fiznat

Do you have any experience? What kind of work are you looking for? What are your long term goals? I started out with Armstrong Ambulance in Brighton while I was in college. There was lots of transfer work and a few (very rare) 911 calls, but I didn't mind it at the time. I thought it was a decent working environment and a good introduction into EMS. On the other hand, if you are looking at making EMS a career and you live in Boston, it might be a better idea to start with Boston EMS right off the bat if it is at all possible.

We use Versed for active seizures when no IV access is available (as another person said, the IM uptake is better than Ativan). We also use it for sedation post ETI if a patient is bucking the tube. I've used it for both situations, although not many times, and my observational experience is that it works fairly well.

Why not look into a job at a hospital? I don't know about Oregon but the hospitals around here hire paramedics to work as kinda "advanced techs" in the ED. Pay is decent too, around $20-$23/hr with benefits and access to con-ed. Sounds like just what you need.

Interesting. That isn't the case here, at least for EMS. My protocols specifically say that "atropine is not indicated for 3rd degree or mobitz II heart blocks." That's why I said it would be difficult to defend in court, because even though atropine may be used in this way elsewhere in the country, it is absolutely not here, and to do so would directly contradict our standing orders. We may not like it sometimes, but the fact remains that paramedics practice protocol-based medicine. Not ACLS-based medicine, not evidence-based medicine, not "they do this everywhere else-based medicine." It should be no surprise that people have different estimations of this atropine thing, because protocol differs widely from region to region. HERE, if a patient suffered an adverse outcome after being given prehospital atropine in the setting of a high degree block, it could potentially be very difficult to explain, and the paramedic would most likely be found at fault.

Are these standards coming from a medical control physician or the company you work for? It seems a little ridiculous to me that you would withhold O2 from someone with a SPO2 in the 70's and 80's, but then again maybe things are different up there in the cold and high altitude. I don't have any experience with that. How high up are we talking here? In either case, the direction (or magnitude) of your treatment should never hang on a stupid oxygen saturation value. That's what nursing home CNA's do.

JEMS has an article this month about the potential for EMS utilization of prehospital ultrasound (http://www.jems.com/article/patient-care/ultrasound-applications-ems). The article argues that ultrasound can be useful in the diagnosis of cardiac tamponade, pneumothorax, ABD trauma/bleeding, pulmonary embolism, and cardiac arrest, as well as helpful in cases of difficult IV access. The article refers to some (yet unpublished) research that says prehospital ultrasound can be useful in as much as 1 in 6 EMS calls. My personal feeling is that number seems to be a bit overstated. What do people here think? Do we need ultrasound? Is it a legitimate expansion of necessary prehospital care, or just an opportunity to sell ultrasound machines to an already technology-happy industry?

Why is this only a problem now, after 10 years of treating patients as a paramedic?

Why don't you just post the questions here? I'm sure you'll get plenty of responses.

Morphine for a trauma patient with a BP of 70?

Is giving Atropine here (given the right circumstances) probably the right thing to do? Yes. Would it be really difficult to justify in court if something bad were to happen as a result of that choice? Hell yes. Remember that while medicine is a "practice" and an "art," our slice of it as paramedics is extremely limited. Before you start blurring the lines, make sure you know your environment well and are acutely aware of the potential consequences of such a choice. It is naive to think that just because your choice was medically defensible that it will be supported by the powers that be when the chips fall on a call gone wrong. Worth thinking about...

Step 1: Curse, defecate in pants. Step 2: Call medical control, who will almost definitely tell you to honor the DNR. Step 3: Worry. Hope that nothing comes of it even though you did nothing wrong.

The vagus nerve innervates the heart at the SA and the AV nodes, which is why atropine is generally contraindicated in high degree heart blocks. Increasing the rate of the atria is not going to effect the ventricles if you've got a distal block along that line of conduction. Anticholinergics aren't going to "unblock" a node. That said, cardiac conduction (and it's pathology) is complicated and dynamic. Even though it makes sense that a distal block would undermine atropine's effect, it doesn't mean it will *never* work with a high degree block. I've seen it work, in fact. I think what Doczilla (and others) suggested is right on. If you've got the extra hands and the time to trial a dose of atropine WHILE you are setting up the pacer (which is the clear-cut ACLS answer to your question, by the way: pace immediately), I don't see anything wrong with that.

