fiznat

Its a wide complex tachycardia with probable P waves. You need a 12 lead before you decide for sure, but my money is on SVT with aberrancy. I probably wouldn't be giving nitro without at least a 12 lead. It takes maybe 20 seconds to get one, so there is no reason you should start giving meds knowing so little about what's going on with your patent's heart. I only give NTG without an IV if I've seen the 12 lead, and even then you need to be cautious. There are also other assessments that are particularly pertinent here as well: lung sounds? JVD? Distal edema? Skin color/temperature/condition, etc etc.

Ill be there with 3 other guys from work. Not sure if there any particular plans to meet up yet, but we're definitely open to it..

If these are actually seizures (there seems to be some doubt?): call an ambulance. To hell with what the family wants or what the patients says when she is conscious. This is tacit consent and seizures (especially status seizures as what you described) are pathological. The nurse (maybe not you) has a responsibility to this patient and you can't simply sit there and watch her seize for an hour because someone told you on the phone that its all fine. If she his having 9 "seizures" PER DAY she needs to get it handled properly before she comes back to school.

Although I'm not familiar with the laws in NY, I can say that here in CT the mechanism for dealing with overloaded departments is hospital diversion. Hospitals around here frequently go on diversion for specific types of patients, usually psych or trauma. What that means to us EMS workers is that we should take patients of these types to a different facility (a pre-arranged "accepting hospital") as long as they are stable and otherwise could stand a few more minutes in the ambulance. I understand hospitals don't like to go on diversion, but if this is as much as a safety issue as you are saying, then you do what you have to do. This halfway method of requesting EMS agencies under the table to transport somewhere else is kinda BS, because then you put the responsibility of changing requested destinations on the prehospital people, which isn't right and isn't fair. If a hospital tells me they are full but refuses to go on diversion I may mention to the patient there there will be a long wait, but I will absolutely not refuse to transport to that facility. If a hospital is so overloaded that it can't handle another patient: it needs to go on diversion. Otherwise, suck it up. (IMHO)

^^ LOL activate the stroke team!!!!

Ah, what? This is definitely not a-fib. There are clear p waves preceding each QRS and the rhythm is without a doubt regular. Let me show you: The red lines indicating the R-R interval are all of the exact same length (they are cut + paste versions of each other). The short red lines are underlining the p waves. Also, the QRS is likely wide, although I admit it is difficult to tell exactly since we can't see the small boxes very well. If it isn't wide then it is close to wide, which qualifies for an incomplete LBBB at the least. While an axis deviation is sometimes seen in the presence of left bundles, it certainly is not an absolute criteria nor a rule-out. Remember LVH is supposed to cause a left axis as well, but there is definitely LVH in this ECG. The normal axis doesn't rule out anything.

Since the other two questions have been mostly answered, I'll post the more detailed info you wanted about depolarization and repolarization you wanted. At rest, it is important to remember that sodium (Na+) is the most prominent extracellular ion, while potassium (K+) is the most prominent intracellular ion. Its silly, but I remembered this when I learned it by thinking that the neuron says OK to potassium (K+) and Nah to sodium (Na+). This balance is maintained by the sodium/potassium pump, which uses ATP (energy) to actively pump 3 sodium ions out and 2 potassium ions in. Remember that even though we are dealing with all cations here (positively charged ions), the relative amounts of those ions is what causes the differential in charge across the membrane. Because three positively charged ions are being pumped out for every two that are pumped in, the outside of the cell becomes more positive than the inside of the cell. Therefore, at rest, the inside of the neuron is negative and the outside is positive. Depolarization is the process by which those charges (negative in, positive out) momentarily switch places in response to an electrical stimuli. When the cell is stimulated: 1. the "channel" that normally allows free passage of potassium closes 2. the "channel" that normally allows free passage of sodium remains open. Because there is less sodium inside the cell than outside the cell, sodium rushes in. This causes a rapid change in the relative charge. Inside the cell becomes more positive, outside the cell becomes more negative. That is depolarization. After a certain period of time (note, this period, phase 2 of the action potential, is longer in cardiac cells due to inflow of Calcium (Ca++) ions), the cell will repolarize: 1. Sodium channel closes 2. Potassium channel opens. This causes potassium to rush out of the cell, helping to restore a balance of charge. The sodium/potassium pump then does the rest of the work to re-establish the resting potential (negative in, positive out). Hope that helps. Its a difficult thing to explain. Try checking out this flash file, it explains it really well: http://outreach.mcb.harvard.edu/animations...onpotential.swf

