fiznat

I have to commend Mr. Woo on his ability to remain calm, relaxed, and consistently respectful throughout this thread. A lot of people have been pretty aggressive in their criticism of him here, and I am surprised each time he posts that the he hasn't blown up in anger or frustration. Well done for that. For the OP: I understand your intent, but as I said about 4 pages back you really are going about this the wrong way. Passion is good, but you need to understand that the language doctors speak is the language of science. Linking to opinion pieces and web definitions shows doctors (and us!) that you're really not understanding how decisions are made in the field of medicine. In addition to that, your grasp on English writing is not good. It sounds like English isn't your first language. I don't mean that as an insult, but I think we've seen enough here to know that it is true. If you expect to be taken seriously, you need to have someone proofread your material before you send it out. Even the best ideas will be cast aside if they aren't presented in a coherent manner. If you care whether people pay attention to your ideas, you need to make some efforts on your side of the fence first. Oh and by the way: Nicely put, sir. Hats off.

Our general protocol for this guy would be: Vents/Oxygen - Sounds more NRB than N/C but I'm not looking right at the guy. If the patient looks sick enough (sounds like he is!) he'd be getting CPAP. Works sweet for situations like these. BVM on standby if he really is that tired. Nebs - A combivent or two to start followed by albuterol dosing PRN. Steroids- Solumedrol 125 General stuff - ETCO2 would be a nice assessment tool here. IV, monitor (3 and 12), don't make the guy walk down the stairs, etc etc etc.

No CPAP??

...Because you are going about this the wrong way. If you are interested in influencing a protocol change in your region, you need EVIDENCE that the changes you are proposing will be efficacious, practical, and safe. That evidence cannot be found by simply referencing protocol in other regions and saying "but they get to do it." You need scientific research. Start here: http://www.ncbi.nlm.nih.gov/pubmed/ I can save you the trouble though. NTG has not been shown to be cardioprotective in any setting, by any route, or by any dose. We use it because the mechanism seems to make sense, and it decreases pain (and therefore anxiety) in ACS patients. Increasing dosing to infinity will increase risk without increasing benefit. Its a no-win, and no matter how many copies of protocols you get from EMT City members, the docs just aren't going to go for it.

There is *much* more to know about this patient's condition beyond his complaint of chest pain. The patient needs to be fully assessed, and a decision should be made given that information. Not every patient who complains of chest pain is "decompensating" or requires emergent transport. A complete assessment will help to differentiate who needs what.

gr8t thread. lol.

Would I be considered a wacker if I rocked this scope? I think its badass.

Well jeez, you're going to make me cite references huh? There is no "mandated minimum" hours, but there is an expected course length as described by the DOT. http://www.nhtsa.gov/people/injury/ems/EMT-P/ The US DOT National Standard Curriculum for Paramedic Training, which is as you say the NREMT's guideline for course approval. Page 17. They say that the course can be reasonably completed within 1000-1200 hours of instruction. Add 400 hours of clinical time (which is what my school does) and you get 1600. That works out to about a year, which is the average medic school length.

Hey sorry, the argument in the other thread is taking up all of my time haha. How'd I determine "stable?" I'm sure Iassessed the patient. Step 1. Assess patient. Assess patient. Are they hypoxic? How the hell do you know they're anemic? Assessment? Sounds like this patient needs to be assessed!! I suppose. I like to think the phrase actually has some meaning, though. That meaning would be: Heeey you said it too! By proactive do you mean treatment before assessment? If so then yes, we are on different wavelengths. I don't think we really are though. Are we just splitting hairs here? You don't really pull out the drug box having only seen a strip do you? I don't believe it.

Fine, I agree with this. IF our paramedic programs included 3 years of study and a host of prerequisites (which I support!), I could maybe see reducing a portion of the EMT experience requirement. As you well know however, this is not today's reality. The NREMT currently requires 1600 hours, and in my opinion schools cannot reasonably train students "from zero to hero" in that amount of time. The purpose of comparing nursing training to paramedic training was to identify differences in established modalities. What "some nurses" are "starting to do" in "some places" with "sometimes" inexperienced providers is an exception, not a rule. The point stands. Inexperienced providers should not be expected to serve in leadership roles for dynamic situations at some distance from their support structures. Currently, this applies much more to paramedics than nurses. Interesting, yes, but I get the feeling that neither your nor I are satisfied with it. I don't know if this is meant as a slight or what, but both EMTs and paramedics talk about how BLS should come before ALS. That is because it is true. Paramedic schools don't have time to teach EMTs to be EMTs before they can become paramedics. If you want to argue that 1600 hours (the NREMT standard) is not enough time then I am all for that, but don't tell me that my school is deficient because it is not cramming in the EMT curriculum as well. The school where I teach does do some targeted BLS refresher stuff, but this is in no way is expected to replace EMT training and experience. Maybe this is true where you work, but not here. An ambulance around here includes one EMT and one paramedic. When that ambulance arrives on scene, that paramedic (and nobody else) is in charge. There is no "reduced leadership" role. My school is aware of this, and has a responsibility to graduate paramedics who are prepared to handle that reality. You can't just ignore the time spent. Physician training takes six years at an absolute minimum (not even counting undergraduate). Of that time, at least four of those years are spent in the clinical environment (and usually even more than that). If paramedic schools want to model their system that way, then the length is going to have to dramatically increase. As it stands today (which is the frame from which we should be talking), paramedic schools cannot hope to achieve such a complete "start to finish" product in the amount of time they have. I'm glad you listed these. Physicians - 6 years (minimum) graduate level Nurses - 2 or 4 years undergraduate or associates level Physician Assistants - 2 years graduate level Radiology - (?? radiology is a physician specialty. Do you mean rad-tech? That's 2 years undergraduate level) Physical Therapists - 2 or 3 years graduate level Social Workers - 4 years undergraduate level, most have graduate degrees Paramedic training is MUCH, MUCH shorter than all of the professions you listed. Different worlds, really. Not only that, but with the sole exception of physicians (who's training is the longest), not a single graduate from any of these systems will be expected to perform as an independent leader and provider for the sickest, most critical patients. A paramedic is unique in that he/she has the least amount of training among his/her "peers" in healthcare, but one of the highest levels of responsibility. I see that as a dangerous situation, and I want my students to be as experienced and prepared as possible. The ultimate answer to that problem, yes, is to increase the time we spend training paramedics. Until then (and I might argue even then, really), I would much prefer that paramedic students have some experience in the field before they apply.

