firefighter523

I am sorry that in your world, Flight, Rid, and Ruff, you are subjected to such poor standards of care. Here in PA, you can't even take a person on heparin on a transport if you are not in-serviced on it. Where I am, fortunately we work in a well oiled system, and it would be unheard of for even a dual medic unit taking a IABP on a ground run. Here also, the "Critial Care Nurse" in Cardiology WILL always go with us in our unit, because He or She is trained specifically in the operation and maintainence of these things. Your idea of the perfusionist where you are is integrated in the scope of practice for them where we are. A pre req for our flight nurses to be hired here is at least 3 to 5 years as a critical care RN, preferrably in the open heart unit, as well as the NREMT-P cert. I think it is that way for a reason, and that has been that way for MORE THAN 11 measly years. Ruff, your stories are far fetched, I can see right through your inexperience!!! To this day you still could not provide the answers to two critical RX's that I have asked you. Your good friend Google couldn't even help you!!! Your credibility is nule and void with me, so you can continue to say whatever allows you to sleep good at night, I will still doubt you!!

Ruff, you lie, and you've been pimped on it!!!

PS. You are WRONG about the insurance Rid!!! A nurse on duty is asked first, and then if nobody goes, then one is assigned by the hospital!!! So when a nurse leaves the hospital in a helicopter, that means that they have no insurance???

"Hospitals do not care, as long as they don't crash" What the heck kind of statement was that Rid??? I think the question to ask is "What if THEY DO crash" !!! So if a helicopter is equipt with a nurse and a medic , I think that is for a reason. It is NOT in the scope of any paramedics practice to transport any of the following without a nurse... Balloon pumps, VAD, BiVads. Rid, that was a reactive, unacceptable statement, not proactive. You don't render less care, in hopes that someone doesn't CRASH! I think we need to re-think the cave statement!!! Ruff, you are full of it!! Even giving you the benefit of the doubt of running with a dual medic system (which you probably don't) you still would not be allowed to transport a pt with a balloon pump.

Ruff, A hospital let you transport a person on a balloon pump without a critical care nurse on board???? They just assumed that you had the training, and you didn't?? You wonder why I question your credibility!! Please tell the truth for once!! Cardiac nurses go through a rigorous 20 some weeks of OJT, in a critical care intership to learn about the things that you just told us was dumped on you, and you decided to transport it on a whim. This is America, and hospitals Do Not do that.

People die of blunt cardiac trauma because of chamber rupture, not tamponade, they usually die on scene, and a needle will not help them. You presented a "1" person out of thousands that have died from blunt tamponade. Penatrating injury, aside from a disease pathology is the leading cause of pericardial tamp, because of the breach of the membrane...

AZCEPT, lets look a little at A&P, the pericardial sac is closed, if you have a penetrating insult to that area it usually fills with blood. A sharp blow to the sternum will not usually cause the sac to be compromised. A knife will. Myocardial contusion is my path.... I can never say never with anything, nor can anyone else I guess. You very well could manifest "I guess" with cushings from a penetrating wound, doubt it though, I have never seen it, probably because it is a late sign. They usually see it days after an insult in the Trauma Neuro Unit, if they make it that far.

Rid, I will tell you that pericardial tamp is caused not by a steering wheel to the chest, but usually from penatrating injuries. I guess what I am saying, is that my field diag would lead me more towards myocardial contusion, if the only suspected injury was from a steering wheel to the chest. BTW..... on the MICU, you would be very hard pressed to hear muffled heart sounds, you might want to look for the "JVD, clear lungs, and HYPOTENSION instead,........ with a "penetrating injury". Getting back to the Cushings thing. I also would not suspect cushings if someone was shot in the head. "Kelly's Doctine" points out that the cranial vault consist of very tightly packed brain tissue, CSF, and blood. If you upset that balance, you might be on your way to Cushings. You usually will have a CLOSED vault when you manifest Cushings, not a GSW....

Im sorry, ruff, I did not get the answers to the following Rx's. If you decide to bash me, and tell me I don't know a thing, then you better have your ducks in a row. I will give you the answer in case you decide to push lidocaine on someone with an underlying infarct, that is having PVC's. You can cause conduction abnormalities, possibly causing reentry, and precipitating VF. That is why you always do a 12 lead before you give lidocaine. As far as the rhythm too fast to cardiovert, very simple, you need to defibrilate them. You run the risk of hitting and R on T, but the only other alternative is they die anyway. If you think you can pimp me, you can't!!! Like I said before, you caused this anamosity, this is your bed, you made it, you sleep in it. Tell your cronies they can do the same!!! And----STICK YOUR NOSE BACK IN THE BOOK SON!!!!!!

Nice , Nice , Nice!!!!!!! Go have your meeting with Google!!!! BTW, after you come back from googling your first answer, tell me the other alternative if you CANT cardiovert this pt because the rate is too fast. (You had mentioned that you have come across MANY people in this state). Did you leave them die, or were you just lucky enough to get them to the hospital without doing ANYTHING!!!! What would the next line of Rx be if his rate was too fast and he needed cardioversion??????

