1EMT-P

I am seriously thinking about leaving the hospital setting to return to the field after a long but needed break, any ideas about how best to transition back into the field in PA? Just looking to get back to my roots. Thx

Recently responded to a 21yr old female who had overdosed on heroin. She was unresponsive but had a pulse when we arrived. In the back of the unit she became responsive to pain. Rather than start an IV for the Narcan/fluids, the medic dropped an IO in her tibia.

Just curious what the benefit to doing this was. Save time? Does the Narcan absorb more efficiently through the bone? I didnt see any track marks on her arms to indicate that those veins were no good but i didnt get too close of a look.

To be honest with you I am not sure as to why the medic placed an IO, as a rule of thumb most providers will look for an IV & make at least two attempts with in about 90 seconds before they consider an IO. Narcan can be administered several different routes so I am not sure why the IO was used.

I have never had Versed in any of my drug boxes, we always carried Valium. The one service that I worked with that did have Versed, keep it locked up with the Morphine, but not in the drug box.

The real question here is why is your patient in a heart block in the first place.... Is it because they had an Acute MI or is it because they have taken too much medication & they have blocked down. If you can figure out what the cause is then you can address it. In any case I would do the following for this Pt: 1) Consider Causes + IV/IO Fluid Bolus 500 ML x1. 2) 0.5 mg Atropine IVP x1 3) Applying Pacer Pads 4) PACE 5) Additional Fluids and/or Dopamine Titrated to SBP of 90.

Yes Glucagon could be helpful in a Beta Blocker Overdose, but the fact is that most EMS agencies do not carry enough Glucagon with them for something like this, so with that being said another possible option would be to follow your ACLS protocols & to also consider mixing an Epinephrine Drip in the field you could try 1mg of the 1:1000 solution in a 250ML bag of NS & start at 30 gtts/min with a microdrip set & titrate or you could also try a Dopamine Drip.

I would encourage you to practice your palpation skills as much as possible, also please don't forget that you need to have a 10-14 ga IV cath 2" in length.

Just wanted to announce that I am now a National Registered Paramedic! I took my test on Wednesday and found out that I passed yesterday morning. How about that for quick results?

They did a pretty good job making it feel as if I could of failed, but I was somewhat positive I passed as I studied a lot. So for the past two days I have barely picked up a book. That won't last, oh joy, as I have to go over my ALS protocols now for work.

Thanks everyone for your support and answering my questions on the forums from time to time.

Paramedic Nate Johnson

CONGRATULATIONS! MY ONLY ADVICE TO YOU IS FOR YOU TO FIND AN EXPERIENCED PARAMEDIC MENTOR WHO CAN HELP YOU! GOOD LUCK!

1. That's like me saying oh "all Kiwi ambo's are 'Ambulance Officers'" it doesn't really mean anything

2. I've read a few EMT-Basic textbooks and yes, they are taught to assess but a. minimally and b. do minimal things with that information which really amounts to jack

3. Arguable

4. Won't argue there

With all do respect there are different levels of Emergency Medical Technicians, just like there are different levels of Nurses & they have different levels of education & skill. All Emergency Medical Technicians assess their patients & then treat what they find accordingly & then relay that information to the hospitals. The real question we should be asking is which interventions make a difference & what do we need to do to make EMS care better....

First off, we are talking about EMT-B, NOT Paramedics.... please do not derail.

To answer your question, NO. The ass-umption that you are making is the EMT-B's are educated in how to properly assess and interpret and communicate thier findings. They are not.

Paramedics assess and prescribe one time doses under thier own assessment, and a physicians licence

First off, 1) We are all Emergency Medical Technicians ( Basic, Intermediate & Paramedic ). 2) If you read the EMT- Basic scope of practice & you review EMT-Basic texts you will see that EMT-Basics are taught to assess their patients & they are also taught to treat what they find & to relay that information. 3) EMT-Basics are an important link in the EMS System & it is counter productive for you to degrade them! 4. FYI Paramedics do not prescribe, that is a function that is reserved for mid level providers such as ( CNM, NP & PA's ) & Physicians!

Here's a thought, why dont you actually educate the EMTs to use nitro and remove the need to run off and ask "doctor may i?"

As I am sure you are aware here in the US we have a complex medico-legal system, EMT's & Paramedics do not practice independently, but act as Physician Extenders working under a Medical Director/ Physician's licensure. EMT's & Paramedics do not run off & ask doctor may I, but instead consult with Medical Command regarding the best treatment for patients.

Because those pt's who self administer have prescriptions from a physician.

A physician has assessed, diagnosed, and prescribed.