I absolutely hated doing transfers. Hated, hated, hated. I understand that EMTs and Paramedics can learn quite a bit on these types of calls by reading medical histories, discharge reports, and talking with patients, but there came a point for me where I just could not stand it any longer. The work felt brainless and boring, and it constantly made me feel like my job was reduced to something closer to livery than medicine. Luckily I was able to transfer into a different position at work where I no longer have to do transfers. Otherwise, I don't know how much longer I would have lasted.

Below is the symbol for psych, although like others have I would caution you against using it. The purpose of our documentation is to facilitate communication between us and the physicians/nurses. Oftentimes, the more symbols and shortcuts you use, the less your documentation is understood. ...Even if the symbol or whatever is fairly commonplace. In general I think it is a good idea to avoid symbols except for the very common. Anyways, here it is:

I don't really see how pushing an obstruction INTO the airway is the "least risky" procedure. This is assuming the tube can even reach the bronchus (which I really doubt it can), and that once there it is capable at all of moving a bolus in the correct manner (also doubtful). Also, performing this maneuver prior to attempting a surgical airway has the potential to make future attempts at a surgical airway ineffective (pushing the bolus distal to the membrane). What's so risky about a surgical airway anyways? Remember, this patient HAS NO AIRWAY and is NOT BREATHING.... I understand what you are saying about not taking a lot of time to ponder these options, but I think this is a pretty tough situation that deserves well thought-out action and not a rushed decision.

Yeah we fairly recently got the longer ones. I've used the shorter ones before though with no problem... maybe that patient was just inside that lower percentile I donno.

What a ballsy protocol. Push the obstruction farther down into the airway? That isn't part of any standard of care I've ever heard of. I'm not even sure that an orally-placed ET tube would even reach the carina, nevermind be capable of pushing a bolus into a bronchus... Here in CT, the next step after cant intubate/cant ventilate is a surgical airway. Is that option available where you work?

CALCULATIONS Good general drip calculation formula: CC over MG times MG times 60. CC/MG x MG x 60 the first CC is the volume of your bag the MG below it is the amount of drug (in milligrams) in the bag the second MG is the order (in milligrams) per minute -- if the drug is weight based you'll have to figure that out first and plug it in here 60 is for your drip set, which I assume is a microdrip (60 gtt/sec) The result from this equation is your drip rate per minute. CHEATS Dopamine (only for standard (1600 mcg/ml) bags): Take the patient's weight in pounds, drop the last digit (so a patient with a weight of 210 lbs would turn into 21), then subtract 2 (which would make 19). That is your drip rate per minute for 5 mcg/kg/min on a 50 kg patient. If you want to double the dose, double the drip rate, etc etc. Lidocane: Lido clock. Draw a circle with 60 at the top, 15 at 3 o-clock, 30 at 6 o-clock, and 45 at 9 o-clock. Then write a 1 next to the 15, a 2 next to the 30, a 3 next to the 45, and a 4 at the top by the 60. Those are your drip rates. 1 mg a minute is 15 gtt/min. 2 mg/min is 30 gtt/min, etc etc.