Holy hypertrophy! -Looks like we have a regular, wide-complex tachycardia at a rate of about 150 with the occasional (probably ventricular) ectopy. -There appear to be P-waves of consistent morphology and a regular PR interval. -The mean QRS axis is within the normal range and R wave progression through the anterior leads is good. This is likely an atrial tachycardia with LBBB abbarancy. The standout part of the ECG though is definitely the huge QRS amplitude, which is probably due to hypertrophy. Both the left bundle and the hypertrophy are factors that mess with the ST segment, so this ECG is non-diagnostic for ischemia/infarct without more info from the story/presentation. What kind of machine printed that 12 lead by the way? Its weird.

hah! I picked out the right QRS! In all of your faces!! Good strip.

lol, okay. Thanks for the rant!

In my experience, interfacility ALS transport usually requires *more* expertise, not less. I suppose there is a small niche of calls that private IFT companies would be able to run due to this change (basic IV with NS/O2/Monitor transports), but beyond that it seems pretty much useless. These providers are not adequately equipped to handle any sort of critical patient, which is probably the point. I'm having a hard time seeing the motivation for something like this other than for protection of turf.

Even if you were more forceful with that doc I think you would have still been in the right. Unless you obtain your patient's consent first, HIPPA prevents you from simply showing 12 leads to anyone on scene who asks. A doc probably should have even known better than to ask you first.

There aren't enough leads to tell for sure, but my first impression was a-flutter as well. It is a little funny though. Here is a zoomed in version so I can explain: If we are going to call the taller, wide complexes (hashed by the top lines) the underlying rhythm and the in-between beats the "flutter" waves, those flutter waves should all have the same morphology. It doesn't seem like they do. Note the complexes that I underlined (bottom hashes). Those appear to be much narrower complexes also in a regular pattern. Perhaps this is actually the underlying rhythm?

Where are you downloading it from? I can't find it.

We can't accept tips, but one time I did take a free lunch from an owner of a deli that happened to be a patient of mine. He was adamant that I accept, plus they make really good sandwiches there.

I work for a unionized private company, which has a no tolerance policy about DUIs. If you get one, you're fired. Unfortunately for some, no tolerance policies such as this tend to take away from what motivation an employee might have to notify their company of a DUI.

I understand all the things you guys are saying, but did you realize that this training program comes with A NIGHT ON THE TOWN IN NYC???? Talk about sweetening the deal!! LOL in all seriousness this program will probably teach you the very basics, but the time really is just too compressed for you to be able to process it and retain it in any useful manner. On the other hand, this is an EMT certification. It's not like you're trying to learn how to do brain surgery out there. Perhaps the material really is just that easy.

Not really. I did look and I thought the pupils were normal. I didn't find any respiratory depression and there was no overt evidence of drug use (track marks, social cues, paraphernalia, etc). After the doc gave the narcan and it turned out to have worked, he said to me that he thought the patient was "maybe breathing a little shallow." I donno, the respiratory rate was okay (like 16), but it is really difficult to tell in the ambulance exactly how "deep" a patient's breathing is. Maybe if I had put her on the end tidal capinography I would have known. Next time.

Sorry, maybe a bit of a terminology mix up there. What I mean is, we have a really old vent that does not provide PEEP at all. The best we can do for an intubated patient is this little plastic device we attach to the BVM or vent circuit which is supposed to add the PEEP (is that an ATV? I donno). I'm no RT but I don't believe this device is as effective as an actual PEEP-capable vent or CPAP.

To qualify for CPAP where I work, patients must be alert and spontaneously breathing with bilateral rales and a blood pressure over 100 systolic. These patients don't get intubated unless they lose consciousness to the point where they no longer meet the above criteria. We don't have CPAP-capable vents here anyways so once we tube these patients we're pretty much relying on mechanical PEEP which (IMHO) aint so hot.

Good point. This is something that I don't do nearly as often as I should. Another thing that I think providers often overlook cleaning is their pens. I always end up touching my pen both with gloves on and off, during patient care as well as after. I should definitely be cleaning that thing much more often.

