chbare

1EMP-P, I agree in a national board exam. Paramedic should be a 2 year program at a minimum and the Paramedic would be a licensed health care provider. Take care, chbare.

It will be interesting to see how the easy IO works out. The US Army went with the FAST and I have to say that I love it. (Easy access in seconds) I also agree that most people only report pain comparable to a peripheral IV, but the actual infusion of fluids into the bone cavity causes more pain than a peripheral infusion. I agree with the other posts that IO technology is the way to go. I have limited experience with the BIG and I believe the Army considered using this device, but went with the FAST because the sternum is much less likely to get injured in combat. (Body Armor) Take care everybody, chbare.

Battlemedic 345, check you email. Take care, chbare.

I support a nationally recognized exam that tests everybody at a certain level. Like Dustdevil, I see schools or even individuals crank out EMT's that have little to no clinical competency, and at least testing every student to a nationally set competency level could help improve quality. I think the national registry has a process in place for testing. (psychomotor and written) The registry has it's flaws, but the NREMT has more experience in testing the NSC, so I think the NREMT is probable the best vehicle for delivering a nationally recognized exam. (after changing the testing process) In addition, I agree with increasing the course length. I have and still advocate learning in a college environment where students must take English, A&P, and science courses in addition to their core emergency medicine courses. Teaching would be done by qualified teachers with an appropriate education background. I also advocate a well developed clinical experience. I see EMT's with as little as 16-24 hours of standing around watching people work in an ER providing front line patient care in an ambulance. I am going a little off topic here but, you are in the back of an ambulance treating a patient. You do not have a doctor with you telling you what needs to be done. You may or may not have medical control available to help you. There are many times where EMT's are independent providers, you are making decisions based on your training, experience, and background. That is allot of responsibility and 110 hours followed by a cheesy test just does not cut it. Take care everybody, chbare.

Unfortunately, we must accept that some people will think what they think regardless of public education, high standards of professionalism, and above par health care delivery. A little off topic, but a funny story in any event. I took care of a guy who limped into the ER holding his gut and screaming like somebody put a 12 ga slug through his abd. He had a barium study done several days prior to ER arrival and failed to follow his post procedure instructions. Can we say large solid mass in the colon. Unfortunately, you can guess how I ended up clearing his little problem. Once the problem was clear I ended up having barium stained stool all over the floor, bedside commode, and my entire arm. After helping the guy clean up, mopping the floor, and washing my self up, I gave the now very much relieved patient his discharge instructions. As the guy was leaving the ER he look right into my eyes and said, "Nurse, I want you to personally thank the Doctor for taking such good care of me and making me feel so much better." :shock: Take care everybody, chbare.

CD: celestial discharge. Take care, chbare.

Firemedic78, I think allot of the resistance regarding EMT-I's and advanced procedures is based on the observation that allot of EMT I programs just do not teach enough background and physiology regarding performing these procedures. I cannot speak for your training, but I know there are several state certified EMT-I programs that are about 100 hours in length and popping out people who are performing very advanced procedures. In New Mexico we have people with under 300 hours of training pushing EPI, Benadryl, Promethazine, Narcan, Dextrose, Monitoring potassium, and giving beta agonist nebs. Even the I-99 NSC only recommends 300-500 hours of training. I do not want to imply that any EMT-I is stupid or not capable of learning these procedures, It's just that from what I have seen and experienced EMT I programs are inadequate at teaching people to be competent ALS providers. I would also bet that many of the paramedics on this site believe that most of the current paramedic programs are inadequate as well. Again, I do not want to imply that anybody is inferior or unable to learn. Take care, chbare.

Mountain_Man, I am sorry to hear that. I think CHP medic has a good idea. I know that national parks hire nurses for seasonal work, and the same is probably true for EMT's. Yosemite sounds like a pretty busy place, or you could look in my home state for medical positions at Yellowstone. If you want to go full time law enforcement, you may want to check out Border Patrol. I know that they have BORSTAR teams that specialize in search and rescue. It would take a while to work you way into this position after the long hiring process, the academy, and the probationary period as an agent. Hope this helps. Take care, chbare.

Mountain_Man, have you considered the military? I have trained with several PJ's and search and rescue is their full time job. We have a National Guard medical aviation unit in my state that is very active in wilderness SAR and I imagine there are other similar units in States that have allot of wilderness and national forest land. Take care, chbare.

Medik8, that is an interesting article. Thanks for posting it. Spock, thank you for your post, and happy birthday. I agree that there are allot of intelligent posts on this site. I like the fact that there are so many experienced people on this site in addition to docs and advanced practitioners. Take care everybody, chbare.