"Treat the patient, not the monitor" is so oft-repeated because it should be drilled into our minds. In general I think it is bad practice to look at a standalone ECG and start talking immediately about treatment. Docs don't do that. Show a doc a strip and he/she will immediately say "well, what's the patient look like." Try it. Fair enough, it's a nitpicky point anyways. ...Someone had to say it!

If you are up for taking some college level courses, I would do that. Take classes that will also serve as prerequisites for nursing (or whatever else you might be interested in) so that this isn't "just for fun." Use your time and money wisely, and understand that doing this stuff a la carte is never as good as just sucking it up and doing it all together at once. If you don't have a BS/BA or AS degree, give that some serious thought.

Definitely take a look at the next thread down (this one: http://www.emtcity.com/index.php/topic/19330-first-post-just-graduated-and-passed-the-nremt/). That guy is asking a lot of the same questions as you....

Really? Because I am an experienced instructor at a well known and nationally accredited paramedic program. I don't think it is fair to say that my feelings about paramedic students derives from "ignorance" of this educational system. Far from it. I believe that preparation at the EMT level is absolutely essential to the development of good paramedics. Paramedic training is extremely abbreviated for the amount of responsibility and accountability the job demands, and I think students need to be completely comfortable with "the basics" before they can attempt to focus on advanced medical care. By "basics," I mean proper scene control, patient interaction, equipment management, radio, scene, and hospital reports (written and oral), dealing with family, coordinating resources, and general comfort within the system. Graduates from paramedic programs are expected not only to be experts in their medical care, but leaders in the field. It is my firm opinion that you cannot be an effective leader without experience in how the system works, and if recent graduates have to focus their attention on that aspect then the medicine will suffer. I've seen it happen and it is ugly. You can try and make the argument that nurses and doctors don't require this kind of preparatory training, but it just isn't a fair comparison. First of all, medical school starts with a four year undergraduate degree followed by four more years of medical school. Then there is residency training that lasts several more years. You simply cannot compare that to the 1600 hour class that paramedics get. As far as nurses, they work under the direct supervision and instruction of physicians inside a controlled and highly regulated environment. There is a safety net there that we don't get out in the field. Paramedics are expected to work independently in dynamic, uncontrolled, and often dangerous situations in first few minutes following an incident. Moreover, individual paramedics are expected to be leaders right out of the box, and serve as the absolute highest level of care on a given scene. This is NOT asked of new nurses. If you respect the work that we do, you must recognize that paramedics face difficulties and responsibilities that many other healthcare professionals just don't see. New graduates need to be thoroughly prepared for this job before they start shouldering the whole load on their own, and I believe that preparation starts with a sold BLS background. Despite your attempt to buffer it, you are defending accelerated paramedic training by saying that the job we do isn't deserving of the time and effort. This can be an extremely demanding job, and our young need to be throughly prepared. Start with that. See above. Entry level RNs and MDs don't work in our environment, and aren't expected to immediately perform as sole leaders with very little safety nets or assistance. Our jobs are NOT THE SAME. Really? Because you have to have an undergraduate degree and solid MCAT score before you even think about medical school, and nursing training has prerequisites that take more time than the entirety of paramedic education. What do we require? A high school diploma and/or a pulse? Ours is a unique and demanding job that takes place in dynamic and uncontrolled environments. I believe that respect for this work very much warrants some extra thought about how we train our candidates.

Why were they looking for veins in the palms of the hands and soles of the feet anyways? The story doesn't seem to make sense....

I have a nice LED flashlight that I use to find veins fairly often. If I leave it on for more than a minute or so it does get fairly hot, even though it is an LED. It doesn't surprise me that someone might have caused some minor burns on a pedi's skin using that method. For that reason, I am always very mindful of the temperature of my light when I'm using it.

