firefighter523

Brock................. Oh my God, I cant even think strait after reading the rest of your post. I hope you just started class!! Please don't come to PA!!!!

Guess what, If you see a supraventricular rhythm, and you cant tell if it is SVT or AFib, I don't think you would give a CCB before you would give adenosine!!! Adenosine is a natural occuring agent that will chemically convert PSVT to NSR. In the event that it doesn't, it will slow the Afib down so you can see it. Then you will treat accordingly!!!

Yes sir you are right about letting them know what is going to happen. I guess that came out wrong, If they are that critical, there decision should not dictate your treatment. You are just delaying the inevitable. That is what I meant, but yes, you are right, about letting them know. That is just common sence. I have cardioverted atleast 4 pts and not one of them I told that it was going to hurt, you know why? They couldn't HEAR nor SEE me, because there eyes were rolled to the back of there head!! This is not the ER, and the conditions out here arent the same as in the controlled environment that you are in. Sorry about the confusion!!

You should NOT let them decide, that is what you are there for. You are the professional, and are the one that is supposed to know what to do. Make a decision and go with it. Just hope it is the right one. This pt sounds like they are unstable. I would cardiovert, if vitals and and pt impression indicate. Blue lips, resp distress with rapid A fib would get electricity.

NICE!!! Bravo!! Well said!!!

Albuterol is the wrong tx to this person. And I don't have any idea why you would give someone solu-med considering it takes all of about 6 hours for that to take affect. The problem, which you can't rule out, therefore you need to fix, is his rate. He is probably hypoxic because of his pulmonary htn, and the lack of oxygenation to his tissues, do to the lack of filling of his ventricles. You could put someone on high flow all day long, but if it is not getting delivered properly it is just being wasted. And another point, he does have a hx of COPD, do you treat the wheezing from the underlying lung disorder, or is it cardiac asthma??? Fix the rate, release some of the pulmonary pressure, see if the rales decrease, I am betting they would. Beta agonist to a sick heart is a bad idea.

Doc, you take the fun out of a good debate, LOL. However, I think it is not such a good idea to ignore his HR. This rate indicates that his cardiac ejection fraction is probably a bit low, creating pulmonary hypertension, hence pulmonary edema, hence hypoxemia. If you were in the hospital, I could see the cartizem if he wasn't on coumadin. Out in the field this person will not last much longer. You need to cardiovert this person asap to hopefully fix his problem. I know you run the risk of throwing a clot, this situation is grim anyway you look at it. Definately fix the rate first, while on high flow 02!

Rid, well, you and I don't seem to agree on much. Your initial statement, you say wasn't directed at me, directly! But, indirectly, you know as well as I, it was! You might impress the various providers on here with your titles that are under your name, and the fact that you say you are old. My last post was 100% correct, I mean by saying a dead heart, is on its way out, it is dying!! Here is a good example: If you have a pt with malignant PVCs that are caused by an underlying MI, and you give them lidocaine because you didn't do a 12 lead, hence not finding the MI, you have a good chance of causing conduction abnormalities, facilitating re-entry, and hence the outcome of possible VF. Here is the point I was trying to make, the point that you didn't grasp. If you numb (blunt) the conduction of an already ischemic myocardium, you will do more harm then good! I rarely google on this site, of course we ALL do, even you, MR perfect!! Get off your highhorse, come down here with the rest of us, you are not God, you are a tool that might make a difference in someones life, just like the rest of us. If God wants to take you, He will. You DON'T impress me, you never did, and you never will. Your attidude is poor, and it reflects to me that you are only in this for yourself, to satisfy your little adrenaline rush. You do nothing but put yourself up on a pedestool, by constantly telling us about all of the things that you do, and have done. Who cares. You want to impress me, QUIT GLOATING!!!!!

Somedic: Before you reply to a topic, it would best if you've read the previous posts, K. Find out for yourself who asked the question, before you make yourself look like an ass.

Mr. Rid, I guess I should have spelled it out for you that when you block sodium channels of a cell, it actually DOES slow, numb, or here's the kicker, make it less irritable. Numbing was not to be confused with the topical kind. Sorry for your confusion!!

Don't know what he was thinking! Contraindication for Lidocaine: Hypersensitivity to amide local anesthetics, Stokes Adams Syndrome, second/third degree HB, sinus brady. Nothing like making a dead heart numb!!

BTW Rid, recall back in the "Duh" post, you stated that reducing an open femur is "strictly contraindicated", but I am, um......Confused, because ya see, I thought you said that they were guidelines?? Just want to clear up the confusion!?

Rid, bottom line is the only thing that was pompus was your origional "Duh" , you set the tone between you and I, not me.

Becksdad, the analagy about the nail in the foot was just that.