I understand you are saying, the EMT-B should be allowed to do the same in the absence of a prescription. That is what I disagree with.

Ok, but why do you disagree? If an EMT and/or Paramedic is working under a Physician's licensure acting as the eyes & ears of the Physician in the field & assess a patient & relays that information to the Medical Command Physician and the Physician issues a Verbal Medication Order to the EMT and/or Paramedic based upon the assessment is that not the same thing as a prescription?

Simple.....

A pt experiences an illness. Let's say, stable Angina.

Dr. goes to school for 8+ whatever years.

Dr. gives Pt prescription based on years of education, combined with knowledge of up to date trends in treating said illnesses.

Pt goes home and has angina attack.

Pt gets scared and calls EMS.

EMT-B shows up and applies his/her 3 weeks of education to the situation and assists pt with thier Rx med still under the physicians licence and direction.

When put in this context, does it not seem silly to take the physician out of the equasion?

I know I don't want a undereducated Med happy EMT spraying Nitro under my tongue!!

It should also be noted that EMT-B for the most part do not aquire 12 leads, or provide IV therapy either, both of which are the standard of care with Nitro.

I urge you to carefully read my post again. At no point did I say anything about excluding or eliminating Physician input. If we are going to allow EMT's to use AED's, Blind Insertion Airways ( CBT's, Kings & LMA's ) Medical Direction & review is essential. I am sorry but the simple fact of the matter is that Nitro is self administered by patients around the world everyday for chest pain without 12 lead & without IV access! If a patient with no medical training can administer Nitro then why can't an EMT with medical training administer life saving medications like Epi Pens & Nitro? Explain your rationale!

So you want to give EMT-Bs access to, say, nitro?

I am in favor of giving EMT's access to life saving medications with medical supervision including, but not limited to Activated Charcoal, Albuterol, Aspirin, Epi Pens, Nitro, Oral Glucose, Oxygen & Tylenol.

QUOTE (mobey)But aside from that Epipen's are pretty safe, although the EMT's should have to take extra education in recognizing anaphylaxis.

Seriously. The 40hr First Responders I train can recognize anaphylaxis pretty quick and thanks to Sabrina's law are expected to be able to get a patient their own epi-pen if the patient is unable to. If an EMT-Basic isn't already qualified to use this piece of equipment, then let's drop all the pretenses and call them Ambulance drivers. I know Basic education sucks, but I'd expect that giving them the epi autoinjector to use should not be a huge deal.

All EMT-Basics in the US are taught the signs & symptoms of shock & how to treat it. They are also taught how to assist patients with their own life saving medications. If an EMT can assist a patient with his or her own medications then why should they not be allowed to carry & administer those same medications during a life threatening emergencies when ALS is not available?

Yea, due to the incontinance I'd almost certainly say stroke/TIA. Due to interventions we can rule out Beta blocker overdose and hypoglycemia. What did the neuro exam tell us? Quick check of pupils, "doll's eye" movement, break open an ammonia amp and wave it under the pt's nose, that type of stuff.

I always like to have as much information about my patients as possible, sometimes you can get clues about what may have happened. Did he have a history of CAD, CVA, Diabetes, HTN, Seizures orThyroid etc. AMI, CVA, Diabetes, Drugs, Hypothermia, Infection, Seizures & Thyroid would have been on my short list.

Welcome my friend, welcome to the other side. Now, I know I'm going to be preaching to some of the converted here but still:

If it is one thing that annoys me the most about EMS it's this American attitude of "BLS vs ALS" and its like you blokes think they are somehow an actual procedure to be carried out like splinting a broken arm "oh I gave this patient BLS" mmmm yes .... Because this patient is stable he is a "BLS" patient even tho he's been shanked in the stomach but only has a teeny-weeny hole despite the fact he is gonna crash ten minutes into his "BLS" transport.

All patients to not require "life support" and I think this is an outdated term, as you said they require care. Most care is very simple and carried out by all levels of Ambulance Officer be they a "BLS" level Technician or an ALS level "Intensive Care" officer. Included are the essential primary elements of practice like communication, safety, history taking, vital signs, physical assessment etc and does not vary between practice levels except maybe for 12 lead ECG monitoring, you can also include fundamental patient care like splinting and transporting, oxygen, salbutamol etc. This is one of the reasons I am really pleased with the way Ontario has structured its education program for Pirmary Care Paramedic; it's two years and includes the in-depth education in A&P, patho etc so that they can go in and conduct a good, detailed assessment and differential diagnosis of a patient and begin to hone and develop thier skills and knowledge rather than just a two page four hour class on how to take a few vitals and ask SAMPLE questions, for example. Australia with it's Advanced Care Paramedic (ILS) internship and post-graduate qualification for Intensive Care Paramedic (ALS) also offers a good comparison to draw here as they should offer simmilar outcomes. Ask your basic EMT to tell you how to differentiate between say indigestion and .... a gallbaldder attack for example.