I'm not going to take over the thread with this discussion since it isn't the main question the OP is asking, but I would strongly advise the OP to seek out other opinions on this point before he starts school. We discuss this issue fairly often on these boards, and there are lots of threads with good well-articulated arguments. As far as Excelsior, I do know a few paramedics in my region who have successfully completed the program and are currently working as nurses. I agree however with the advice that you are young right now and you should do things the right way instead of trying to take these shortcuts. You will be a better provider for it. Also just some general advice. This job is not always what it seems like it will be from class. I would caution anyone against making EMS a "career choice" without experience in the field. I know you've graduated class and everything, but you still don't really know what you're getting into. The realities of the work are different from what a lot of people expect, and I would advise you (and anyone) to experience it before you make any hasty decisions. Working on a truck doing inter facility transports will not, in my opinion, give you that perspective.

Facebook link is a 3rd degree. Posted ECG has gotta be ventricular standstill. I see some activity which is likely atrial (p waves), but nothing happening below the AV node other than that one beat. Atrial activity without ventricular response or escape = ventricular standstill. We shouldn't be discussing treatment of this patient at all, as no assessment is possible. Still, I think it's probably safe to say that this patient is sick, sick, sick. Cool strip, thanks for sharing!

Ah, does this patient have a pulse?

You are missing a couple things: 1. You should NOT. Not, not not go right into paramedic school fresh out of EMT school. Being a good paramedic is about knowing how to be a good EMT first, and without any experience you have absolutely no idea what that means. Nothing personal against you, but jumping right into medic school is a dangerous disservice to you, your partners, and your patients. 2. There are lots of different kinds of nurses, and only some of them have four year degrees (the BSN and above). Some nursing schools do have a bridge program from Paramedic to RN, but the degree you would get would be just the regular two year degree (the RN). Excelsior College (http://www.excelsior.edu/) has a paramedic to RN online/distance program.

1.) Do you transport cardiac arrests? Some. We leave obvious deaths at the scene, along with those with asystole/rigor/lividity/etc. If the patient is asystole but warm/no rigor or lividity etc we will work on scene and then call to presume death. All others we transport. 2.) Do you WANT to transport cardiac arrests? I think our current system is reasonable. 3.) What are the benefits gained? Benefits gained with what? Transporting those we do? Some come back. Not transporting those we dont? Avoid unnecessary transport, futile care, etc. 4.) What are the risks? Same as all calls. 5.) Should any code blues be transported or should they all be called in the field if no return of spontaneous circulation? As noted above, I think our current system is reasonable.

Yeah pretty much. If you do that you should use new pads. Other options are to use different pad positioning, or a razor. Usually a little bit of hair isn't that big of a deal.

No problem! You should know though that regardless of what ECG interpretation book you get, that knowledge will be incomplete without the anatomy and physiology that is intertwined with all of this stuff. Medicine isn't a fungible commodity that can be truly appreciated a la carte. If you are interested in this stuff you should really think about going to paramedic school to get the whole story. I promise it will be extremely interesting and open up new worlds for you and your patients.

A bundle branch block is a dysfunction in the normal depolarization pathway in the ventricles. Generally, the electrical signal starts towards the top of the heart and propagates downward and outward through "bundles" of fibers. Ideally, this propagation should be fast and uniform so that the corresponding contraction of the heart muscle is as efficient as possible. Sometimes, though, damage to the nerves or ischemia (lack of oxygen) in specific parts of the heart can interrupt or delay these signals, and you can get all kinds of "blocks" in the signal. These blocks can be acute or chronic. Lots of people have chronic bundle branch blocks, but new BBB is one sign of a possible acute cardiac problem. By itself, though, (as in, without any other signs or symptoms of an acute illness) BBB isn't very meaningful and doesn't require treatment. Bundle branch block is also important in ECG interpretation in that it alters the "ST segment," which is the portion of the ECG that we use to identify acute MIs (heart attacks). In left bundle branch block especially, the block can be bad enough so that it is almost impossible to tell (on the ECG) whether or not a heart attack is happening. There are of course other parts of our assessment and a few tricks to alleviate this issue. As far as the ECG you posted, there is a definite acute inferior STEMI (heart attack), but I'm not seeing too much bundle branch block. There is rSR' in V1, but the QRS is normal width. Maybe a bit of an incomplete Right BBB (RBBB), but not the best example of BBB in general.

For the past 6 months or so I have worked as a (paid) contracted paramedic at a volunteer service, so my appreciation of the volunteer side of things has grown somewhat over that time. I see what you are saying, the agency where I work really bends over backwards to make sure their volunteers feel appreciated- holiday dinners, awards, gifts, an annual Christmas party, uniforms, stipend, a nice crew room, etc etc etc. Retention is a big issue in volunteer EMS (volunteer anything, really!). Agencies should do whatever they can to make sure their staff feels welcome and appreciated. That said, it doesn't mean you need to spend a ton of money. Small things like bringing the crews food, publicly posting thank-you letters from patients and supervisory staff, etc are cheap ways to spread good will around the organization. If you are in a position to do that kind of stuff, why not start there?