch and you probably see them put up the ultrasound probe on the patient's chest to check for cardiac contractility. Personally, this would be one of those cases where fluid boluses would seem indicated along with aggressive but appropriate vasopressor therapy, at least more so than electrical intervention. But as someone said, local interventions may vary. I'm going to post this to another forum I belong to and see what the EM docs suggest. The other point I have is the suggestion of giving calcium channel blocking agents or beta blockers to arrest patients- are you three stops from West Ham? That might (MIGHT) slow the rate down, but once again- the underlying problem in many cases will still be present, and also is going to complicate maintaining cardiac output and tissue perfusion by reducing vascular resistance. IF the patient survives and obtains ROSC, it would be a further complication probably requiring higher doses of pressor agents to maintain a functional BP.

That's fair enough. I don't really like you much either, but only because I think you let your ego get in the way of your progression as a provider. Check it at the door and you have a lot of potential and will earn far more respect from those with more experience than yourself, myself included. That's my opinion, you can take it or leave it, but I don't imagine I am the only one who feels this way. By the way, I'm glad you respect me...honestly it means a lot to know I'm respected by my peers.

Holy crap, I guess the "report" button actually works! Really it should be relabeled as the "Adjust Attitude" button.... Alternatively, the "Instill respect for those with more experience and education" button. I don't know about having a metal plate in their heads but I know more than a few EMS providers (including a few of members of various online forums- a couple here at EMTCity, more than a few at EMTLife, and a few at the prehospital section of SDN, etc) that remind me of Eddie.

Does that mean we can use the magnet on other EMS personnel?

Yet another obviously well thought out recommendation from our staff cardiologist :roll: As someone else said, unless you have ALS capability- EKG, pacing, cardioversion- do NOT use a magnet. Even if it doesn't kill the patient (assuming you were stupid enough to override the AICD without checking the rhythm first- which is something I wouldn't put past certain individuals on this site who shall remain nameless), trust me they will not be happy with you if you swap out a 10-20 joule internal shock for a 100-200 joule external cardioversion.

Agreed. So you're a member over at SDN too? PM me....I'd like to know who I'm talking to

http://forums.studentdoctor.net/showthread...081#post3737081 It started out being about how docs in the field is a bad idea and it's rapidly turned into a pissing for distance contest between the better educated medics and docs and the lower end of the EMS food chain who can't seem to get past the fact that skills are not what matters. BTW, my screenname over there is DropkickMurphy.

Part of my current job is occasionally picking up bodies for the coroner's office.....because people around here seem to think it's the way to go, we deal a lot with pedestrian vs. freight train cases (even more than I ever realized in several years of full time EMS). Two of these cases have been interesting.....one being hearing a cop holler "SOMEONE STOP THAT CAT!" Everyone turns, looks at him..... "He's got one of the eyes!" The other one was the most recent one I worked and the guy did it out in the countryside....higher speeds....i.e. more pieces to pick up. Well we had this young volunteer firefighter who was out there to "assist" (later found out, that he jumped the call without being dispatched) and had brought his girlfriend along (clad in a VFD shirt so no one would "suspect" anything :roll: ) Basically Randy Rescue wanted to show off.....well he was pale and sweating profusely as we walked the tracks gathering up parts of the victim. I got tired of his "help" and decide to make him look like an ass in front of his girlfriend, so I look at Mike (the guy I was working with) and smile. We keep walking.....and I come across a spleen. So I turn and very loudly proclaim: "Looks like I win! Here's his spleen! You're buying dinner!" Needless to say I bet his girlfriend took a different opinion of his macho BS about being a tough firefighter after seeing him faint and puke because of someone holding up a spleen. :wink:

ONLY in Indiana: "Engine 12, Rescue 12, EMS 12-Charlie, Squad 11, respond for a 10-50 major with entrapment. Car versus COMBINE :shock: Caller advises he believes the combine won." :shock:

As an RT, I must point out that SaO2 and SpO2 are not interchangable and you can have a great sat and a crappy PaO2. For example if you have a severely anemic patient you can have a 99% sat and the patient may only have a PaO2 of 70mmHg. So while PaO2 and SaO2 are related, and you get both values from a blood gas, they are not the same, and SpO2 is only an estimation. I've never seen anyone mistake a SpO2 for a PaO2....just so you know especially since they have totally different units (one being a percentage and the other being measured in mmHg or kPa depending on where you are (US vs. Europe and Canada I believe))

Our department is rural, so most of our responses are without lights and sirens (although the airhorn will get deer out of the way ), we have uniforms but we only wear them for parades, funerals and conventions, and I am a health care professional first and foremost, so I will always be in EMS until the day I am forced out by failing health.

This is the new T-shirt design for a fundraiser we are considering.....What do you all think?

I dealt with the SIDS death of the son of one of my high school classmates. Count yourself lucky that you have not had to do the same.

And by the way, it's nitrogen narcosis, not necrosis. :wink:

I would highly recommend getting in touch with the Divers Alert Network (DAN), which is run as an affiliate of the Duke University School of Medicine's Anesthesiology Department. They are the go-to guys (and gals) on anything dive medicine related. http://www.diversalertnetwork.org/ But Rid is essentially correct, the theory behind the left lateral recumbent positioning is to place the right atrium uppermost in relation to the other chambers to allow the air bubbles to pool there. I believe there have been ultrasound studies done to test this theory, but I do not have copies nor citations for them, but I would imagine that the researchers associated with DAN would either be able to direct you to them, or provide them for you.

Our department is it in our area- fire, rescue, EMS, water rescue, etc. Thanks for the comments guys.

Poetry. Bad Poetry. Enjoy. Time and again, without regard except for the pain his first thought might be his last the kid he was is the past into the line of the fire he runs, a job without end never seeing the danger, only hearing the screams of his friends time and again Time and again, Without his touch, without his aid this might be their last day he is the “Doc”, he is the first to volunteer the last to tire never to flag or to fail, without question, without ire only to come up short against that which assails time and again Time and again, he tries to drag them back from the brink sometimes against their will regardless of the trauma without thought of the ill he does his best time and again Time and again, he goes without thanks, his sleep is just a tormented time he tried to kill the dreams with a drink like a stone dropping in a hole he feels his heart sink a black pit where once resided his innocence now there is a pain which is a sardonic recompense Time and again, her touch is all that will sooth a tortured soul she doesn’t belittle his screams in the night, she doesn’t question his love for her or his dedication to his fellow man he’s proven both time and again “Time and Again” (by me)

Granted, I'm an EMT-I so I can't give medications to sedate or otherwise calm a panicking person, but even if I could I would be hesitant to do so unless I felt that the patient's life was endangered by their combativeness (example: their airway is impaired, but they are too responsive to intubate, etc) because to give such medications would further complicate the assessment both in the field and in the hospital. In hospital, I am certain that the assessment would involve a head CT ("cat" scan; to rule out damage to his brain or bleeding within the skull) and either a CT of his abdomen or an ultrasound exam of his belly or both (to rule out intra-abdominal injuries).

I hate to be blunt but chances are that if he resisted needed care, he would be treated in a manner similar to how we handle combative head injury patients- restraint to allow a proper level of care to be delivered. Granted that's always a last resort in my book, but that tends to be necessary (unfortunately) with a lot of autistic kids (including two autistic children I took care of following a bus crash; one of whom became openly violent towards anyone who got close). The very situation you described is one of my worst nightmares as an EMT because of the sheer unpredictability involved.