Some care that ambo's offer patients is quite invasive and advanced; such as rapid sequence intubation, thrombolysis and chest decompression. These advanced skills require a solid grounding in bioscience and extensive experience, competency and overall a high level of confidence which is inherently linked back to the other competencies I outlined. It takes four to five years to become an Advanced Care (Canada) or Intensive Care Paramedic (Australia/NZ). Contrast this with some dude who has 700 hours of education over 14 weeks at the Houston Fire Department's Paramedic-R-Us patch factory.

You mentioned fundamental skills like bag mask and this is often a problem I see with people. They bag the snot out of patients and don't understand the reasons why they shouldn't. Try to explain to them about hyperoxemia, hypocapenia or dynamic hyperinflation and they just give you a glazed over look. Ask any ambo how GTN works and they'll tell you "dialates blood vessels" and no more.

So who does which? Which what? Well if we want to refer to "life support" my argument is that ambo's don't really do that and I am sure a lot of intensivits and ICU RNs will agree with me. My spin is that "care" is provided. Therefore we should do away with this "life support" nonsense and embrace what Canada has done; term everybody some level of "Care" (ehem, Alberta and Manitoba excluded, whacky Albertobaians...) because that's what 99% of my jobs have been .... providing CARE and not "life support".

Two level systems (US)

Primary Care (old BLS)

Intensive Care (old ALS)

Three level systems (US)

Primary Care (old BLS)

Advanced Care (old ILS)

Intensive Care (old ALS)

Everywhere else in the world smart enough to not have a "BLS" level

Advanced Care (old entry to practice)

Intensive Care (old ALS)

Until you guys fix that whole BLS vs ALS crap it'll continue to be what makes your system a joke.

While I support increasing the educational standards for EMS providers in the USA, I have to take issue with calling our system a joke. As I am sure you are aware just because a system is different does not mean that the care provided is not good. The USA has some very good EMS agencies including Medic One & Richmond Ambulance Authority just to name a few. There are pros & cons with each of the international systems that you mentioned. In other words my friend " people who live in glass houses shouldn't throw stones".

Compressions should not be stopped.It is rarely necessary to stop doing compressions while attempting to intubate.whether you are using a NRB mask to oxygenate or a BVM to ventilate look at your pulsox while attempting and when you see the rapid drop stop your attempt and begin to ventilate again. Intubation is knoced way down the list in cpr anyway if your having that much trouble just drop an LMA. Granted there are those patients that have the hump back and the bobbing head with each compression and there you may have a problem but otherwise get prepaired suction the pharynx remove the dentures stick the blade in get a good visaulization slowley advance the tube to the glottic opening time it and push, or get all set up at the 3 minute mark and at 4 minutes when you stop for your first rhythm check then stick the tube in.

Please keep in mind that a pulse oximeter may not be accurate in states of low perfusion ( cardiac arrest, hypothermia etc).

I am sorry, but you must of have misunderstood what I said... I did not say that saline locks prevent you from pushing fluid. What I said was that I am not a big fan establishing saline locks only in these patients without fluids. As I am sure you are aware strokes are a leading cause of death & disability in the US. There are an estimated 700,000 strokes that occur each year in the US. It has been reported that over $23 Billion is spent each year on the care of these patients. In many parts of the US EMS agencies have stroke protocols & they work hand in hand with designated stroke centers to not only rapidly assess these patients in the field, but to also get them to one of these designated stroke centers so they can be treated aggressively. If a patient is going to be taken to the Cath Lab or OR for immediate treatment then it is important that we in EMS do everything we can to "prep" the patient, including having IV access x2.

Fluids here is contraindicated. I also noticed you did not check the blood glucose of this AMS patient? My first option would be a saline lock, if you don't have those I'm on the fence as to whether I would start a hypotonic solution like d5w or an isotonic like normal saline. I have heard that glucose is bad for a CVA but I think that came from the day when we use to give 25 grams of D50 to all patients who had an altered mental status, but we haven't done that since I climbed down from my dinosaur. I would have started a D5 line and kept is kvo, the small amount of actual glucose she would have received would be immaterial and d5w diffuses across the membrane not contributing to increasing the b/p.

Lastly if you going to hydrate someone then do it. To stand in front of your medical control doctor and explain why you gave a "little more than kvo but not enough for a fluid challenge" would be a waste of breath and a wrath coming from the doctor for my indecision would be more that I could bear. I think you made the right call not giving fluids at all.

