Lithium

I know I'll probably get flack over this, but I rarely write anything down while on scene or in the back of an ambulance. For one, the laws in Ontario are very grey regarding what is admissable into court (yes, it's happened that gloves with scribbled vitals on the backside have been entered as evidence) that if I don't write anything down, I don't have to worry about it. I believe in using my short term memory for things such as patient allergies, medications (and usually, all pill bottles are brought with us to the ER so I can just look at the label) past history and events leading up to the call. Vitals are easy to remember, as it's very rare that they change drastically. Then, all this information is present when reporting to triage or the MD. Same thing for patching. I hated looking down at my glove when giving reports initially, so I dropped the habit. Plus, it's better interpersonal skills and body language if you're looking the person you're talking to in the eyes rather then looking down. Then, after the patient care has been transferred, I grab a cup of java and go write my form. No gloves involved! As you do more calls and develop your own routine, you'll find you can pick up certain things quickly. When I first started out, I'd forget the patients name right after they told me, and the reason being, I wasn't really paying attention. I was too concerned about other things then I was the patient. That quickly stopped, and now my full focus is on them and what they tell me. Plus, I'll usually repeat it multiple times during assessment/procedures (okay Jane, we're going to take your blood pressure, Jane we're going to move to our stretcher, Jane Jane Jane Jane Jane Jane .... repetition builds memory). If that doesn't work for you (using your memory) then ask the FD on scene with you to be YOUR recorder. There's no reason why they can't stay an extra two minutes to write down patients name, contact information, meds etc etc and hand that sheet to you which you can place in your pocket. Same thing for vitals ... have them write down your first set, even on the back of a 6 or 10 second strip! With regards to gloves, I only use them when in direct contact with patients. As far as everythin else, I try and use a glove free environment. Using the stretcher, switches in the back of the ambulance, driving, talking on the radio ... none of that requires the use of gloves, and is easily cleaned with wipes after the call. Don't let your dispatch push you back into service if you feel you aren't ready. If you need an extra 5 or 10 minutes to wipe down your vehicle, then take it. It's your work environment, you need to feel comfortable in it otherwise stress will build up. peace

Yay! So my BLS skills actually worked (see first post ... trendelenberg!)? And 250 mls over 10 mins? I don't think so ... but anyways. Now that he has a palpable BP (although it's still too low for my liking) how's his mentation? GCS? HR improved at all? Repeat focused exams (and you still didn't answer my questions about abd/flanks and skin temp). Continue with my other treatments previously mentioned (atropine, consider pacing but most likely leading to dopamine). peace

That's another reason why I do feel this is more of a volume problem rather then rate. The beta blockers are working more on his rate then on vessel size/diameter. We all know HR x SV = CO. So yes, even tho his HR is fairly low which could correlate to the lowered BP, if we start pacing him, all you're gonna be doing is speeding up the pump, but if all his vessels are huge, you're not going to see much difference. Add in some dopamine, get some vasoconstriction, his BP will rise, CO will increase, perfusion to the brain will allow his mental state to return to normal, and I still don't need to mess around with sedation (which has the possibility of lowering BP once again) and I haven't caused him any pain by actually pacing. Remember Hammer, your protocols are guidelines. If you have access to a medication (ie. dopamine) and you feel it will be beneficial, even though it's not one of your protocols for unstable bradycardia (just bolus, atropine/pacing) patch! Depending on your relationship with the MD, how well you present your case, you'll probably get the order. Just don't get sad when they switch over your primitive dopamine drip set up with a buretrol over to an infusion pump ... Edit: didn't see your post! Id go ahead with a fluid bolus first, it's the least amount of harm I can do. I'd start it on scene, and depending on where we are, how long extrication takes from where he is, reassess once I got down to the ambulance. If 500 mls isn't enough to cause an increase in his mental state or atleast get a palpable BP, I'd move to atropine and wait 5 minutes, then onto dopamine.

BBT? Two reasons ... if the atropine couldn't help bring his rate up, then there's something funky with his ANS. Secondly, alcohol has really weird interactions with a vide variety of medications, especially those affecting the CNS. Was it red or white wine? How much, over how long of a period? Any food with it as well? Is he a regular drinker or none at all? Levodopa has been known to cause orthostatic hypotension itself, add in some alcohol, and the pressure can drop. Not to mention if he's also taken his beta blockers and maybe even a squirt of nitro.