Ruff, thank you for posting my reply in the general forum, I really wanted everyone to see it anyway, since it explaines the right treatment. Did you like the analogy about the nail in the foot? ER Doc, I understand that if you correct the (Rate) specifically it will increase ventricular filling time, hence increase cardiac output, BP, tissue perfussion. Unfortunately we only use Verapamil, and WILL NEVER get orders in the field unless out transport time is long and his BP is well over 100. They would rather us not give it in the field. We have not graduated to wonderful Cartizem yet. Once again Ruff, my kids would go running to their friends like YOU did!!!! This bashing has actually gotten us off the beaten path about Rx modalities.... So to answer your question about the pedi pt. He or she would get high flow 02 (That is oxygenation and not airway) We will assume his airway is open since he is breathing that fast, K? He would get an IV, and up to 3 fluid boluses to equal 60cc's/kg, 30cc/kg if he was an infant. If his heart rate dipped below 100, he would get PPV at 1 breath every 3 secs, if his hr dipped below 80, and remained there for longer than 30 secs or more, or just plain dropped below 60, he would get chest compressions at 1 every 1 1/2 seconds. If his respiratory rate, and HR failed to rise with those efforts, he would get .01mg/kg of IV epi 1:10,000. Now my friend........I have a question for you...... Tell me if you will, I answered your question, If you encounter a pt with malignant PVC's, (Closely coupled, multifocal, or in salvos, with assoc symptoms of CP, SOB, or hypotension what would you do! Tell me the pathology of giving lidocaine to a hypoxic heart !!!!

Medic 001, sorry about that, we have the same protocols for SVT, disasterous effects only due to the hypotension and CHF, and cardiogenic shock that this pt is presenting with.

Thunder, if you can't discern if it is reg or not, and the pt is stable, you need to give adenosine first to slow it down to see if it is reg (SVT) or irreg fib or flutter. If you call medical control, they will tell you that also. If you give CCB to a reg SVT it could have disasterous effects. I definately agree with the profilactic CaCl before the CCB. Ruff, I thought I said don't respond to me unless you have the right anwer for my question. Not only have you perfected your mistakes for 15 years, but you can't follow directions either!! Stop crying that I offended you!! It is almost as bad as Rid's gloating!!! Bye, bye sweet pea!!

Scrat..... Um lets see, if you don't see p waves, (you didn't specify) and this person was 70 years or older, and was wheezing, yes I would give adenosine. Only, if you can answer (correctly) this rational, please reply, if not, don't waste my time!!!)

Ruff, Do you make it a habit giving a beta-agonist to a person with a tachy arrhythmia? Let's make a sick heart work harder, why don't we!! Broke, YOU ALWAYS FIX DYSRHYTHMIAS BEFORE YOU DO ANYTHING ELSE!!!!! They will compensate for only so long.

If all of you cackling hens would stop crying about how I hurt your feelings we can get to the point on this "AGAIN". I am trying to tell brock that if you find a pt in a tachy rhythm as well as all of the above manifestations, YOU NEED TO FIX THE RHYTHM FIRST!!!! Unless this thing has been going on for quite sometime and the pt was unaware due to his/her compensation, and taking in fluids, this pt is probably not in fluid overload, it is just in the wrong places. When someone goes into a tachy rhythm, it causes back pressure in the pulmonary vasculature, due to the poor filling of the left ventrical, causing a "screen door effect, releasing the plasma into the aveolar spaces. If you allow the heart to pump properly, the fluid will return from the innerstitial space back to where it belongs. This is why I am saying you need to take care of the underlying problem. You are right when you say "treat the pt and not the monitor", but you need to use the monitor as a tool, and take the pt's status in concideration with that. If you see a narrow or wide tachy arrhythmia, you NEED to assume that that is the pts problem! For one, you can't rule out that is not, therefore you need to treat it, and two, the pathology of a dysrhythmia makes all the sense in the world!!

Scrat, whatever your name is..... Go back a reread AEIOU TIPS!!!

Thunder, Severe intercostal retractions with an altered mental status, and BP hovering around 90, with a rate of 220 WILL, get cardioverted in the field any day of the weak. AMS with severe respiratiory distress is an OMNIOUS sign of impending arrest, respiratiory or cardiac!!! Brock, you WOULD NOT push lasix, give nitrates, or ASA for this pt. His rate is causing the resp distress. You must treat the cause of the problem, not the manifestations resulting from the problem!! His BP is TOO low for any calcium channel blocker, and I doubt you would get orders for any of them if you give any competent MD this report, especially Verapamil. I don't know what you use in your system, but that is what we use. Severe hypotension, and CHF are contraindications for Verapakill.

