mobey

I`m a bit lost and can`t concentrate right now (I know, lame excuse).

Has he experienced something simliar before?

First onset of Multiples Sclerosis?

Never had anything similar.

I tend to do what I can to massage their uncomfortable spots. The reason they're having the discomfort is because of the beginnings of a pressure ulcer.

http://www.ncbi.nlm..../v018p00051.pdf

Masking that discomfort with pain meds does nothing to reduce or relieve the damage being caused by the board. Providing a return of capillary blood flow in the affected areas is what is required. Since my patients can be strapped to a board for as long as 6 - 7 hours I do everything I can to alleviate the pressure on contact points.

That is a great point to put in this thread, as I have in many others.

Tricks like a BP cuff under the lwr back to inflate/deflate periodically, Tipping the board a bit and every half hour or so with towels under one side, and loosening/retightening one strap at a time to allow blood flow can alleviate alot of discomfort by actually solving the problem.

Hi, I have been an EMT for about 2 years now, but have not gotten a job with which to use my knowledge/skills during that time. I' am moving to Portland very soon, and plan on applying with a few companies in and around that area. But here is my question: will I be hired, or even interviewed if I have no experience? I have been out of the game for a while, and before heading out to the field, I would like to refresh myself, or practice, before my first day. Will an ambulance company...be ok with this? I believe I could be a valuable asset, but could use some (extra) training before working. Should I get into an EMT refresher course, and then apply? Or, apply, and mention my concerns with the company/agency? I'm a little lost. Thanks!

I don't know what your looking for here. None of us can answer these questions without knowing the future.

I suggest taking an online refresher, instead of "expressing your concerns" to an employer (AKA, telling them you're incompetent).

Tennis elbow Hahaha

He has been drinking mildly all night.

Possible stroke? I'll ask him..... Yup, it is possible! (but not this time)

HINT: Consider the pathophysiology of the pain.

They are pink and dry. From the elbow up they are warm, and he will not let you touch below, however, there is no visual difference between the distal & proximal arm.

Beyond what I know, but was this at night or day? You said 2 am, then warm summer day.

Keep me on my toes.... I like it!

It was a nice summer day leading up to the middle of the night call

He binges once a week, drinking 8-10 drinks.

Headache? Dizziness? Vommiting? Nausea? Nope

Any obvious marks with the neurological examination that could be separated from his ETOH intake? Pupils, etc.? Nope

SOB? Thoracic Pain? Nope

Any traumatic injury prior? He denies falling, but states he was in a "scuffle" earlier in the night with his scronny friend.

Heavvy Lifting? Prior problems with back/spine? Not any more than usual while setting up the carnival rides.

First thought says either cerebral problem or propable spinal/nerve thingy, although presentation would be kinda weird with only both arms being affected... Circulation/motivity/sensibility in legs or arms in any way changed? He will absolutly NOT allow you to touch his arms from the elbow down, for pain to even lightest touch. Legs are unremarkable, and he seems to be holding his immense body up just fine with them while standing.

OK, the title was to get you reading. Now that I've got you...

Called to the fair grounds where the Carnival crew is in town. Looking for a 28y/o who has been electrocuted.

There you find 20+ "Carnies" drinking and having a good time.

You ask for the patient, and a 6'4 340lb young man walkes over and introduces himself. He is in no obvious distress, however is holding his hands out in front of him as if they were soaking wet (if you get the picture).

He is slurring his speech slightly, and has ETOH on his breath.

He states that he was sittng on a step drinking rum & Coke, when he started to get tingling in his fingers, that has now turned into an "electric feeling" in both his arms from the elbow down.

It is 2am

Warm summer day

BP 188/92

HR 76

RR 22 Sp02 99

BGL 10.2mmol

Temp 36.6 (normal)

Medications: Metoprolol, ASA 81mg, atorvastatin.

PmHx: Pre-diabetes, MI w/Stent x14mos ago. Hyperlipidemia, Hypertension, Smoker - 7 pack-year.

Not for pain control mobey. I use it for pt. comfort. I have Fentanyl or Morphine for pain control. As you know though, not all pt.'s require it. I just think it is bad form to transport someone for over 30 minutes of so on a backboard w/o making them as comfortable as possible.

That was a bad play on words on my part there.

