fallout

I believe atropine works specifically on the SA node while v-tach is the ventricles firing to attempt to maintain perfusion in the absence of signal from the higher pacemaker sites. 1 mg atropine would do nothing in that scenario in my opinion, but some more experienced people may provide the absolutely correct answer.

Where to begin:

1.) Patient leaving nursing home for "hypotension." On scene I learn they used a Dinamap to take a BP and it gave an erroneous reading. I take a manual and low and behold, a perfectly normotensive patient. Still ended up transporting him.

2.) Patient discharged off the hospital floor with "chronic dementia." On scene patient is alert and oriented x 109375070820, telling me about stuff from 20 years ago, telling me about her current stay at the hospital, obviously completely with it. I hate being lied to by hospitals.

That show hit me pretty squarely.

The guy weaping after his driver was killed by an IED.

The last rites over the dead on arrivals.

The doctor in the last 4 minutes or so of the series telling the exsanginuating soldier it was acceptable to die, if he wanted to.

It reminded me of the emotions of my first cardiac arrest I ever worked. The patient went from spontaneous circulation and breathing as well as fighting her ET tube to dead within two minutes. There was nothing me or anyone else could have done.

I needed the reminder of why I started working in medicine, to do some good for those in a crisis (at least to them) portion of their lives.

I'm alright with variations in grammar, as long as it coherent. But, when I have to determine if the language is english, german or yiddish prior to trying to read it, we have a problem.

This a professional forum. Coherent communication should be the standard.

Wow, that guy was in my last semester of paramedic class. He came completely unglued during patient assessment and started banging his head on the building.

The issue of authority in EMS is a confusing mess at best.

At my current employment, we are expected to exercise authority in certain specific situations.

1.) Providing for the safety of our scene. If it's a MVC/MCI/you name it we have the absolute authority to request people to move from the area in the event of risk to themselves and to call for any and all resources we need. We also have the authority to refuse to proceed if we do not feel public safety officials have adequately secured the scene. Occasionally, we also pull over for someone whose vehicle is disabled in a dangerous position and activate the secondary lights because we feel that someone will eventually ram into that vehicle, creating a MVC. This is a stop-gap measure until people with the true authority for the management of the problem are on scene. Emergency medicine should be proactive about preventing injury as well as treating injury.

2.) Providing for the confidentiality of the patient. Most of this is move to the ambulance and shut the doors.

3.) Authority to advocate for our patient to other medical personnel, be it a nurse, physician or other allied health. Several times in the past month, we have filed reports with the state regarding facilities having no knowledge of their patient, inadequate records, wait times in excess of 45 minutes at the ER on unstable patients or long term care refusing to call 911 on unstable patients.

I firmly believe emergency medical personnel do have authority in regards to the safety of our crew, safety and treatment of our patients and trying to maintain safe practices in the communities we work in. It is inexcusable to not attempt to control a scene, even on a very basic level. In the early stages of any emergency response, it is important to have someone exercising leadership until those officials with true authority over the problem are on scene and assume command.

Eh, this was just a discussion. No argument here. Move Along. These are not the droids you're looking for.

I've never understood trendelenburg

The patient is in shock and having a hard time pushing all the blood out to the body and extremities. If we tend to shut down the peripheral circulation then if the legs were up wouldn't the heart have a harder time pushing that blood into the legs especially if the patients extrems were shut down basically.

to me it's like this, think of pushing a barrel up a hill, it's pretty hard, wouldn't it be more logical to keep the legs at the same level as the heart? It's easier to push that barrel on a flat surface than up a hill.

Just my thoughts.

The logic is is that

1.) Venous return, which is a significant component of cardic output (Starling's Law of the Heart) is increased by lower extremity elevation.

2.) Fluids tend to run where the resistance is least, so in theory, the core regions are perfused vs the limbs.

Honestly, it sounds like the use of trendelenburg and modified trendelenburg needs more study.

