zmedic

The benefit is that nebulized (or more commonly intra nasal spray with an atomizer) gives you the ability to have people like EMTs or bystanders who don't have the ability to give IM/IV drugs to give Narcan. There are a lot of rural places that don't have medics and have a big problem with opiods. Narcan is a pretty safe med and narcan up the nose sure beats bagging the patient for an hour.

When I took a concealed carry class they were pretty clear that it wasn't an unrestricted right to carry. So if there was a location (hospital, school, post office etc.) that said you couldn't have a gun there you couldn't bring it in, regardless of your license. People who come into my ER get parted from their guns, knives, pepper spray and billy clubs. Those that have a problem with that policy are welcome to leave and seek care elsewhere, or don't get care. Someone else's right to carry does not extend to my ER, a place with children, intoxicated people, gang members. Those that disagree are welcome to have a talk with PD. And I find they tend to take my side.

The above protocol I think is great. Take the animal if you can, but if you have a specific reason to think it is going to harm patient care or be a danger you can have someone else bring it to the hospital. And a nice compromise between the "you must bring the dog no matter what" people and the "all dogs are dangerous and can't come in my rig." It's also a nice reminder that this is exactly the sort of issue that protocols are great for, things that are likely to happen but aren't every day events and are hard to sort out on the fly.

I feel like in general services dogs should be brought to the hospital with the patient. What makes me a bit uncomfortable is that I can think of a lot of situations where the patient isn't in a position to actual hold or control the animal, so now you have this dog that no one is really responsible for. For example, what happens when a trauma patient is brought in backboarded and c-collared, and has to get evaluated by the trauma team and then taken for CT. Where exactly is the dog during all this? The dog can't sit on the patient's chest during the CT. The x-ray tech can't take care of the dog and do the scan. I think it is important to make the distinction between the normal case of "I have a service animal and I want to bring it with me to this location and will be monitoring the dog" and the situation of "I am incapacitated and need someone to bring my dog to the hospital and then take care of it while I am being treated." The situation in the article seems to be that the patient was fairly stable so fine, let the dog sit on his lap and try to ensure that someone could meet the patient at the hospital to take care of the animal while he was being treated. Or quickly see if there was someone else on scene like PD who could transport the dog. But I'm not sure that a paramedic has a legal requirement to bring a transport a service animal if the owner of the dog is not in a condition to care for the animal themselves. All that being said, EMS has a lot of situations that fall into the grey area where you have to make a judgement call. And ideally should should be able to find some solution that is acceptable to you are a provider, and that doesn't piss off the patient to the point where they are calling the paper and a lawyer. I have a feeling that the medics took a position and were jerks about it, that if they nicely explained to the patient "I am really worried about you and can't provide the care that you need if I am also taking care of your dog, is there another way that we can help get your service animal to the hospital that is acceptable to you so we can treat you?" Something like that.

Didn't mention them because a lot of ambulances here in the US don't carry them. And I'm sorry that my one liners didn't have the complexity that some people were looking for. One of the previous posters said that they couldn't keep straight when to use which treatment so I generally broke them out. Sure there are specifics on which afib to use diltiazem, which bradycardia get atropine. Hence why you can't learn ACLS from a internet post that takes 30 seconds to read. For the test, you need to know the cookbook. And in practice during a cardiac arrest it should be fairly automatic. Seeing vfib without a pulse should automatically trigger CPR, defib, epi/vasopressin.

As far as ACLS goes, you are dealing rhythms that are either too fast or too slow. Too slow and you speed them up (atropine or pacing), too fast you have to slow them down (syncronized cardioversion, diltiazem, beta blocker, adenosine) or they are a mess (fibrillatiing) and you shock them. Asystole they die. That's most of what you need to worry about. If they rate is about right, and it's a narrow complex and something like first or second degree heart block, the problem isn't the rate or the rhythm. It's something else. So a 1st or second degree block, or a junctional rhythm with hypotension needs some other treatment (stopping bleeding, fluids, dopamine.) It's not really an ACLS problem in that case. You say you can't get a straight answer. Here is what I have off the top of my head: Adenosine-SVT Cardioversion- unstable narrow complex tachycardia, unstable afib/a flutter Defibrillation- unstable Vtach, Vfib Atropine- bradycaria Pacing- symptomatic bradycardia Mag-Torsades Epi- PEA, vfib/pulseless vtach Diltiazem- afib/aflutter that doesn't need electricity and is new onset There is ACLS in a nut shell.

Isn't there something about how FedEx/UPS can carry toxic/hazmat materials if they are under a certain weight/size? Scary.

New York City, manhattan.

Not sure I'd start antibiotics. Especially since 1) she had similar symtoms before delivering (thereby less likely that it's a new problem) 2) The uterus is usually examined after the delivery, so less likely that the has a big retained piece. 3) A quick ultrasound can rule out retained products. Before you start thinking she's septic from retained products, does she have a fever? Sounds like no. vaginal discharge? Is she writhing around? More typical for kidney stones. Does the pain radiate to the right shoulder or get worse with food? More likely gallstones (especially since she's had them. Appendicitis, round ligament pain are also on my differential. Truth it it doesn't really matter. She needs rapid transport, an OB/GYN consult, ultrasound, maybe a CT. And ideally pain control, but if she wants to suffer that's her choice.

