Mateo_1387

If you were looking a treatment modalities, your first option of nitroglycerin and aspirin may not have been the best of choices. Being that this is a rate problem, slowing his rate down would have been the best choice. Remember that you patient is stable at this point. A call to medical direction may get you what you want. Pain a clear picture for the doctor in the emergency room. The doctor may allow you to use amiodarone, but it is obvious that this patient does not need cardioversion. The doctor may say for you to just bring the patient in. In which case he just made your day easy. You would want to monitor the patient, make him comfortable, start an IV, some O2, and take him to the hospital. To me, if you are not allowed under protocols, call the doctor and get their advice/permission.

Wow, is really all I can say. I also feel for the family. [web:cb93048329]http://www.msnbc.msn.com/id/24982210/&GT1=43001[/web:cb93048329]

Just from initial impression, I would have probably treated his rate problem, which was the uncontrolled a fib. When dealing with patients, there are chances that different people will treat the patient with different modalities. In my opinion, this patient would probably be having a rate problem, which is causing his chest pain and shortness of breath. Think of it like this, his heart beats 150 times a minute for a long period of time. It is bound to get tired. You have to remember how closely the heart and lungs are related. Often times when you stress either the heart or the lungs, it is going to affect the other organ. For instance, you have pulmonary edema, The fluid builds up in your chest wall, you become short of breath, it causes your heart to race, you get tired, you have lower oxygen levels, the heart keeps using more and more oxygen until it is starving, and thus causes the patient to have chest pain. The same goes for a patient having a cardiac event. For instance, an MI patient. They have ischemia in their heart that causes them to have less cardiac output. Oxygen is not delivered as well to the body. They already have the chest pain, but they feel like they are not getting enough air. Hence they are short of breath. Your patient may very well have been having a nonSTEMI, but the part I think others see is that he has a rate problem. His problem will probably be fixed by it. There are also links to A-fib and pulmonary edema. So if they fixed the uncontrolled a fib, I would imagine it will take care of the pulmonary edema. From the ECG you are describing, it sound like a possible right sided MI. Maybe you can find an ECG that is similar to the one you saw that is online. Had this been my patient, I probably would not have cardioverted. The patient had moderate pain, has a stable blood pressure, and was conscious. Electrical cardioversion would not have been indicated. I would have probably used a drug such as diltiazem or possibly amiodarone to bring his ventricular rate down by slowing impulses through the AV junction. How did the doctor treat the patient?

:laughing3:

Please show me a negative triphasic QRS complex.

Seven Nation Army- By The White Stripes ! Definitely the song of any day.

I do not remember saying to take short cuts. In the scenario I presented (the MVC) it would have been easier on the body to clear c-spine and let the patient walk.

No offense taken.....yet...... There are always exceptions to every rule. Sure there are some degreed idiots out there, but there are a lot more medicmill idiots. To be fair, they are probably not all idiots, just uneducated. The two examples I gave I see commonly. Believe me when I say this, in the two systems that I have worked in, I have not seen a single medic mill medic listen for heart tones, not a one ! The only other medic I have seen (besides myself) listen to heart tones is one other degreed paramedic. I have never seen a non degreed paramedic listen for them. I do not think it was a deal of laziness. I think it was a combination of being uneducated, and scared. It is a whole lot easier to clear someones C-spine, let them walk out of the car and into your ambulance than it is to apply a KED, and you lift the person out of the car, onto a backboard, and then wheel a stretcher to your truck. In the chest pain case, it would have been easier to just say the patient had aortic stenosis, and not to give a drug like nitro, which may severely reduce his pressure for one, and is most likely not even indicated for this patient. That to me is easier than going through a chest pain protocol, checking blood pressure out the yinyang, and get the patient all worked up that I am only doing this because it might be a heart attack. My main point is a degreed medic will have a full Anatomy and Physiology course, Psychology courses, English courses, and other courses such as what I listed, plus more time for more intense medical education making them a well rounded, more educated medic, that will be much more prepared to deal with patients then someone who goes through a medic mill and gets the bare minimum. Me too ! Medical knowledge is not common sense. If we want to be professionals we have to have the degreed education. :roll: Forget it

About what? You are being very vague. I am curious how you came to your conclusions and why you see things as you do. I am talking about your view on patient presentation.