What I meant was patients most commonly complain of pain at contact points with the board (back of head, shoulderblades, pelvis, etc, as well as general lwr back pain). I give these patients morphine.

If they were generally squirmy or claustraphobic I may consder Midaz, but have never really had that.

Not disagreeing, just intrigued.

. For really long transports, I will medicate the pt. for comfort. 2mg of Versed usually does the job for openers. I have had some MD's question this practice but once I explain my reasoning, they're usually ok with it. Mostly though, I don't have a problem.

Interesting that you choose sedation as pain control?

Dwayne: I will indulge as devil's advocate. (Sorry chbare)

When looking at a bp as a make or brake on diagnosis (don't defend yourself here... just being general) I think it is important to take it to the next level.

If systolic is a representation of LV output and Diastolic is a representation of vascular resistance, we can put this into better context.

Typically, a low systolic is a result of poor preload, or poor LV function.

Typically a low diastolic is representative of poor vascular tone.

So in this patient we see a slightly low systolic, and perhaps a lack of hypertension.

It can be argued that this could be a result of poor preload, as a direct result of hypovolemia caused by the tachypnea.

With the diastolic of 75 we could accept that her vascular tone is intact and working normally, which does not fit with the vasodilation caused by histamine in anaphylaxis..

I agree, this is a great resource for students trying to memorize assessment algorithms.

This is however, possibly the most micromanaged set of protocols I have ever seen!

OK, so you see a child drowning in a lake that has a sign posted that says "No Swimming". Do you honor the rules and let the child drown ? EMS is all about gray areas that lie in between the rules.

I would call the lake owner to quantify if that is recreational swimming, or lifesaving swimming to save a drowning child.

This is as likely as seeing someone choking on the side of the road on the way to a call.

You're reaching.

Please see my signature below.

I have a pair of gloves and a high visibility vest in my glovebox and that is it

It is interesting you can carry adrenaline for administration; do you have a prescription for it?

Epi is not a controlled substance, so no prescription nesassary. It is like carrying antibiotics.

, I do not carry medications in any of my packs except paracetamol, Aspirin and GTN.

After my girls got into a wasp nest and recieving over 10 stings each on a remote part of Vancouver island, I started carrying Epi and Benadryl as well.

Chicago Paramedics have prehospital licenses?

Cool

The specific law is covered in a few places here in Canada.

First to clarify.

The charge you are asking about is negligence.

In order to be true negligence there must be 3 criteria met.

1) Must be a duty to act

2) Must be a breech of that duty

3) Must be adverse outcome as a direct result of that breech

Duty to act: If we are already on a call, we are classified as "not for hire", then we have no duty to act.

That was easy....

Now the grey part: If we are enroute to a low priority call, and we witness a potential patient, we must advise our dispatch or call 911. At that point we may get re-routed to respond to that scene instead of that original low priority call. The legal responcibility at that point is on dispatch.

Now if you stick your head out and ask if everyone is OK..... well then, you have created a relationship with the potential patients and you're back on the legal hook. You have put yourself in a tough position, as you now have to triage between the people at the crash and the patient you are responding too.

Of course you can always give the crash-patients information to dispatch, and let them advise you which call to attend too, giving them back legal responsibility.

I hate you News Robot.

I refuse to watch the news because it is depressing and full of death, shock, and awe.

Seems every 4th post on my "View new posts" is the same shit from you.

Nothing against Robots.....

I think it really depends on your resources.

If you are in a highly populated state, I would suggest very little. Stopping to help someone brings about it's own risks, and if you are in a poulated area, help is never far anyway.

The reality is, there is really only a very few times when having sonething done in the first 15min will effect the patient outcome.

I have a basic 1st aid kit and a pair of gloves for my local travels, but if there is no obvious severe injury, I don't stop..... I just call 911 and move on.

That said, I travel into remote areas of the prairie provinces frequently. There are stretches of road lasting hours that do not have EMS or police coverage for 100km or greater.

So I choose to carry a fully stocked ALS kit with me on those trips.

I've noticed a good bit of EMS providers suffer from ADHD, so I'm just throwing my personal experience out there for those that are in a similar situation.

Yes, well ADHD/ADD was the "autism" of the 90's. Everyone whom learned as an individual rather than the way our school's model demanded of them was labeled with it.

Moving on before I offend someone......

