Mateo_1387

Get your epi and the tube ready, he's gonna code if you don't start to fix what's wrong.

I agree, be prepared for the worst. To fix his rate problem I would start an amio drip, 150 mg of 10 minutes, and also give a fluid bolus.

As far as the rythm, the patient appears to go from a sinus tach, to v tach, to possibly a fib, if i saw a twelve lead at a slower rate i'd expect to see a LAFB and probably another block.

Had a Lifepack twelve give a pulse ox reading on the truck antenna of 89%, so we put a NRB on the truck and it brought it up to 98%, :wink: jk about the nrb, but the pulse ox did read at 89 on the antenna.

had another lifepack at the same agency i was riding with on clinical break when we put it on a patient in hemorrhagic shock due to an abortion go bad. the sucker wouldn't do blood pressures or read in lead II. POS, we actually had to do a manual BP (OMG, thought I was gonna die, jk) But it was a good call that I got to run cuz I had to work around equipment failure and still treat the patient accordingly.

With 1 Million dollars to spend on my EMS agency I would increase the training of the paramedics to be able to understand patient conditions better. With the new understanding of patient conditions they would then be able to tell which conditions require transport by ambulance or by taxi.

Part of the money would go to buying taxi tokens. When a patient does not meet transport criteria by ambulance, they can get a taxi token to get to the hospital. With this program the ambulances can transport patients only needing ambulance transport and not waste time with the patients who don't need it !!!

With the money saved every year there should be enough for better things like even more education and lots more taxi tokens !!!!!!!

Now that I am a secret agent looking for terrorist I want a raise and a federal retirement plan......

Two cases:

20 YOM, GSW to left shoulder with no exit would, cardiac arrest. Unsafe/Unstable scene, Do you LSB?

35 YOM GSW Chest, No Neuro Deficit, A0x4, CC: Resp Distress corrected via Needle D, Do you LSB?

Case 1, Unsafe scene, Cardiac arrest, probably wouldn't work in the first place.

Case 2, No LSB, he needs a truma surgeon, not a long spine board....

the problem I see, is that remote possibility where a penetrating injury may have compromised the spinal cord.

I don't know...

The question is... When can we expect to see it back in PHTLS??? Or will it stay out of the books for good???

There is a chance of a compromised spinal cord injury due to penetrating trauma. If you do a complete and adequate neurological assessment then you can find a spinal injury or the absence of one. Like I said earlier if the patient is not showing the signs of the injury then he most likely doesn't have one. Statistics prove this. Spinal immobilization has always been a "standard of care" and it is being researched. The findings show that too many people are back boarded unnecessarily.

I'm helping as a role-player (and getting to sit in) for PHTLS, again. Apparently, PHTLS is saying that spinal immobilization is no longer indicated for penetrating injuries (including GSW's) to the thorax if patient is A&O without pain or neurological deficits (they had this whole little flow-chart).

It seems really counter-intuitive considering concern about cavitation injuries from bullets, but apparently if patient has not had a neuro deficit by the time EMS arrives, then there isn't one (NOT to be confused with faulty thinking that patients with cspine indications can be walked to backboard if already ambulatory).

Has anyone else been taught this? What do you think?

I have been taught this in my medic class I am currently in. I agree with it whole-heartedly. We use the BTLS book, btw.

In the trauma situation we are taught as medics to deliver the patient to the hospital as rapidly as possible. Trauma is something we can try to manage, but not something we can fix. It takes surgeons to fix trauma problems.

When we encounter a patients say with a GSW to the Left side of the chest and he is A/O and no neurological deficits, we can safely assume there is no immediate spinal injury. At this point what is going to help your patient is a trauma surgeon, not a backboard and C-collar and 3-4 extra minutes on scene to package the patient.

Every second used unnecessarily is time the patient is possibly developing one or more of the deadly dozen. In the cases where the patient shows neurological deficit or possibly AMS, ETOH, Significant MOI (the drunk guy who falls from 2 floors up) then spinal immobilization is necessary. He still needs the surgeon, but he also needs the backboard. But there are still times where I would move a patient who meets backboard criteria without immobilizing the patient. For instance if the patient is in a tight spot and he has a pulse but is unconscious due to trauma, and not able to be immobilized, at that point it would be life over limb.

I can see vaguely what you are saying. In EMS there is definanatly a shortage of Medics. Since our schools do not require us to work EMS and gain a ton of experience like physicains, then we need to be able and experience some of it at a lower level certification in order to obtain a knowledgebase. If we each worked for a year as a student, and I mean working it like a job every week then we'd all be great technitains. Doctors do that in their resedency.