Either you had some really bad classes/schools, or some horrible textbooks, and horrible instructors. My paramedic education has helped prepare me to identify what is going on with my patients. The blanket statement "more times than not, your patients isn't going to be the one you read of in your text book" needs to be backed up. My patients constantly present "textbook." Why do you have the perceptions that they mostly do not present "textbook?" Why have the education with the textbooks if they are not going to do us any good? It does not make too much sense to me. I agree with the statement that education makes a more confident provider. As an educated provider, the paramedic has an understanding of what is physiologically going on with their patient. I believe that an education makes us better at assessing our patients also. I also think that a solid education, degree, and the whole DustDevil Curriculum will help any medic in the long run. If and when EMS advances, those medics are going to be the ones with the education and foundation to be advanced providers. As far as how education affects treatment, I think education affects treatment in a positive way. I can give you two examples that come to mind. A MVC. Low velocity, patient was restrained, sitting in car when you arrive. Its an accident, it does not look to bad. Now how many medics have you seen that go into CYA mode and immobilize a patient who has absolutely no physical injuries, complaints, or symptoms of injury? The care the paramedic would have provided in this instance would have been cookbook, CYA, and just plain stupid. The patient did not need to be placed on a backboard. An educated medic in this instance would be expected to understand the kinetics of the accident, the effect it would have on the body, the patient presentation, and make the right call that the patient did not need immobilized. Second example. You go to a chest pain call. Patient has been having chest pain for a couple of hours. Maybe some cardiac history. The patient is obese and ate bojangles his whole life (for those who do not know, bojangles is a friend chicken restaurant chain in my area). So FD pops Aspirin and O2 on the patient before you get there. The uneducated medics asks a few questions that they will probably not take into consideration about the patient presentation and put on a monitor and go ahead with nitroglycerin and maybe morphine. I am sure all of us have seen this countless times. An educated paramedic would be expected to get a detailed patient history, do a detailed physical exam, which would include listening to heart tones, at which time he would not aortic stenosis. This would clue the paramedic into how to properly treat the patient, or better yet what is probably the cause of the patients chest pain/discomfort. The list can go on and on. These are just some examples that I came up with and have seen.

I never understood wanting to marry someone in EMS. Here are my reasons When you get home when you talk about work, its all the same, all the time Your significant other may be smarter than you and put you down. EMS people can be......well.....just.....plain weird. and reason number 1 Very hard to find a sugar mama in EMS

Now that I think about it, I would have gone off to college, partied my ass off, flunked out, worked some crappy jobs, gone back to college, and then do something worthwhile.

You mean this time it was not a mexican driving drunk? How did that happen??? (We have a bad problem in my area with mexicans driving drunk)

Sorry Dude, I dropped your pizza. Oh Crap, I left the drugs at home, how's about I go ahead and take the money? Oh, were talking about babies, my bad.

Cool thread, if I did not get into medicine, I would have gone into either music, language studies, or working in one of the family businesses. To be quite honest, being a paramedic and a nurse (yep, I am going for nursing school soon) was the last thing on my mind when trying to figure out what I wanted for a career. It has only taken 5 college switches to figure this out, and two more (or maybe three) switches, before I finish all the degrees I want !

I know this was last year, but I was looking through my old posts and came across this one. So I was thinking about what the answer would be and this is my newest conclusion. The patient is hyperkalemic. She also takes Dig, so that is going to inhibit the sodium potassium pump. So we give Calcium to counteract the potassium, hopefully causing it to enter into the cell by the CaCl gradient. So, so far we have increased potassium, and increased calcium, but we do not have increased sodium. So the sodium that enters the cell is not able to cause depolarization of the cell and the patient ends up ends up in cardiac arrest. I guess the way I am thinking of it is the calcium and potassium are kind of like a Sodium channel blocker, they do not allow the sodium to work. I am really digging on this one. If this is not the answer, let me keep working on it, please. Thanks Matt