I too learn under a different model than reading and memorizing words. I MUST have a concept of "why", for every single illness/treatment. Sitting to read a textbook to me, becomes like reading the maintenance manual for my truck. I can sit and read the whole thing, grab hold of a few important points, but the bulk is glazed over as I bask in the excitement of having a new truck. So by the time an oilchange is due, I can't find the drainplug let alone remember the oilfilter number.

Is my redneck showing??

My suggestion is video's. Grab a uncomfortable chair, some playdough to fiddle with, and start hunting down videos regarding pathophysiology, then how our drugs interact with that Patho.

Youtube is just great these days.

Check out: 02demand, ancient scholar, USMLE, to start.

That's how I got through most of my education, and people rarely die under my care.

ever tried normasaline for pain control.... works wonders

I have never heard of Normasaline.

If you mean Normal Saline, I can direct you to literature that disproves your analgesic claim.

Back to the thread.....

I have dealt with a few pseudoseizure patients multiple times. This was complicated by the fact that hey also had epileptic seizures as well.

I am with Doc on this one, in that, if you think pseudoseizure means "faking", you need to do some research to start providing better care for your patients. That said, I am not real quick to give benzo's to pseudoseizures, as I am so charming - I can usually stop them with some coaching.

I do not however, say an absolute "no" to treating them with drugs. It just goes from treating a siezure, to treating a psyc event (Which uses the same drug).

These are my anecdotal tips.

Pseudo:

Typical patient - Female, teen to early 20's. Hx of depression. Perhaps drug us history, current or recovering

Eyes cannot be pryed open

Eyes making purposful movements (Looking at you)

No tongue biting, peeing, (as was said by Dwayne)

Will be in a safe place (Bed, couch, floor away from furniture)

Will be ventilating adequatly (As detected by EtC02 and Sp02)

Cannot tolerate NPA

Rythmic up and down movement of head, but not hitting head on the floor when it comes down

Withdraws from pain at toes

Withdraws from pen scratch on foot (as if testing for Babinski)

Cooperates with I.V. start

I dunno.... that's what I look for.

Bottom line for me is, wheather it is psycogenic,or neurologic, it needs treatment.

A all out faker is prety easy to disern by taking a proper history IMO

I am not refreshing on the clotting cascade, but basically platelet adhesion is the first step in forming the clot. Once the clot is passed that initial point, platelet adhesion is less important. Thrombin activating fibrinogen to form Fibrin then becomes a more important factor in forming a solid clot.

True enough, platelets will stick to this now solid clot, and continue the cycle..... but in this case, inhibiting that aggrigation is not going to prevent the clot from continuing to grow through the: Thrombin - Fibrinogen - Fibrin mechanism.

Furthermore, and possibly more significantly, if platelet adhesion is stopped and the clot weakens, one would expect it to possibly break up and continue in the circulation till it becomes a Pulmonary embolism.

Now you got a sore leg, short of breath, and a pneumonia..... and you have to hear me tell you "told you so".

Another thought: Ever had your INR checked?

Yeah man, I am with the Doc's here.

i fully understand that you know the ASA is not breaking down the clot. But I am unclear as to why exactly you are taking it?

Perhaps you think it will stop further clotting? Or prevent any new clots? Either way, you know it does not hold water.

I am also concerned the dose you are taking may result in further complications over any significant amount of time.

You are much like me. A terrible self-helth advocate.

If this were one of your patients, What would you recommend to them?

Go get this one dealt with, then concentrate on preventing them in the future.

You old guys gotta take these things more seriously

Edit: totally unrelated, but I hate when volts, amps and so on are used without proper context.

Buddy, I love that you commented on this.

When I first wrote my post I just said "volts", fully aware that I do not really know enough about electricity to be using tthe terms. I thought to myself.... better soften that a little because Chris will call you out. Hence, I wrote Voltage/Amps.

Thank you for living up to your neurotic label

Anecdotally, I have had lightning hit a lightning rod a hundred feet from me, and it knocked me off my feet. With no entry/exit burns I doubt this guy was actually zapped directly, or if he was, by the time the electricity hit him, it was low enough voltage/amperage to not do significant harm.

In patients with no insurance, I do scare them into driving or hitching a ride to the ER. This preticular case, I would probably inform him that although he looks ok on the outside, he may have a "cooked" organ inside.

But then again,..... I have been accused of being too abraisive at times.

Sounds like you did good.