I found a bit more indepth recounting of studies where they attempted to analyze the data of pre-existing studies

[web:f0d6e0bb03]http://www.findarticles.com/p/articles/mi_m0NUB/is_5_14/ai_n15950331/pg_1[/web:f0d6e0bb03]

and this study http://www.findarticles.com/p/articles/mi_..._n15950331/pg_1 seems a bit more damming.

Personally, I've been laying patients with hypotension supine and elevating 5-10 degrees on the lower extremities.

In the research I did in response to this, every study was rather quick to state they did not know the optimium position for shock managment. Hopefully there will be a clinical study that examines shock management from beginning to end.

Another EMT that actually believes trendlenburg works..!

R/r 911

Hrm, elevating the feet isn't exactly definitive care, but I've definitely seen a change of > 10 mmHg systolic between non-elevated and elevated. /shrug.

I think the pants need a lightbar and integrated radio before they are up to emtcity standards.

My protocols for field termination basically say:

1.) Dependent Lividity

2.) Decomposition

3.) Decapitation

4.) Visibly destroyed brain matter

5.) Destroyed thoracic contents (aka the heart and lungs)

6.) Injuries incompatible with life (catchall, used with online medical consult for someone who is doesn't truly fit the above criteria but is highly unlikely to survive)

Even a BLS crew can use that.

Unfortunately, we haven't arrived at a protocol for sudden cardiac arrest that allows BLS to terminate resuscitation, though we are expected to get ALS to intercept us in the event of cardiac arrest, so to some degree this is a non-issue.

I am starting my paramedic clinical rotations in the next few weeks.

I would appreciate advice from those who have been on them before on how to get the most out of the experience.

I get the opportunity to spend a fairly significant amount of time in emergency rooms, labor and delivery, cath labs, ORs, pedi ER, geriatric care and field rotations.

I'm fairly comfortable with the field rotations. I basically show up, talk to the in charge regarding my experience, where I work, etc., help with the truck checkout and generally meld in pretty well there. It is their turf, and their job, but I just glide into matching the mindset of people there.

Hospital based rotations, I'm not so comfortable with. Something about the anti-septic, JHACO-heavy atmosphere makes me feel incredibly out of my element. I try and be professional with the staff, let them know what my level is (and in many cases explain what a paramedic can do) and attach to one of the nurses/allied health people that seem ok and go out of my way to give them a hand with whatever is going on.

Just to give you an idea of my usual routine. Initially, I familiarize myself with where stuff is at the facility. I've been going to the same hospitals since basic, so usually it isn't too hard to find stuff. Then I make myself available for assisting in moving patients, IV starts, running ECGs, pulling vital signs or whatever else comes along to do. When it slows down, I try and find a patient and assess them, then find the patient's nurse and ask if my impression is matching up with theirs.

I really get varying responses with this system.

I would appreciate advice on presenting as a knowledgeable, interested student without looking arrogant or too excite-able and hopefully, to be able to get involved in patient care and treatment on a level appropriate to my skill level, rather than being the nurse's IV and bedpan monkey for the day. I don't mind doing helping them out, but I would like them to return my assistance by allowing me to learn appropriate to the paramedic skill level.

Another concern is drug administration. I understand that medication errors are a massive problem in hospitals and it's the nurse's fault if it happens, so I am reluctant to ask to administer drugs that I am knowledgeable about and are within the state's proposed scope of practice for my skill level. Is it appropriate to request to? Again, I don't want to step on toes, but I think it's important to give IV/IM/SC/nebulized/oral drugs while learning so that your first time administering one is not a stressful field situation.

Anyway, advice appreciated, fire away.

I bet the lingerie section is an interesting place also. "No, that bra doesn't make you look fat."

36 hours isn't one day? It is roughly 6 days worth of OR time, since all the ORs around here do surgeries for a very limited amount of time (i.e. 6 hours per shift)

I know my upcoming airway practice consists of 36 hours in operating room with at least 5 successful LMA or ET tube placement. Realistically, I hope to have done more than that though as 5 advanced airway placements isn't that many.