I concur with everyone so far, but if I'm unable to get a BP, I don't think he'll be able to answer my questions much longer. At this time, consider moving him to the stretcher prior to any major interventions (including IV). This gentleman will receive a full cardiac workup, and for further physical, how's his belly and flanks? Any distiention/rigidity? After all primary interventions (O2 100% via NRB at 15 lpm, continuous cardiac monitoring and repeat 12-lead in 5 to 10 minutes) he will be placed trendelenberg based on respiratory rate and patient comfort abilities. Ask his wife if they have a typical hospital where he's been treated for his MI. How was ambient temperature? I'd really like to make sure he isn't mildly hypothermic prior to initiating cardiac care below ... I'll place an 18 or even a 16 gauge right AC and follow through with a minimum 250 cc bolus and reassess while beginning transport code 4 CTAS 1. I'll be querying him regarding cardiac history and how he's feeling now (ie. OPQRST etc.) During transport if he deteriorates further or atleast shows no sign of improvement, I'd like to give him 0.5 mg of Atropine and perhaps another dose of 0.5 mg in 3 to 5 minutes. If no improvement with this drug, I'll be patching to my base hospital MD for orders for dopamine. Asking the doc to start at 10 mcg/kg. Skp pacing due to the fact I believe this really is more of a pressure problem then a rate, and he's not going to be able to receive sedation immediately. Hopefully we're only 5 minutes out tho ... :wink:

Thoughts? Yes, I have lots of thoughts! If you weren't nervous about starting this, I'd be nervous. Nervousness is a good emotion to have when you're starting something new. It will keep you sharp, and really make you question what you're doing and why. It allows you to challenge yourself, and that is how you become more comfortable with what you're doing. Please don't hold yourself back because you're afraid of feeling stupid or making a mistake. If at any time in your career, there is a time to mistakes, it is when you're a student. Your preceptor should be experienced enough to know when to step in and intervene, and when to let you try things and find out for yourself if it works or it doesn't. For me, one of those "well try it and find out what happens" moments was for a narcotics overdose. After giving the standard dose of narcan IV, I elected to intubate the patient after administering the drug with no immediate signs of improvement. Big mistake. It wasn't a pleasant experience trying to deal with his return to consciousness with a tube down his throat and vomiting profusely. You stated you want your paramedic cert so badly. If this is what you want, that should be enough of a desire to initiate the fight. You have a wealth of knowledge available to you here, just let us know what we can help you with. Good luck, and see you on the streets! peace

Ha! It's either there, or Hamilton :wink:

I find this interesting ... especially coming from Dust and Rid. I'm coming from the same standpoint as Asys, heck, I DO mop the floors of my station on a weekly basis! The point though, is that even though you may be classified as a BLS provider, you still have the education and ability to perform ALS assessments. Isn't that the whole point of Advnaced care? Just because you have fewer 'toys' to support your way of doing things, doesn't mean it still can't be done. That being said, now that I think about it, I would LOVE for a US trained/certified EMT-P or CCEMT-P to come and practice ALS for a few days in Ontario. You guys would go NUTS. You know how many drugs we carry? On average, 18, 5 to 6 of them available for our BLS crews to use independently. ALCS meds? Let's see ... we only have 3 or 4 depending on the service. And, no choice to choose between Lidocaine or Amiordarone as it's prechosen for you by your service which one they want to carry. No access to RSI even .... and yet, in most cases, we have 3 to 4 years of education to attain our ALS level. Talk about having your hands tied behind your back ... peace