If you would please explain your rationale for saying that fluids are contraindicated. The purpose of IV fluids is to 1. allow fluid replacement & 2. provide for medication administration. The usual indications for IV fluid administration are as follows cardiac emergencies, dehydration, diabetic emergencies, respiratory emergencies, stroke, poisoning, seizures & trauma.

Why would a saline lock prevent pushing fluids?

A saline lock does not prevent you from pushing fluids, but there are some places that do not hang IV fluids on CVA patients. They start saline locks only!

I am not a big fan of starting saline locks only on CVA patients, especially if they are neurosurgical patients & going to be going to the OR. I can tell you from experience that during neurosurgical cases for cerebral aneurysms that they will sometimes induce moderate hypothermia by rapidly infusing IV fluids for cerebral protection.

I think you are missing the point, the patient was 1 month Status Post CABG & he developed Atrial Fibrillation & Atrial Flutter in the hospital after his surgery, he was treated with an Amiodarone Drip & 2 Grams of Magnesium IV & converted back to SR & discharged to home, three weeks later his symptoms returned. He developed palpitaions along with some shortness of breath! The patient was not in a ST, he was in Atrial Flutter!

First, without looking at the 12 lead myself, this anecdotal evidence is pretty useless IMO. Is the Atrial Flutter versus SVT what the 12 lead printed out as interpretation, or was this interpreted by the paramedic? There can be a huge difference in what the 12 lead says at the top, and what is actually going on.

Aside, from having a tachy HR and mild tachy RR, he " sounds " pretty stable. Did anyone think to call his cardiologist or cardiac surgeon before transfer?

Respectfully,

JW

I am sorry, but I have to respctively disagree with you on the ancedotal evidence. A patients history & physical can tell you a lot more than a 12 lead! As I am sure you are aware Atrial Fibrillation & Atrial Flutter are fairly common among Status Post CABG patients. This patient had a history of Atrial Fibrillation & Atrial Flutter following his CABG surgery. The ED & PCP were the ones who did the interperetation of Atrial Flutter vs SVT on the 12 lead. So a patient who is 1 month S/P CABG with Atrial Flutter, palpitations & shortness of breath is stable??

Dust, I am sorry but I have to respectively disagree with you. When I first became an EMT in the 80's we were taught how to do an assessment & what was considered normal vs abnormal & what that might mean & why. It is important for all EMT's & Paramedics to be able to not only assess their patients but to document & relay their findings to the ED staff. Examples: Decreased Circulation, Motor & Sensory with a dislocation/fracture, Trauma: Flail Chest, Fractured Femur etc.

I was talking with a Paramedic who told me that he respond to a primary care clinic 30 minutes away from the hospital for a 50 year old white male patient who is 1 month S/P CABG. The patient went in for a routine appointment for palpitations. Upon arrival you find the patient on an exam table, on 2 liters of oxygen with saline lock in place & Dynamap in place. The patients vs were as follows HR 130, BP 110/50, RR 20, SPo2 95%, T 98.7. SAMPLE History was as follows: Hx of Palpitations. Allergies: NKA, Medications: Lopressor 100MG, Aspirin 325MG, Zocor 40MG, Lasix 40MG, Nitro SL, Plavix 75MG & Multi Vit. Past Hx.: CAD & HTN. Last intake breakfast. Events leading up to patient was resting at home. Enroute the patient was placed on 4 liters of oxygen, an IV of NS was started an additional 12 lead was obtained HR was 130 Atrial Flutter vs SVT, The Medical Command Physician ordered Adenosine 6MG IV x1 & the patients rate slowed to 113 with Atrial Flutter 3:1. If this was your patient what would you do?

I was called to a 57 y/o man complaining of a sudden onset of mid line abdominal pain while sitting in his office doing some paper work. Patient has a history of hypertension and high cholesterol and is non compliant with his meds. Patient had not eaten lunch yet and tells us the pain feels as if something is "pulling apart" in his belly and lifts up his shirt to reveal an vertical 5-8cm oval lump in his abdomen just off the mid line. While in route to the hospital my EMT "ride along" placed him on oxygen, moves down and begins to palpate the abdomen? I yanked his hands up telling him not touch the any of my patients abdomens, ever!

Regardless of what anyone thinks is wrong with this patient, could someone please tell me why we still teach EMTs to palpate the abdomen!

The reason that we teach EMT's to palpate is because we want them to assess their patients. As the senior provider on the truck you have an obligation to mentor the EMT. Yanking his hands away in front of the patient served no purpose!