N.S. ACP and Dustdevil, if you are still interested here are the fundamental differences in I/85 vs. I/99 course length and curriculum. The I/85 is based around a 110 hour course. The primary focus of the curriculum is patient assessment, IV therapy and shock management, and airway management. ACLS, pharmacology, and all of the "cool guy" stuff is not in the I/85 curriculum. I am talking about the NSC, not all of the supplemental material states add on. The I/99 is based around a 300-500 hour course. In addition to the 85 material, 99's get "cool guy" stuff taught to them. If you really want, you can download the entire I/99 curriculum from the DOT web site. ( www.nhtsa.gov) As much as I support paramedic level education, I believe the I/85 may have a role in prehospital care.(unconventional role) I think this course could work well as additional training to Army medics. I attended a I/85 course a few months back and the instructors went through allot work to put a military flavor into the course and emphasize hemorrhage control and actually Incorporated the Army's technology into the course so we could get hands on use of the products that are in currently being utilized. (FAST IO, King LT, CAT, etc) The course can be condensed into a few weeks and at least give medics a working review of critical life saving skills. Take care, chbare.

We have a rather flamboyant ER doc that uses some interesting terminology. Patient with multiple medical problems- "TBF": Total Body Failure. Ready for discharge- "LG": Long Gone. Discharge instructions for viral syndrome: "Go home and rest, lots of fluids, and grandma's chicken noodle soup." It's just a virus (cold/uri): "Billy Ray Virus." Take care, chbare.

HF-EMS, we live in a free country and frankly I do not care how many patches somebody wears. However, you may misrepresent yourself by wearing BDU's and tactical patches, and people who actually provide tactical medical care could take offense. I would personally refrain from wearing the uniform around. I would urge you to concentrate your energy on learning how to be the best EMT possible. Take a biology or anatomy course, this will help you out in the streets or in the ER much more than an EMT-Tactical card. You can focus on learning tactical medicine when you get on a team. Take care, chbare.

HF-EMS, DHS offers the CONTOMS course. It is 5 days long and you get about 60 hours of training. At the end of the course providing you pass the written you get EMT-Tactical credentials through DHS. They require affiliation with a tactical team and NREMT-B credentials prior to being accepted into the course. You will learn good information regarding mission planning, Intel gathering, and prepping the team commander with the medical threat assessment. CONTOMS is not SWAT 101, but you do get a very basic tactics overview and get exposed to riot control agents. CONTOMS is not combat trauma management or field surgery 101, and most of your treatment will consist of BLS interventions. If you are looking for a shooting oriented course, you may want to check out the Tactical Medicine course offered by Gunsite. As far as physical requirements and tactical training, you need to check with your team commander. Hope this helps, chbare.

Nate, here is a little information I was able to dig up. Author: S Najjar, O Devinsky, and AD Rosenberg During induction with propofol, spontaneous movements can occur without associated epileptiform abnormalities. These movements may include: dystonia chorea athetosis twitches opisthotonus Abnormal movements may mimic tonic and clonic movements during seizures, especially during the postoperative period.76 In several cases, cortical epilepsy was activated during electrocorticography, with epileptiform activity beginning 20–30 seconds after a bolus of intravenous propofol.77 Seizures may recur for 7 to 23 days after propofol anesthesia, suggesting a proconvulsant metabolite.78,79 Propofol also has anticonvulsant properties in animals80 and humans.81 Continuous propofol infusion can terminate status epilepticus refractory to other therapies.82 In epilepsy patients who underwent dental procedures, administration of propofol in subanesthetic doses to achieve conscious sedation did not provoke seizures or enhance any interictal epileptiform activity.45 One study showed that administration of calcium chloride minimizes the hemodynamic effects of propofol in patients who undergo coronary artery bypass grafting, and thereafter it may potentially reduce postoperative epileptic paroxysms in these patients.9 Recent studies indicate that the synergetic sedation with propofol and midazolam in intensive care patients after coronary artery bypass grafting reduces hemodynamic impairment, which is implicated in the pathogenesis of postoperative seizures.83 Adapted from: Najjar S, Devinsky O, Rosenberg AD, et al. Procedures in epilepsy patients. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;499–513. With permission from Elsevier (www.elsevier.com). Reviewed and revised April 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board. Let me know if this was helpful. Take care, chbare.

Sassafras, . Take care, chbare.

Matt202, if I am making entry, I know there are going to be people acutely deficient in lead. I make it a point to carry lots of 124 grain and 55 grain lead suppositories in my kit. Take care, chbare.

This is how I would restructure things in chbare's magical world of OZ. I would keep the 110 hour Basic EMT curriculum, this would become the first responder level of training. The first responder could not be in the back of an ambulance, with the exception of clinicals and 3rd riding. I would blend the EMT B and EMT I. The entry level EMS provider would simply be an EMT. The EMT skills would be similar to the EMT I/85. (national standard skills) The EMT education would be similar to LPN education. It would be one year long and include 1 year of A&P, 1 year of English, 1 semester of college level math, 1 semester of psychology, nutrition, molecular biology/micro biology and government. The EMT would be the entry level EMS provider The next level would be the Paramedic. At a minimum, the paramedic would attend another year of school beyond the EMT and complete a semester of pharmacology and chemistry. The paramedic would have an AAS at a minimum. The paramedic would also be a licensed provider. In addition, federal law would mandate that every ambulance would be staffed with 1 paramedic. This is just my opinion, so if you do not like it, disregard this entire post. Take care everybody, chbare.