I really have no issues, except being told by a brand new EMT-B about the effects of infection, and losing a limb. I agree, I wouldn't mess with an open femur fx unless pulses weren't obtained. That isn't the issue. The issue is soley, his tone in stating what he said about infections. You say, that I haven't taken care of a fx femur, (not the case), nor is it the point I am trying to make. How many infections do you think that EMT has delt with, of fx'ed femurs for that matter? I would guess, not many, if any at all! I think I speak for all of us when I say, nothing aggitates me more than someone that reads for a couple of years out of a textbook, thinks they have it all figured out, and then opens his mouth about how they have seen and done it all. Education, I agree is very important, however, you need to have the field experience to put that education to good use!! As for you RID, we have had this discussion before. You say you instruct PHTLS, well, if you teach against the guidelines that you are supposed to be teaching, then I am wondering how effective of an instructor you are at all, and maybe it is because of people like you that we are producing the type of EMTs that we have! Guidelines are there for a reason, if for nothing else, we are having a bad day, we can atleast have something to fall back on. I can tell you this, if there are no pulses present, or if the pt is in too much pain, I am NOT worrying about your beloved Osteomylitis, (I know you love saying that word) That can and will be taken care of in the more definative care setting with antibiotics!! Traction, whether open or closed, if warrented IS THE STANDARD OF CARE! Infection care comes later. It goes both ways, ER Doc stated it best, education and experience is relative, it is how you obtained it and are putting it to use that really matters. Remember, my friend, there is someone out there that will always be smarter then the next. All the letters next to your name might make you feel good, but they just might be a drop in the bucket to the next guy that comes along. And scaramedic, we do carry MS, and I do give it to the people who need it. However, don't you think the analgesics would work a whole lot better if you take away the source of the pain first? Traction has been shown to significantly decrease the pain!! Remember, we learned that in EMT school!! If you stepped on a nail, would you not take the nail out of your foot, before you put ice on it? Asyn- you seem like a very intelligent person, and a good role model, my only issue is with some of the attitudes on this site! That is all. I have a very happy life, and am VERY commited to learning more and more everyday.

College boy, and everyone else. For the record, don't worry, I don't think you are better then me, or anyone else because of college. I think it is great that you are going to college and furthering you edu. I am doing the same thing myself. Your mouth, or in this instance, your fingers come off to people that you have it all figured out. I know that infection is possible, especially in the immunocompromised. I also would not mess with a stable limb if I didn't have to. However if you think that I am going to let a pt suffer great pain (NOT STABLE) from a broken femur because I am worried about the latter effects of infection you are mad!! Have you ever taken care of a pt with a broken femur, obviously NOT! It is the most horrifying death scream, that you will ever hear in the back of a bus. I am sorry, but your comments piss me off, at that point, who cares about his infection!!!! I don't care if it is open, or closed, if there are no contra-inds, I WILL hold traction, because it WILL in most cases relieve there pain somewhat. It does help with internal third space tamponade, and also keeps the muscle from further spasms. Then you may proceed with the MS, or whatever you use. You and I both have alot to learn, in fact, the moment you think you are above learning more, you are dangerous! Like someone said before, who the heck cares what classes you are taking, I could give a rats @%* about whats involved in diagnosing mental problems. That is NO emergency to me, but to each his own, right!! Good luck in future endeavors!! Remember my friend, we are all human, and nobody is perfect!! We need to learn from each other, leave your attitude back in the rear with the gear micro-boy!!

Ya know who you remind me of, yes you guessed it, John Kerry! Your little college education was probably given to you by your parents, and you probably still don't respect them for it. You come into this line of work, thinking you know just so much, when all you have done in life is read a couple of books. I don't care about you, your college schedule, or what comes out of your little brain to be placed on your next text. It is cry-babies like yourself who make this job SUCK, and that is the ONLY reason this job SUCKS. Now let me tell you a little bit about me. I am a former US Marine, Crash Crewman who has served all over the world, including Japan and Australia. I have been in the Fire/EMS service for 12 wonderful years (dealing with know-it-alls) like yourself. Don't know what you want to do in your medical career, but whatever it is, STAY IN THE HOSPITAL, under a controlled environment!! That would be the best place for you! Leave the rest up to the PARAMEDICS who make life and death decisions on their own, in a split second. I don't think you could handle such a great responsibility!! You need to grow up, get the silver spoon out of your mouth, and live life son!! You don't know what it is like out in the real world yet, because you are still young and stupid. Anyone can read a book!! You want to impress me, put your little biology book down, and pick up an M-16 and hit the sand!!! For the rest of you, sorry I digressed a little, but people like this (above) make me SICK!!

College boy, I know you probably have it all figured out, since you have all of about 3 years tops in EMS. Don't you think that physicians are aware of the fact that they could get an infection? Do you think they were high on the smoke when they wrote the text of PHTLS?? Yes that text (PHTLS) is sponored by physicians!! You probably didn't take it yet, better yet, I noticed you DONT have a certification down in your profile. You must be a NEW EMT, judging by your stupid statements, that is what I would guess. Sit back, keep your mouth shut, and learn from this sight!! GO TO SCHOOL BEFORE YOU MAKE SUCH IDIOTIC STATEMENTS, AND TAKE A LOOK AT MY PREVIOUS POSTING REGAURDING THE PAGE NUMBER OF THE MOST RECENT PHTLS TEXT!! END OF CONVERSATION

Because the benefits of traction FAR exceed any negative effects of possible infection DOWN THE ROAD in his recovery period!!

Thank you for the info Doc.

To all who think this rhythm is atrial. Extreme right axis means that the impulse is originating deep in the ventricles and has a retro , meaning from bottom to top pathway!! It is physically impossible for this to be anything but VT. ERAD and the fact that the QRS is 120ms or greater further puts the nail in the coffin!! Elvis has left the building!!

I am going to put this thread to bed, it IS DEFINATELY v-tach. Look at the QRS complexes in I and AVF, they are both negative, which indicates extreme right axis deviation. That is the ONLY way you can TRULY diagnose VT. Pending on BP, either Lido, or Cardiovert.

ER Doc, I am curious as to why you buy them a 4 hour ED stay. Please, if you would, explain the rational. Thank you. Respectully.

Our station has steering wheel covers for that. Look into it.

Definitely NOT WPW, not wide enough, I would guess, you could have an incomplete BBB. If this pt was "so stable in the field", one would definitely do a 12 lead, and from there differentiate VT from SVT with aberrancy. Look for the extreme right axis deviation. (Negative QRS in leads 1 and AVF) Treat accordingly, rule out an underlying MI and go for the Lido if it is VT. We all know what happends when you give an already hypoxic heart lidocaine. Could cause conduction deficits, and re-entry, hence possible VF.