I don't see the problem with having a lower trained member on a ambulance. I stepped on a transfer ambulance as a basic fresh out of school while I did the remainder of my intermediate and paramedic classes. I found it to be a valuable experience.

I learned to apply my patient assessment skills to real human beings instead of some mannequin with an instructor verbalizing all that happened. I also learned many of the pitfalls of moving patients and safely driving both emergency and non-emergency in such a way as to minimize both the risk of motor vehicle collision and accidental needle sticks to my partner from stopping hard, etc. I could continue ad nauseum about skills learned on the real ambulance that aren't taught in class.

Another major advantage was applying what I was seeing in current patients to the new material I was encountering in class. Had I never had the care of actual complex patients in my hands, the pathophysiology education I recieved would have been far less useful. Gaining access to experienced paramedic helped immensely. I could pick more brains, so to speak, regarding patients I had seen and what may have been happening with them.

In an ideal world, it would be great to run dual paramedic trucks and have lengthy precepted time for every paramedic. In reality, at least in my area, we are too short paramedics to ever work like that. So, I set out to be a good BLS provider who uses his brain to do all the appropriate BLS intervention I can and then set up for the direction the paramedic is heading in terms of ALS.

The medical director I was under for several months always said he expected us to think about the patient's condition on the most complicated level we could, regardless of what our certification level was. It is firmly ingrained in me that a good BLS provider is the foundation of a good paramedic. You cannot be one without the other.

I really can't support the concept that having anything other than paramedics on an ambulance is negative, when the foundation of your patient care and treatment is founded in your skills before you have access to the monitor and the fancy drugs.

I may be a basic, but I take my job damn seriously and really do work to be very well educated on patient care. I am not perfect, and have a ton of experience to gain, but I won't ever become a highly skilled provider sitting at a table reading a textbook and not seeing the patients I study about.

I know in my area anywhere that is a public facility, such as fire stations, ems stations, police stations, hospitals, doctor's offices or any government owned entity is considered a "safe" place as long as the child is given directly to someone on staff.

In terms of working on an emergency service, I do understand the concept of dedication and fidelity. Our job is to walk into crisis moments, either physical or emotional, stabilize the situation, provide necessary medical care and get to somewhere where the patient can continued to be treated. That is definitively a public service.

AMR, except for areas with primarily 911 contracts, is definitely not a public service.

With AMR, there is no concept of dedication or fidelity, there is only the concept of profit. I will say, I originally began working there with the concept of public service, of measuring my worth, so to speak, in terms of how I treated my patients medically and ethically. The longer I worked at AMR, however, the more I realized that the corporate management didn't measure you by those same values. You are measured by your ability to quickly run a call so you can get the next one and run it, ad infinitum. Nevermind if you throw the patient around by driving like a bat out of hell, or treat everyone, including your partner with contempt or don't treat patients who clearly need it, as long as you get clear of the call fast and move on to the next one, they are happy, because profit is maintained.

My intent is, private transfer-oriented services have breached what EMS is supposed to be about from a moral and ethical perspective. When I realized the route to promotion in AMR was through managing bottom line and not through providing skilled patient care, I stopped viewing the company as a public service. Instead, it is just another corporation that only understands acting to maintain profit and if one begins hurting their profit, then change will occur.

I believe it is unethical to strike from a genuine public service, but most transfer EMS is not at all a public service.

As someone who has worked for AMR in the past, particularly in the Houston area, it really comes down to the local management. If they are solid people who have their priorities straight, you will have a pretty decent place to work. If they don't, it turns into the usual corporate drama and backbiting very quickly.

As a general rule, the less I dealt with office administration and the more I just transported patients and did my job, the happier I was.

Also, for the record, the Houston 911 area is less a subdivision and more an unincorporated chunk of Harris/Brazoria County that no one really wants to have.

I'm glad for the experience I got there when I was new, and I definitely saw some fairly complicated patients coming out of various ER's and hospital floors.

AMR is a mixed bag, at best.