Yeah. At the end of the day it is the responsibility of the person doing the transport to decide if they feel comfortable with the transfer. Whether it is an EMT being asked to do a transfer that is clearly ALS, a medic being asked to titrate a medication they don't feel comfortable with, or a situation like this. I personally think I would have called the supervisor back and had them come to the scene, show them the size of the ambulance etc. If they still want to do the transfer let them take responsibility for the call. I'll drive their truck and they can sit in the back.

The problem with kiwi's data is what do you do with that in the US? It's apples and oranges. I think it's great that down there they have a great success rate, but like he said, they have medics with 6+ years of training and lots of experience. So I don't know what to do with that data when deciding if my medics (when I'm a med director) who have a year of training and 6 months of experience should be able to RSI. I also think the need for RSI is going to go way down as more ambulances get BiPAP. It's reducing the number of tubes we're doing in the ER. And I think RSI is sorta an all or nothing thing. Either you are doing it all the time (like at least monthly) or you shouldn't get to do it. I don't want my medics trying to do RSI once a year.

I'm a fan of my cardiology III, I like having both bells. I've been using it for years, still works well in the ER.

You should take a look online for some general guides about interviewing, I'm no expert but here are my thoughts: 1: Dress appropriately. A little bit tough for a job interview like EMT, where as a guy I might be a bit overdressed in a suit. I'd probably wear a shirt and tie, kaki pants or dockers. You might want to wear the female equivalent (keep in mind you are going to be doing practical stuff, so I wouldn't wear a skirt, I wouldn't wear anything low cut that you are going to be giving a show when you bend down to assess the patient.) 2: Think about the following questions, you don't need to memorize answers but you should have some ideas of things you can talk about: a) what are you greatest strengths/weaknesses tell me about a time you've worked well in a group? Worked well under pressure? c) Why do you want to become an EMT? d) tell me about a patient that had an impact on you? e) why do you want to work for this company? f) What would you do if: you think your partner is doing drugs/stealing 3) Know about the company. Look at the website. ask people about it. 4) Drive to the company where the interview is the day before, last thing you want is to be trying to figure out parking 5 minutes before you interview. Good luck

For all the worry that people have over not stopping, I don't think I've heard of an EMT being actually sued for not stopping. I look at it this way. You became an EMT to help people who are in need. If you come upon an accident or someone needing help and you can safely help them, and there are not already EMTs/FFs on scene, why wouldn't you help? And to the argument that you don't have any gear, if the goal is to make people feel better, if all you do is sit there and hold there hand and check a pulse they are going to feel much better that someone is there with them for the 10 minutes it takes for the ambulance to get there than if they are sitting in their smashed car alone.

The reason to use narcan is because the patient has depressed respiratory drive, not decreased mental status. The indication for narcan is respirations less than 12 a minute. The risk of narcan is taking a patient who is just chilling after an opiate OD and putting them into frank withdrawal. It may have some use in diagnosis but if you have to give it I think you should be giving dosages of 0.2-0.4 mg at a time. 2mg is too much unless you are about to intubate the patient. I second no using flumazinil. Most benzo ODs aren't so bad that they can't control their airway. And the benzos may be keeping other withdrawal, like from alcohol, under control. Then when they seize giving more benzos doesn't work.

Where I used to work we covered a bunch of long canyons. Not a bad idea to be able to handle N/V when you are stuck with an ALS patient who has to stare out the back window at twisting road for 45min

Not to start a fight with Dust, who'd win, but I'd like to talk about the idea of not having BLS rigs. I worked in a county where we were contractually obligated to have a medic on every rig, and that seemed really wasteful. A large percentage of our patients, like 80%, could have been managed on the BLS level. They were stable, didn't need drugs/pain control. It costs the system a whole lot more to have a medic on every truck. A well trained EMT should be able to handle a lot and get ALS backup when they are in over their head. (Clearly ALS should be dispatched immediately to certain calls, like chest pain, SOB, etc.) Thoughts?

One big reason for the discrepancies between places is policies. I worked for a private company that said statistically only about 5% of our patients should be brought in L/S. Every emergent run was QA/QI, and while that was mainly to check medical care, if you were running hot when the patient didn't have any idications you would hear about it. So most patients didn't get run LS, and those that did were the really sick ones who needed it. I thought it worked well.

I think emergent response is still indicated for events such as suspected stroke or MI, where even a five minute difference can be a big difference (MI you lose 1% of infarcted area per minute) I’ve also had patients that in the course of the ten minute ambulance ride went from being awake and alert to unconscious. In most urban situations emergent driving saves very little time, though on long transports the savings in time may be more dramatic (I’ve had 45min emergency transports where I probably saved ten minutes from slower traffic pulling over for me.) But I will agree with you that 90% of emergent transports are unnecessary. They put our lives at risk and risk the live of our patients and people on the road. I also think it's sorta funny that a lot of these patients who come in emergent then sit on the pram for 15min while the nurse triages and looks for a bed.

http://www.health.state.ny.us/nysdoh/ems/policy/s97-04.htm

I think the only thing MAST pants are still aproved for in many places is pelvis fractures.

On our service in Colorado we could call the hospital and pronounce asytole arrests after two rounds of drugs with no results. Depending on how long it takes to get a line and tube, running an asytole code for 30 or 40min is reasonable and we've done it numerous times. The reason not to run such a code is if you show up and there are signs of death, like rigor. But for new arrests we work almost all of them at least to the two rounds of drugs point.