What you are describing is extremely common. Almost universal, I would venture to say. Applicable rule from The House of God (essential reading, by the way): 3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE. I dismissed that as a joke when I first read it (before I was a paramedic). Now I see the genius, and I honestly remind myself of that phrase whenever I feel things starting to get out of control. I would advise you to always remember: -Our job is simple, and often becomes more so as the "crazyness" of a call increases. -Do the same things on every call ALL of the time. Even the BS ones. Cannot stress this enough. -Reassess mental status, check lung sounds and vital signs often. -IV, monitor, O2. If you find yourself "stuck" on a call, give yourself time to regroup by reassessing or doing one of those tasks. -For the VAST, VAST majority of the time (read: pretty much all of the time), seconds do not count. Take your time to do things right and relax. You'll get things done quicker than if you had tried to rush. This is why we walk onto the scene and do not run. Carry that mindset with you for the rest of the call as well. -Embrace the phrase "it is not my emergency," not out of callousness, but out out of respect for a job well done. On a scene where everyone is freaking out, it is your responsibility to calm things down-- even if only by example. -Don't be afraid of mistakes. Be very afraid of repeating mistakes. -Always remember that we are here to provide comfort and reduce suffering, and are placed in a position of trust that enables us to do so. Some of that may be helpful and some not. Just some lessons I've learned along the way and would like to pass on... Things will get much better with time and experience, but don't expect it to happen overnight. Good luck!

Your state should have very specific guidelines on what is required in a licensed ambulance. I would suggest contacting your local department of health to get the details.

What you are describing is a good working relationship between partners. I would argue that this relationship occurs just as often (if not more so) between a paramedic and an EMT. That has been my experience, and I can tell you that my EMT's "passing wink" has saved my ass more times than I care to count. I would also submit that a 2nd paramedic on the truck is only useful for the time that is spent on-scene. The rest of the time, he/she is driving and removed from patient care. I would imagine that those (few) ultra critical calls where an additional paramedic might be of some real help, would also be those same calls that a provider would want to spend as little time on scene as possible. I have these kinds of conversations with my EMT partners all the time. I think it is absolutely essential that we do, and I never really consider those conversations "unequal" in any way. Usually the things we seek to improve on calls are non-medical things anyways (how we moved a patient, how we managed a psych, how quickly or slowly we moved, the order in which we got our tasks done, the resources we called/didnt call, etc). If I want to seek advice about a particular ALS decision, there are plenty of paramedics to ask, and I don't think it is ever really essential that a person have "been there" in order to give advice or an opinion.

I don't feel like an ALS ambulance needs to have two paramedics. Sure, there are situations where extra ALS hands help, but to say "people are going to die" because of this decision is ridiculous hyperbole. I feel like riding with an EMT has made me a stronger paramedic, and I know that if I ever need more ALS help (which is extremely rare) I can simply pick up the radio and ask for it. In a time where everyone is looking to cut costs, I really can't fault this urge to reduce redundancy and get in line with the national standard.

Sucks. I've used other types of chairs before to remove people short distances (out of a tight space or down 1 or 2 steps), but it seems like things went particularly bad for these guys. Without knowing any of the details it seems like they really oughta just used the stair chair, but who knows. It amazes me how quickly you can get into hot water on this job...

What you learned in school is correct and is the standard of care. Nobody uses pressure points for bleeding control as far as I know. I'm actually really surprised that someone would consider it important enough to use in an exam. Honestly I can't see how you would be at a disadvantage by applying the standard of care for bleeding control and ignoring that pressure points stuff completely. If you want to review just a little light anatomy, I guess it couldn't hurt to know the names and locations of the major arteries feeding the extremities. At least then you have an "answer," if not the (antiquated) technique.

No problem! The CCC program here in Hartford gets students doing hands-on kind of stuff pretty much right from the beginning. Lab sessions are generally around 5 hours long, run every Saturday for the first semester, slightly less often for the 2nd semester, and then on again for the 3rd. Throughout that time, students are also expected to complete in-hospital rotations (lots of ED time, also ICU (CICU & MSICU), respiratory, OB, and psych. Hours are required in the OR as well to practice live intubations). This is all during the same time that students attend lecture sessions as well. The 3rd semester is primarily concerned with certifications (ACLS/PALS/PHTLS classes), lab sessions, and the field internships. The school contracts with EMS services all over the state (about 10-15 different places IIRC) ranging from intercept, fire-based, private, and municipal. During this time, students spend around 200 hours riding on these services functioning as a paramedic interns under the supervision of a primary medic. Hope that helps! If you have any other questions feel free to ask.