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ksemt

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  1. Ok guys, I'll gratiously accept positive criticism as I'm a relatively new medic in a rural area and I don't see a lot but try to refrain from ripping me up too bad. My thoughts on this pt. are that both COPD and CHF are relatively chronic problems and if this is truly the first time the pt has experienced dyspnea then I have to question both of them. It's the "first time this has happened" that throws me. At least I'm reading this as being the first time anyway. I'm not sure how "new onset" CHF presents, yes we have HTN, nocturnal dyspnea (presumably the first time though), negative for CP, and possibly cardiac asthma and he does smoke. But we have no hypertrophy on the 12 lead, we have dry lung sounds, we have no pedal edema. I have doubts about this being "new onset" COPD also. As someone said no pursed lip breathing, no barrel chest, etc. Really the only thing pointing that way is the hx of smoking and once again it's an acute attack. Now, someone stated that a PE doesn't increase the work of breathing. Based on a pt I ran recently I will respectfully disagree. Of course my guy had recent surgery and was SOB on scene and only wanted help from his car to the house. The guy appeared to be in distress but not overly so initially, color was good, able to talk in full sentences, no CP, in/out wheezes but diffuse. Within a few minutes - sats in the 80's, hypertensive and breathing like a freight train. This guy was using every acc muscle he had. Granted it turned out to be a massive PE - he later died before our little local hosp could get him flown out. But I no longer believe a PE doesn't cause acc muscle use. And the few PE's I've ran have usually been tachycardic. It could always be an MI although we don't have much, if anything, at this time to confirm it. He has several contributing factors, smokes, overweight, HTN (we have no idea it this chronic HTN or related to the current problem - but it's likely to be chronic) I agree with the theory that most of the tx I've read won't hurt the pt and some can be used to rule things out I suppose. My tx: O2, Monitor, IV, VS - Depending on time out/distance/other factors I want 12 leads every 5-10 minutes if possible. CPAP is new here and I can only use it on "confirmed" CHF with pulmonary edema but I would have it ready in case things change. Neb. bronchodilator - like some said it shouldn't hurt too much and if it doesn't help I can lean away from COPD and more toward cardiac issues. Nitro (if we don't get significant relief from the neb tx) - Negative JVD, dry lung sounds and hypertension don't signal a RVI. Any relief from the nitro I head down the MI/PE/CHF route. And if this guy has convinced me that this is truly a first time problem by now I'm really thinking MI/PE - in that order. Have MS ready and play the MONA game... So, did I kill the guy?
  2. Thanks all for the replies...many were what I expected but most of you made me nervous enough to spend the afternoon on the phone with the KS board of EMS. I'll address that issue first. According the board (and the state statutes they referenced - blue text) I can... "Mobile intensive care technicians; authorized activities.... ©when voice contact or a telemetered electrocardiogram is monitored by a physician, physician’s assistant where authorized by a physician or licensed professional nurse where authorized by a physician and direct communication is maintained, and upon order of such person may administer such medications or procedures as may be deemed necessary by a person identified in subsection c"...without having written protocols is place. Do they recommend it? No, but it is legal. I can call in and get orders to anything that is covered under my "authorized activities"...I won't list the entire statute here but thats the gist of it. Keep in mind I'm talking following simple ACLS guidelines and not things like pericardiocentesis (although in theory they fall under "authorized activities" because I've been trained to do it, according to the board). Also keep in mind protocols are at this time in our medical directors hands awaiting approval, although it's proving to be a waiting game. Dust, No we don't have a good working relationship. I guess I should say the medical community and our service doesn't have a wonderful relationship. It stems from a service that has been lax in, well, lots of things. I'm working my butt off to change that but it's a slow process. Many of you stated you wouldn't work for a service that "hangs you out like that" or some such wording and no it's not a "have to" situation. True, it's not the best situation but it is my hometown/county. I have friends and family here that deserve better than what they are getting. Advancing to ALS is proving to be quite "problematic". A. The community doesn't know a BLS unit from an ALS unit and have no idea they are currently, and have been for 25 years, receiving the lowest legal limit in pt care allowed. B. The "politicians" don't want to spend all the extra cash to move up. C. "Many" of the current staff have no desire to change either...it's hard to argue against "it's been working OK for 25 years".
  3. I have a question regarding paramedics providing ALS care in a BLS service. I'm a new paramedic working in a small rural BLS service. Don't ask why I'm still there - long story plus I'm working to get the service to go ALS, at least ALS assist, but anyway..... My dilemma - for some reason we carry a few first line ACLS meds (in case a doctor happens to arrive on scene I've been told). My question is; I've been told by our service director that in case of a code blue I can call our hospital and get orders to follow ACLS guidelines - even though we have no written protocols recognizing ACLS. Am I safe in going above/beyond our protocols with only verbal authorization from our receiving hospital....I been told it's ok by some and a big no-no from others?
  4. Congrats to all this years graduates! I too walked on the 18th, had practicals and the NREMT exam out of the way so graduation was great! It's been a long two years.....
  5. Thanks Thunder, I know this sounds really basic to most of you but keep in mind I'm new to this and that's why I'm asking... I get the whole preload thing, in general anyway. But wouldn't some type of sympathetic compensatory device kick in to increase the heart rate (like the renin-angiotensin system) whether it affects the B/P or not? Doesn't hypovolemic shock usually present with an increased heart rate, at least early on? Wouldn't the respiratory rate be increased somewhat, instead of reduced (rate of 10)? Are we saying the meds are causing the entire problem by offsetting every compensatory device? I guess we've proven that by finding that the fluids worked? The pt isn't bleeding out, it's not 110 degrees out and the pt hasn't been playing golf all day, and I'm at least assuming the pt is not showing visable signs of dehydration (to cause the fluid loss). The pt is in hypovolemic shock due to the meds causing systemic vasodilation and the meds are inhibiting CNS's sympathetic responses (i.e. incereased heart rate and respiratory rate)? Hmmm, Ok, so assuming this isn't a frequent flier, not a drunk that mixes alcohol with the meds daily (he's been having a glass of wine every night with no problems), what do you guys think caused the problem TODAY? He's "probably" been on the cardiac meds for 5 years since the MIx2. The Parkinsons meds could be new I guess and causing a CNS problem that reduces HR, B/P and respiratory rate? Unless there's been a large shake up in meds lately any idea why the meds caused this today?
  6. Is this thread over? As a paramedic student I was finding it helpful. I have been learning a lot of the "what" to dos but I feel real weak on the "whys". Can someone explain the hemodynamic physiology and what is/was going on with pt. "Why" did the fluid bolus help? A "pipe" problem from the meds? I've been told to be very leary of giving fluids to the elderly. It seemed to be a small amount of fluid to make that much difference? Just trying to learn as I go...
  7. In Kansas, try; http://www.kemsa.org/ Of which our Director is on the Board of Directors.
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