The Non-STEMI is detected through elevation in cardiac enzymes like troponin.

If this scenario repeates itself reply to your medic "Might be a Non-STEMI, but I can only call it unstable angina till the blood work comes back".

Even Angina can cause false positive in the bloodwork. Troponin can be released due to ischemia caused by angina.

This same ambulance medic is not concerned with flight weather, as he wants to ground the patient and believes there is no problem with this. The flight RN, wants to fly the patient, and disagrees with the assessment of the Medic. Who gets to make the final transport decision??? I believe its the RN, but I just don't know for sure. Can someone provide me with some valid basis as to whether I am right or wrong?

Think of it this way. If you can't figure out who gets the patient based on each one's assessment (which should be the same) then put it on a doctor's shoulders. You both answer to one, so present the picture to them and let them decide. Should you not be in Contact with Medical Control then I say the decision rests on the First patient contact crew. I don't care if it’s the RN or the MEDIC. You both have the training to identify and deal with injuries, and the if the MEDIC got onscene and cancelled the helicopter, then there is no difference than if he cancelled him before he landed or after he arrives on scene. I say let the first onscene decide if yo can't reach medical control.

The matter is they must maintain, educate, train, for however many more years then basics do. That was the point I was tyring to make.

For good reason doctors train longer than basics do. They do everything basics can and then 1000+ times more.

If your solution to making EMS more professional is to make everyone take more schooling then I think it will backfire. If everyone went to school two years to just start in EMS, and everyone comes out as a paramedic, then the system would fail. Sure they would have the education, but they would lack good experience. Clinicals can be great places for experience, but not enough. Because everything in EMS goes back to the basics, we need to have a strong understanding of it. When you are new to EMS and take that first EMT-Basic course you are overwhelmed with information. The course needs to teach the fundamentals and then let the graduate get out and experience the whole deal. They have to start out small then grow. Without that initial experience when they become Advanced Learned Technicians, they will be lousy. When basics are first starting out riding they are taking in a lot of information. Not only are they worried about their patient care skills, now they have to worry about how to drive an ambulance, where to find everything in the ambulance, how to call for backup, how to deal with other personnel (fire, police), how to deal with certain patients, and how the whole system works.

If people came out as medics with lots of education and we got rid of basics (just because they are not as advanced as the medic) then we would really be kicking ourselves. The technician would have to have extended On The Job Training (covering at least a year) just to be comfortable with their skill. Also we would have to worry about losing a lot of people working EMS. We always need people and losing basics would hurt us. I am confident the loss would be due to increased demand on education and time. As advanced technicians it is our job to be a team player. When we find any technician who is not knowledgeable in an area, it is our job to help that person. That concept will only help EMS. To get these "wacker" basics fired up it might take a guiding hand from someone who sees the whole picture.

It won't be too long until the EMS system is way overtaxed that its impossible to keep up with. Especially with people always leaving EMS for bigger and better things its going to be hard to have employees. Mandatory overtime will be all too common. Something will have to change and I am sure it will be that we will have to deny transport. I also think it will also include EMS rendering treatment on scene.

This discussion brings up an interesting issue. I also think it leads to another issue which is why should we transport people who can walk to our ambulance. Although walking to the ambulance should not always equal no transport, it should make us think about whom we do transport. When a patient can walk to an ambulance what always goes through my mind is "why did they call in the first place" why not get in the car and drive themselves. Too often we have this view that "you call we haul." Just like we decide to give treatment to a patient because of their clinical presentation we should also be able to decide to deny transport based on clinical presentation.

Too often Hospital staff is ignorant as to what medics are capable of doing in the field. Although specific hospital staff may not agree with the treatment rendered by the medic, another one of their great minds (the medical director) wrote a set of protocols for universal use on patients. To earn the respect of Hospital staff we interact with it is our job to teach them what we are capable of. Nobody else will teach them for us. Our professional encounters with them should always be learning ones for them. When they understand what is being done and why they are sure to have more respect for the medic.

As for the doctor who gave you a piece of his mind......He sounds like he must have had other problems. When he was ready to blame something on you and disrespect you in front of other adults and professional colleagues he stepped over the line. I guarantee you that if you pulled him aside after he was done with the patient and flat out told him "Hey, Do no ever disrespect me like that again, if there is a problem you can address it with me privately” that he will give you the respect you deserve. When people know you are strong enough to stand up for yourself they will respect you. That guy might be a doctor but he is not God.

From my experience I do not believe 5 mg IM for a seizure patient who weighed over 180 pounds and was already on benzos was getting tubed because of your treatment. 5 mg is in the protocol for a reason, your medical director knows it is a standard dose for someone in a seizure.