I think the differing P wave morphology is most evident in the rhythm strip, which makes sense because you can only see 4 beats in each view on the 12 lead. You really need the longer strip to make sense of the varying PR interval and (what I agree are) varying morphologies. I called MAT on this as well, although the docs all disagreed with me haha. The answers were: 1. A-fib (?? you tell me. He pointed at lead III in the rhythm and said he saw the fib. Meh.) 2. Sinus Arrhythmia (I agree with above that the varying PRI is a strike against this) 3. Accelerated Junctional Rhythm w/ retrograde P waves (no.) I got the distinct impression that these docs didn't really care what the rhythm actually was. I understand that the patient was otherwise stable and precise identification of the rhythm isn't exactly critical, but I have to say I was a bit disappointed in the answers I got. I also posted these strips in another forum I frequent (for docs and med students). They called MAT as well. Here's the link if you're interested: http://forums.studentdoctor.net/showthread.php?t=608265

I'm not sure if the amount of "patient care" is really going to be all that much more at the hospital. It may well still be a good job, but I wouldn't make this change based on the idea that you're going to be treating patients. As an inexperienced EMT on a floor you will be the absolute lowest on the totem pole, and will probably be stuck doing mostly stuff that nobody else wanted to do. Scut work. That said, the tuition reimbursement sounds like a good deal, and you can't argue with the bigger paycheck. If not now, then eventually you will outgrow this transfer service you're on. IMHO you should start thinking about what your long term goals are and what job is going to best get you there.

I know there are some people that say the auto cuffs are so inaccurate that they don't use them, but that hasn't been my personal experience. The hospitals use this technology almost exclusively, and I have found that the auto results usually agree fairly closely with my manual readings. Noninvasive BPs are pretty much estimates anyways. I have no problem using an auto cuff as part of a complete assessment. By the way, there wasn't an option for "I'm not sure which auto cuff is best" for people like me. I've only ever really used one type (the LP12) consistently, so I'm not really in a position to judge it's value over other brands. You have to answer the quiz to get to the second part, though, so I just picked Physio.

Heh, had one of these this week. I'll play! Dispatch Notes: 28 y/o male involved in a MVA, significant damage Upon Arrival: 28 y/o male found seated in driver's seat of a motor vehicle that apparently veered off of the road at a high rate of speed, drove across the front yard of a house and struck another car sitting in the driveway. Very significant damage to the front of the patient's car although no intrusion into the passenger compartment. Bilat airbag deployment, patient was wearing a seatbelt on our arrival and was reported to not have moved. Patient presents crying, not answering questions. GCS 14. Unable to obtain any history of the event from the patient (due to mental status) or witnesses (none available). Patient was extricated from the car with c-spine precautions. During extrication and assessment in the ambulance the GCS drops to 3. Lung sounds are clear bilat, no JVD, no distal edema. Skin warm/pink/dry. PEARRL and normal size, no neuro deficits noted at this time or when patient was more conscious. The trauma assessment is without any findings of deformities, the ABD is soft non tender without masses although there is a positive seatbelt sign. VS: BP 100/80 HR 120 RR 16 SpO2 95%. BGL is 82 mg/dL. Sinus tach on the monitor. Patient received an OPA (no gag), 15lpm O2 NRB, 2 X IV access, transport to the trauma center. Reassessed enroute without any changes, patient remained GCS 3. No past medical history/meds/allergies available. Didn't even know the dude's name. Arrival at the ED: After assessing and verifying the GCS, someone says "well, wanna try narcan?" 0.8mg wakes the guy right up, he's moving about on the board and now a GCS 15. Crying again. Apparently took too many of his Rx oxycodone "by mistake." Shit. Review: Due to the significant mechanism and the witnessed acute change in mental status with this patient I was pretty much thinking about head injuries the whole time. I did a very detailed trauma assessment and didn't find anything though, checked the sugar and didn't see too much standing out with the vital signs. I thought there was a good respiratory effort and the sat was decent considering cold fingers. What I didn't think about as much was "why the hell did this guy drive off of the road." The scene gave me a clue that I pretty much completely ignored, which was that there was apparently an event that preceded the crash. I was stuck on head injury, but I should have noticed that there was probably something wrong before the impact even took place. That little bit of information may have lead me down the right path, even if there wasn't much in the physical presentation to point me in that direction.