That is my favorite feature of the LP12. other than that I do not care for it too much. The large screen is nice, but not necessary to me. I have had sufficient use of both Zoll and LP12 to know that I like the Zoll. I have never had a zoll fail in the middle of a call. Countless times I have had troubles with the LP 12. I have had the trouble of the phantom pacer spikes, and some of the BP reading problems mentioned earlier, but those are easily solved. Look for a pacemaker, or make my partner take a blood pressure ! Zoll just seems to be a sturdy machine. I've seen them go through hell and back and they work just fine. I cannot say the same for the LP 12. They are so fragile. Zoll has a better size. The strips from a zoll seem to be better quality, in my opinion. The number 1 thing I like about LP12 is the turny knob thingy. It makes marking interventions during a code a breeze, and just navigation through the menus a lot faster. Even with that feature, I still prefer a zoll.

You never think your family is really sick, and when they are you think they are just using you like every other loser that really calls an ambulance, but they cannot help it that they live with you, and as EMS were in the mindset that "you do not need an ambulance, or me."

I get what you are saying. Thanks for the reply. I agree, if you have to transport codes, just because your system says/demands so, then there is no reason not to drive in the manner you described. As far as calling codes, I think AHA calls for 20 minutes before calling. Personally, my service calls for 25 minutes, but for a coarse V-fib code they have worked much longer than 25 min. I know what you mean about "tradition." It can be such a stubborn and annoying quality of an EMS system. I hope for your sake and your patient's sake that your system moves to working codes on the scene. One of my agencies currently does, the other I am working on !

I have to disagree with most of your post toutdoors. A highly educated Dr should realize that when a cardiac arrest patient is transported by EMS, the chances of ROSC fall greatly. It is more of a benefit for the patient to be worked on scene. Your quote above said it all. When we transport codes, the chances of them leaving the ER are very slim. Working codes on scene have many benefits. 1) The risk to the life of paramedics and the general public is eliminated to nearly zero. 2) Chances of ROSC are much greater. 3) The family does not get a false hope about their loved one. 4) Families usually appreciate the effort that is put towards their loved one, and generally accept that their loved one is dead, should the code be called. 5) Probably most important - you give the dead patient the best possible chance they have to live by working them on the scene. I am sure there are more, but those five were the first to come to mind. ACLS is ACLS is ACLS is ACLS in the hospital or in the field. Transporting codes is a thing of the past !

I can give you another reason why the fire department should not have to answer a medical call. When the fire department goes out on a call, who do they call for back up, they call another fire station. Lets see, when a police officer needs assistance, does he call the ambulance to wrastle some guy down, no, he calls another patrol car to assist him. When an ambulance calls for assistance, they call an ambul......oh, oh, oops....they call a fire truck. What sense does that make!?!?!?!? They should be calling another ambulance. That way they can get double the personnel and double the paramedics on scene to help an ill patient.

For known kidney stones, I do not think it is a problem to give pain meds. One place I work for specifies that persons with kidney stones are given Ketoralac, and if it does not work then a narcotic may be used. As far as the other agency I work for they are under the impression that abdominal/flank pain = no pain management. I believe it was Doczilla who had a post that went into some detail about how narcotics should not cause a problem for a physicain to performing an assessment. If I remember it right he said there would be lab work done, physical exam, thorough history, and many other factors that will lead to the diagnosis. I am just thinking out loud, but if a medic used morphine to treat abdominal pain, and the doctor really wanted the patient to be in pain to perform a proper abdominal exam, then could he just use narcan to reverse the effects of morphine?

The system I work for uses "Trauma Alert" and "Trauma One." When a paramedic calls either in, it is because the patient meets certain criteria, and only that criteria. This way everyone is on the same page, and trauma's are categorized properly. The statistics we see each month show that our alerting system is accurate. Only one or two traumas a month get downgraded or upgraded. The trauma notifications can work. I would just think that getting everyone on the same page would be the right idea. At least giving the trauma notification gets the gears into motion to get the patient into surgery, and definitive care.

Unfortunantly this practice has been very prevalent. The supreme courts have justified it in their rulings. Quite a shame if you ask me. Something about the parents have the right to be in control of their child's welfare and healthcare.

Well, since you said it...........WTF, they let that idiot pass !!!! One day I hope to join the ranks of the great degreed paramedics......sigh.......one day soon. CONGRATULATIONS Kaisu !!!