Okay, so I was taking one of my services optional elections for CME this year, entitled 'Defensive Driver Course'. Essentially, just a reminder of safe driving principles/practices. Surprisingly, my services most frequent amount of accidents occur when backing up, but anyways. Anyways, I'll get straight to my question. When you're assessing a head-injured patient post MVC, often, they all have some form of memory impairment before or after the accident. This is referred to as antegrade or retrograde amnesia. After taking the course however, I have some thoughts about retrograde amnesia. In the course, we discussed 'highway hypnosis' and such. It's been proven that for people who do an aweful a lot of driving, especially of the same routes, that at times, they're subconcious can take over and drive for them, and that person is no longer consciously aware of their surroundings. I know it's happened to me for a few times, especially on my drive in or back from work, sometimes I won't be able to remember the events that's happened in the past few minutes. So, suppose now this person is driving around 'subconciously' but they happen to be involved in an accident. With this new information (ie. hitting the steering wheel, loud crashing sounds) the brain snaps out of its state and brings the person back to reality and what's occuring. However, they have no recollection of the events that happened prior to the accident, simply because they were zoned out, not due to head injury. What do you think? Is this plausible for most patients? I'm not trying to say that a person suffering from a head injury wouldn't show signs of this form of amnesia, only that, it may be more common for the reasons I listed above. Discuss! peace

Cuz that's what your protocols say! ha ... sorry, had to throw that in there

Do you wear these in the air acosell or on the road? I've never seen or heard of anyone wearing something like that in a land vehicle, and honestly, the siren (atleast to me) isn't all that loud in the newer vehicles. Engineers are cluing in when designing the vehicles, which is why a lot of the siren speaker housings are in the grill of the front of the vehicle as opposed to being on top built into the light bar like they were in the older ambulances. The downfall is that sound will reverberate off vehicles in front of you instead of going over it (making it harder for you to be heard) but less noise for your ears.

Hammer, I would love to have a student like you ... to be able to come up with something so 'off the wall' as myxedema coma is great. To be honest, I've noticed a change in how you post lately since you've started your ALS classes, more like you're not afraid to actually talk about medical things... haha Continuing with the pacing however, what would you consider for sedation for this patient? If any? And remember, ALS is still about the ABCs, we just have more tools to support them.

And (no offense here Vs or akroeze), this is exactly what is wrong with EMS. People feel they don't have the luxury to sit down and think. I feel bad for those patients, their families, but not so much for their lawyers. But that is beside the point ... it just struck a nerve with me. Back to the scenario, as soon as her airway was secured I would have considered TCP much sooner then what it seems everyone else was thinking. Let's get some perfusion going before I concern myself with rewarming. peace PS, why wouldn't ANYONE make a field impression (or diagnosis, as you wish) of myxedema coma?

Haha ... my apologies. I do the same thing at work to. I start a conversation that gets everyone involved (you should see how touchy some of these firefighters can be) and then disappear. It's quite fun ... but yes, this topic is doing better then I expected. Now where did my reputation points go?

Alright, I'll make this short and sweet. In most every paramedic program and textbook, they mention that paramedics must develop a sense of 'critical thinking'. This is supposedly what seperates a medic from the general population (EMR, EMT-B, bystanders, firefighters etc etc). My question to all of you is, is it really critical thinking, or (playing devils advocate) is that just a term coined by schools so they can teach someone how to think using common sense? (still play devils advocate) Most of what we do in EMS, I would argue doesn't require much 'critical thinking', and usually your local protocols will be applied. (ie. a diabetic who is unresponsive with a low blood sugar ... hmmm, well, let's just get their sugar up with some D50!) Most protocols designate when you can and can't do something, how much of it you can do and how often you can do it. Again, not much thinking involved, just a matter of knowing what the 'book' says. I'll admit, this is where it comes tricky, as I do realise there are a lot of "protocol medics' out there, but that isn't what this thread is about. To me, it seems the only patients that would seem to require critical thinking, are those who are indeed 'critical'. (about to code, circling the drain, whatever your preferred term is). These patients are the ones who require the most help, but you need to be careful what you do. Thoughts and feelings? peace

Well, I think I solved your little dilemna right there. You were driving, therefore your partner was the one attending correct? This means that he or she is ultimately responsible for patient care, which would include return priority and destination. Since you 'assumed' this patient was stable (I'm not going to get into the argument of whether the patient was or was not, that's not the issue) you decided to take it easy back to the hospital. Your partner, on the other hand, believed the patient warranted an expedited trip. What this amounts to in my opinion, is a lack of communication between you and your partner. A simple "what return would you like?" to your partner, and there is no doubt where their head is at, at that moment. You may certainly disagree, but that is the time to dispute it, not afterwards. If the patient truly was stable, then rationally explain this to your partner. Perhaps, the patient began develloping chest pain or something else you were not aware of and he didn't mention it. All I'm saying is that I've made it a habit to ask my partner before leaving the scene, and to keep me updated on the way in. Again, failure to communicate! peace