Ruff, like I said in the past, you always have that rare case where the person does not want anything done. In 97% of the patients you will encounter, you already know what they want, they called 911. I am sorry for coming off aggressive to you. It did get a bit heated, I hold no grudges, that is ems. As far as throwing your letters at the end of your name at someone to gain respect, that is for the birds. You must earn respect, I don't care if you are the President. I once had a doctor ask me why I gave nitro to a pt with JVD, rales, and pedal edema, with a hx if CHF. He asked me if he complained of chest pain, the next words I heard from his resident was "get me 4 of morphine". The point I am trying to make is that we are all human, and there are 10% idiots in all ranks, even doctors. You get out of it what you put into it. I know many paramedics that will stand there ground in a 12 lead debate with any cardiologist.

Ok this is really getting annoying now. Let reiterate it AGAIN. I simply stated from the beginning.... If at pt is CRITICAL, UBTUNDED, UNRESPONSIVE, and is ready to die, ie..... Low sugar, high sugar, increased ICP, anykind of shock, OD, unstable tachy dysrhythmia.... am I hitting them all? You then fall under IMPLIED consent!!!!! Not EXPRESSED, expressed being the words NO or YES coming out of the patients mouth. Did I mention that is EXPRESSED!! If before they become unresposive, I guess there is the RARE possibility that they will tell you they DONT want anything done. If that is the case and they don't have a DNR present, you must CALL MEDICAL COMMAND!!! I think I am fully aware of this RARE situation!!! If they DONT state the above mentioned statement and crap the bed, you MUST assume they want to LIVE!!! This is NOT so hard, is it??? This will NOT get you nor I in trouble and is the STANDARD of CARE folks!!!! Call me whatever you would like, I don't care. I am my pt's best advocate all of the time. I will always tell them what I am doing, NOT ask them what they want, do you know why fellas, because they DONT know!!!!!!!!!!!!!!!!!!! We are the ones that must tell them, not ASK. If you tell them and they don't want it, then they sign the dotted line. Is this ENGLISH understandable.

I'm sorry, there it is, it must have just popped up in your title!!! Amazing, I am proud to be one, mine was up a long time ago!

Newsflash Ruff, people CANNOT hear you when they are unconscious!!! Answer my question, are you an als provider, or an ambulance chaser!??

Doc, with all due respect, I was talking about an EMERGENT situation. So you mean to tell me that is someone has an accucheck of 17 mg/dL, and is unconcious, you would be held liable if you didn't tell them that you are giving them an IV and sugar???? That is implied concent, and this is the same situation, it would be negligent if you waited for an answer from them. I want to reiterate, if the pat is aware of there surroundings and looking at you, of course I would let them know what is going to happen, I would do just that " Let them know" , not give them the choice, their life depends on the critical decisions we make. That is why we go to school, and put everything we have into education, to learn more and more everyday. Part of being a good provider is being decisive, it makes the pt more comfortable with you, and gives them the sense that they are in good hands. I have dealt with a handful of critical pts that could NOT understand what I was saying to them, much less, they became flacid, and were on the brink of respiratory arrest, among other things. How the heck can anyone hold a provider liable for NOT telling them what you are going to do. YOU WILL BE HELD ACCOUNTABLE FOR YOUR ACTIONS IF YOU DON'T PROVIDE THE RIGHT THERAPY FOR THEM IN A TIMELY MANNER!! That is negligence and that is what you call CRIMINAL. And Rid, If I have to see that you have done this for 30 years again in your text, I am going to puke!! Gloating is for CHUMPS!!

Ruff, Are you even an ALS provider, I didn't see it in your title???

Ruff, wow, um was that a cyber-threat, with the whole fist thing!?? I'm over it..... Please refer to the BLS curriculum about implied concent!!! Let me help you understand this a little better. Watch this, we will do it in the 1-2-3 method just like in grade school. 1) If they are hemodynamically unstable, ie with or without pulmonary edema. 2) If they have a tachy arrythmia, wide or narrow. 3) If they don't have a DNR or living will present. All of that equals, yes I know you hate to hear this.... Not telling them, and here is the worse part......CARDIOVERT!!!! PS, and possibly without sedation. This is the standard of care. OBVIOUSLY...........if someone is awake and ABLE to hear you, you would, like a good paramedic, tell them what you are doing, even down to "little stick" right before you jab them with your cath!! Brock.... Learn a whole lot more before you start picking your battles with Rx... If someone has a tachy arrythmia, and is unstable with or without rales, you NEED to fix the dysrythmia FIRST. You, hopefully wouldn't hit someone with Lasix to rid them of the PE before you would correct what is causing his low cardiac output, hence the back pressure building up in his pulmonary vasculature. He or she is not in fluid overload, it is just in the wrong place because of the screen-door effect, in the vasculature. Increase the cardiac filling time, increase ejection fraction, fluid goes back to where it is supposed to be, and finally call your report in!!!! This horse has been beat enough, keep your nose in the books!!!!