Nate, are you able to talk about the situation or circumstances regarding the seizures? Take care, chbare.

Nate, I have never had a patient develop seizures while sedated with Diprivan. I know that patients with seizure disorders are more prone to seizures during recovery. The most common side effect I have seen is hypotension. I know that people with low levels of zinc (major burns) can develop problems, and people with lipid metabolism problems may develop problems because Diprivan is a fatty emulsion. However, like you stated, anything can cause seizures, and you are altering your patients neurophysiology by giving Diprivan. Have you had a bad experience? Take care, chbare.

The hook, I see what you are talking about, however, like Dustdevil pointed out, the P waves and complexes do not appear to march out. I would have to go with A-Fib for the underlying rhythm. However, I do work ER and 70% of what I see is runny noses and earaches, so take my word for whatever you think it's worth. Take care, chbare.

I would have checked sugars on both of the patients. Take care, chbare.

Matt202, I have two bags that I use to support our state QRF team. If I make entry with the team, I will throw my support bag down at the door or drop it at a pre determined casualty collection point. During care under fire I only carry a small range bag, (about the size of a dump bag) the only medication I carry in it is an adult Epi pen if I have team mates with documented allergies. The rest of the supplies are BLS materials. Combat application tourniquets, dressing and bandage materials, nasal airways, extra grenade pins, flashlight, 5 1/2" shears, occlusive dressing materials, and a couple of 14 ga angiocaths. I carry a large support bag with more medications and use it if we do extended operations in the field. Medications that I carry vary greatly on the environment I am in. My basic sick call kit contains; PO Motrin, PO Tylenol, promethazine injection, po Benadryl, Benadryl injection, triple antibiotic ointment, PO Pseudophed, epinephrine 1:1000 injection, PO Zantac, fluorescein strips and a small cobalt blue light, a 1000mg vial of ceftriaxone, and a depending on the age and history of the people I am supporting, I will carry PO aspirin. I do not carry narcotics or benzos. I imagine that could change if I deployed OCONUS. When our team deployed to Louisiana, I ended up carrying tetanus/diphtheria inj, HEP A inj, and HEP B inj. We ended up giving allot of vaccinations. We anticipated allot of GI related illness and my mother unit (a medical detachment) sent allot of antibiotics, Flagyl, Levaquin, & Cipro, however, we saw very few cases of GI illness. I hope this helps. Take care, chbare.

I cannot speak for Physicians and other health care providers, however, I am startled by what I have encountered regarding nursing students. I see students nearing graduation that have very little knowledge regarding pharmacology and pathophysiology. I am talking about students giving Motrin that do not even know the basic mechanism of action of NSAIDS. I have asked people, do you know what prostaglandins are? "Prostawhat" is a common reply. I have talked with several students from many different programs and I am saddened when I hear that many students do not look up drugs or do drug cards on every medication they give, or are allowed to buy pre-printed drug cards. Students are doing very little to no preclinical work as well. I remember preclinical work involved several hours of researching you patients problems and writing down pathophysiology of the patients problems and explaining the implications of abnormal labs, in addition to starting the basics of a care plan the night before taking on patients. I have noticed very little instructor oversight of the students, especially when students are working specialty areas. I have a theory, I believe the shortage of health care providers creates an environment that encourages schools to make "shake and bake" health care providers. Pump out lots of new and under-trained grads into the field. I have noticed problems with paramedic students as well. Poor instructor oversight of students, lack of motivation and good work ethic, and lack of basic knowledge regarding pathophysiology and pharmacology are problems of both nursing and paramedic students. I have seen many paramedic students simply copy all of their assessment information off of the patient chart over actually going in and assessing the patient. I remember not too long ago listening to an apical pulse and hearing a rather profound systolic murmur, I asked the paramedic student if he wanted to listen, and he told me no, "because I already know what they sound like." I no longer precept students because I will not let them give meds or provide care if they do not show motivation or fail to tell me the basics of how a medication works and at least have a fundamental understanding of the pathology behind a patients condition. Of course the expectation is different regarding a first semester student, but by graduation time you need to have a clue, and good work ethic/motivation is required regardless of where you are at in your education. On a positive side I have met many highly motivated students that "have their poop in a group." I just do not think schools are creating a challenging environment that promotes learning and good work ethic, and an environment that weeds out the dirt bags. This is just my opinion however. Take care, chbare.

Neb.EMT, I cannot comment about your local protocols, however, the romazicon issue may be related to the medications action. Romazicon can actually cause lethal problems, especially when given to people who take benzos on a regular basis. (Take xanax three times a day for anxiety, and now overdosed on xanax.) Romazicon works by competing with benzos by binding to GABA receptor sites. Patients are then free to withdrawl and seize. Unfortunately, all of the meds we can give to stop seizures, (benzos) may not work and the patient is free to seize all day long. Hope this helps. Take care, chbare.