Yes, but not very comfortably. I remember when I first started, most services still utilized the 'type 2' high top van units. Let me tell you, I hated working a vsa in those, there simply was no room. I'm assuming that's why they started buying the type 3 modular units. Much more room, but still, not a very comfortable ride. They're basically placing a metal box, surrounded with some fibreglass on top of a truck chassis. The ride and suspension isn't much fun, especially for the patient.

emtd29, I feel I must disagree with your rational for why he gets an ECG in this instance. His PMH may have A LOT to do with why he was involved in this mva, cardiac history, could equate to lack of cardiac output therefore a syncopal episode. So I really don't think that it's moot point. Who knows ... but again, you HAVE to consider everything when it comes to these older chaps. peace

I apologise if I seem to have contradicted myself, it's just I'm not very ... shall we say ... proficient or articulate with what I'm actually thinking. Anyways, what I should have said is that the reason given in the question/answer is not why I would personally apply the monitor in this instance, however I do believe it to be the reason your instructor wants to hear. I'm not sure which Province you're in, but if it's Ontario, the AEMCA has these sort of questions on it. It's a matter of giving them what they want to hear, so to speak. Again, I don't agree with that at all, but when programs and tests are develloped by individuals, those biases play through. And since chbare touched on it, those, plus your typical "Becks Triad" of signs and symptoms, should lead you to a higher degree of suspicion of cardiac tamponade for this patient. But I'm still curious ... do you actually find out why the MVA occured? Was it the patients fault or the other driver? Medical condition basis or purely being in the wrong place at the wrong time? Clear as mud?

woohoo! So I'm exempt? Just kidding of course I would have to admit that because of this, I did miss out that we were cancelled on a call once. Oops ... sent for a code and show up with a BLS crew on scene and the patient was well past her expiry date. BLS crew ... didn't you guys get our cancellation? Ugh ... no, sorry, must have been radio problems :oops: Another habit I need to rid myself ... my my these forums can be enlightening. All in good taste though.

How sad, my thoughts go out to their family and friends. How are you coping with it? I've always worn my seatbelt when driving in my own vehicle, and when in the cab of the ambulance, but the only time I've worn it in the back was when I'm on transfers ... A habit I know I should rid myself of.

I'm on the same side as Dust, as purely because of his PmHx of 'heart' problems, that is not my rational for applying a monitor. The way the question is worded however, it is TRUE. A monitor is just that ... a machine that lets you monitor the electrical activity of this dudes cardium. What it doesn't do is interpret the rhythm for you and put it into context of your patient. This you have to do on your own. I'll admit, EVERY patient I encounter (except those who are obviously dead ... ) will have the cardiac monitor applied to them during my initial assessment. Whether it stays on or not, will be based on their event and medical history. It's another piece of information that helps me come to a clinical decision, and, has saved my butt on a few occasions. If anything, this patient is at high-rish for a cardiac tamponade, which, with a monitor in place, you can start to see signs of. Remeber, early alert of your receiving facility with your suspicions will provide better care for him when he arrives. peace

Hello all, What are your opinions on the Canadian EMS magazine (and for safety sake, won't mention which magazine speficially) but they are well known as CEN .. Anyways, to be quite honest, I'm not overly impressed with them compared to JEMS. I've subscribed to both for the longest time, and as 'ad-driven' as JEMS is, (and even tho it's focused on USA practices), it contains much more information and I find it to be more user-friendly then CEN. What do y'all think?

I've often wondered if RNs and RPNs often complain about their experiences to each other with the most recent EMS personnel to show up for their 9-1-1 call. I'm sure this isn't a one-way street, but it would be nice to know what the 'other side' has to say about us ...

Someone mentioned what exactly is faith a few posts back, and to me, faith is best defined as this: "Faith is not to have a perfect knowledge of things; therefore if ye have faith ye hope for things which are not seen, which are true."