FL_Medic

The idea behind these "strip teases" is to get a good discussion going, and some good guesses. I will have the true answer to this shortly, but as I said, I think it's paced. I may very well be wrong.

Yes I was. Also, I realized that I tagged this as Pacer-1, but I still don't have the rhythm analysis from whom I receive these anyhow. I am assuming that this is a ventricular pacemaker, but that is not definitive. I noted the bifasicular block, and deviation. This made me question what might cause this pattern, and a paced rhythm could cause this, along with ST-elevation. I'd say, a pretty low voltage implanted ventricular pacer.

Back to the rhythm in question. So we are stating that this is surely a bundle branch block? What about the poster that mention paced morphology?

Well wht might cause changes like this?

I think maybe you should elaborate.

Obvious P waves. I am unsure of the Hx. These strips are sent to me in the same format. The only advantage I have is the ability to zoom in, and see them better. Sorry. Wish I knew the full presentation as well.

I feel this may turn out to be less in depth than you are presuming. You're welcome though. Ps. Check out the first two strip teases.

Yea, I guess. I actually didn't know about that phaeochromocytom thing.

You're like 4 posts late Kiwi.

Yea, it is the cause. That's why they call it broken-heart syndrome. The stress of a break up is used as an example.

Yea, I just posted this site to see if I got a response. This syndrome is most prevalent in Japan for some reason. (Click to view this embedded page in a new window)

By too big, do you mean personnel wise, or protocol? Tuttle always says we have to cater to the bottom 1%, I think that's crap. The only way to beat this logic is to educate so our bottom 1% is still made up of damn fine medics. Unfortunately, that is easier said than done. You see who attends inservice training, who probably reads or looks things up on off time, and who would be apt to ask a question. I have gotten more slack with the success I have had, and the extra work I do from our coworkers, than praise. No one likes an over achiever I guess, but I don't think we should crap on those that decide to be educated. Sorry, kinda getting off topic...

Ok, the education thing is obvious. Paramedics poor at intubation? Improve training, don't pull the skill. This starts at the beginning. We see every type of patient an ER does, and we are the decision maker and healthcare provider on scene. We have to make the same decisions a physician does for his emergent patients. Yet, we have less schooling than an RN. This is why members of our profession lack proficiency, and in turn we don't get the respect deserved. The school where I teach wants us to pass everyone. If our fail rate increases, we get punished. This is ridiculous. I'm not saying we shouldn't be accountable, but my instructor passed 15 of us out of 75 students. He taught, but he didn't give breaks. That's how it should be, this is a serioous profession with some not-so-serious individuals getting in to it.

I wasn't rejecting the idea, just stating that it isn't one that would be used. Our medics, unless told otherwise, would not contact medical control for pre-eclampsia. I know, that's a generalization, but for the most part it's true. Severe Pre-eclampsia: Systolic BP of 160 mm Hg or higher or diastolic BP of 110 mm Hg or higher on 2 occasions at least 6 hours apart Proteinuria of more than 5 g in 24-hour period Pulmonary edema Oliguria (<400 mL in 24 h) Persistent headaches Epigastric pain and/or impaired liver function Thrombocytopenia Intrauterine growth restriction Our protocol would focus o the BP and blurred vision, or headache. We already carry Magnesium Sulfate. The training would take place at our monthly inservice. With over 500,000 citizens, our service is likely to see this condition a few times. Maybe not me or Nifty, but certainly a few other medics. I have no problem, as stated, with the use of medical control, if our medics were trained to use it.

That's a thought. With that train of thought though, why have protocols for any stable patient? We have a medical director for a reason, while I encourage the use of online medical control, it should be for unforeseen circumstances. Pre-eclampsia is pretty common has a whole. It effects at least 5-8% of all pregnancies, is responsible for 15% of premature deliveries, and 17.7% of maternal deaths per year. We practice evidence-based medicine my man, our bit of anecdotal evidence doesn't mean much. I'm always going to be an advocate of expanding our training, knowledge, and scope. I understand where you're coming from, but there is a bigger picture. This is within our scope of practice, and would be useful if the situation presented itself. How many medics in our system would call for orders for pre-eclampsia. If not zero, close to it. They would wait, and be ready for the seizure. From the research, that is poor medicine. Not much different than waiting for a CHF patient to go apneic.

I recently competed in a scenario-based ALS competition in Temple Terrace Florida. One of the patients in the finals presented with pre-eclampsia that developed into eclampsia. As my protocol dictates, I treated the patient with Mag Sulfate once she seized. All the other competitors treated the pre-eclampsia. This was foreign to me, but once explained, made sense. I spoke with my medical director and he asked me to present the research. We practice evidence-based medicine, so I am going to write a paper with all the sources outlined. I have access to medical research databases so that isn't a problem. If anyone has experience with this including the fallowing, I would appreciate it. I need sources on the fallowing: -Current prehospital protocols -Morbidity caused by pre-eclampsia -Risk factors of pre-eclampsia -Benefits of Tx -Anything else that would support my position. All help would be appreciated, I am of coarse open to discussion on this topic.

That is interesting, you would think a regular IV cath might be too flexible. I guess in a neonate, it doesn't take much.

I believe the point that they were making was that it is pointless to check v-fib/asystole for a pulse. To respond to your first paragraph.. I meant in cardiac arrest, your monitor will dictate your treatment. Your patient assessment should lead you to the conclusion that they are in cardiac arrest, and then you will treat per your rhythm-dictated algorythm. Of coarse there are exceptions to every rule. If your patient's Hx indicates a possible special condition such as OD, hypoglycemia, acidosis, etc... You should probably change your treatment accordingly.

Good question. I believe the thought was that the patient had malignant PVCs, which as stated, they did not.

I agree with you 90% of the time. Although, during cardiac arrest you almost exclusively treat the monitor.

With my experience, I always have to pressure infuse the line attatched to the EZ-IO. Not sure why, but our flight medics have told me they usually have to do the same thing. A little redness is expected in my opinion. Did the nurses attempt to aspirate marrow again? Did you administer Lido?

Yea, a hyperventilation patient that hates everyone. I have had these patients present in different ways. In my experience the common factor is usually drugs or alcohol. I have had the patients seem to be euphorically happy and then like a switch, change to a LSD-like patient. In my experience, they also get worse the harder you or LE fight/struggle with them. Crotchity is right about attempting to talk them down, although you may not feel completely safe even if you do get them talked down. If you chose not to restrain them I would have LE close by. Frequently, I have noticed the alcohol abusers may befriend someone on scene, stating "I like you" or "I love this guy, the rest of you are assholes". It may be a good idea to have that person do the talking. Like I said, this is all just anecdotal from my experiences.

Cardiac arrest dose is 1mEq/kg. I believe crush syndrome requires a similar dose. Just delivering 1 amp to any patient doesn't make much since, but as stated it is prophylactic anyhow. In conjunction with NS it would probably do the trick on most patients, but we are attempting to practice evidence-based medicine here.

I think they do educate them and they may even use some brochures. We have the brochures but they are more aimed towards teaching children when t call, not teaching adults when not to call. I just think we should have a non-emergent transport option. Maybe something we call for after responding and it is deemed necessary. I believe Miami Dade FD utilizes this option.