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Just realized my questions had already been answered previously. This is a great scenario. If I was doing this in real life, I would hold off on any aggressive treatments and just go code to the ER. She is in a wide-complex tachycardia, which we'll have to assume is VT, but her rate (130-150) isn't what you'd expect with VT. She is stable and in fact, as you say, her LOC, skins, and BP have not changed with this change in rhythm. Since she's stable, I wouldn't cardiovert, and I would be very hesitant to give lidocaine due to the fact that she was brady before. Like I said, if I was close to the hospital, I would hold off on aggressive treatments as long as nothing changed. I would also consult with my base, which in my protocols is actually required for stable VT. Great scenario!

Have her skins signs, LOC, or BP changed with this change in rhythm? Hx of pacemaker?

I'm still amazed that full arrests at our nursing homes often come in as "unresponsive." I mean, can't they feel for a pulse or at least tell if the patient has stopped breathing?

What favorite EMS/medical books would you recommend to a fellow paramedic?

I just found a used copy on Amazon for $15. Thanks for the tip, VentMedic.

I once tried on an NRB and found that if I had a perfect mask seal, was breathing at a fast rate, and had the O2 turned out up to 12 LPM, the amount of oxygen flowing into the mask was not enough. I imagine that sucking the bag dry (feels like you're gonna suffocate) would be frightening to someone having severe SOB, so I now always turn up the mask to the highest setting. (Granted, I'm tall, so I may have a bigger lung capacity than most people.)

Here in LA not too many years ago, LA City Fire was forcing their firefighters to go to paramedic school. That was their solution to a shortage of medics.

hey fiznat, if you email me your address, i'll send you the riverside CA, AMR contract. karim

Well Comanche, whatever it was that was wrong with him, I think it's killed him by now.

The best way to learn is not from your own mistakes, but from other people's. The beauty of having several years of 911 experience as an EMT is that you get to see not only how things should be done, but also how they are done badly. Anyone who goes from EMT school to medic school with little or no field experience should not be surprised that their first year as a medic is going to be very stressful as they will have to learn the hard way from their own mistakes. If you know that you're going to get a job working alongside another medic, then you can lean on your partner, but most new medics won't have that luxury as they'll probably work on a private ambulance alongside an EMT partner. Having said that, I agree with Dust that in a perfect world there would be not EMT's. Instead, if you wanted to become a medic, you'd go to school for several years and your education would be divided between the classroom and the field. After graduating, a new medic would have to work for at least a year alongside an experienced medic mentor before being allowed to work with other new medics.

When I first starting working in EMS after having worked in an office for years, I was surprised how much gossiping/backstabbing/politics there are in this business. I'd thought this sort of stuff was only done by bored office workers who needed to create some drama in their dreary lives.

I'm sorry, but I just don't understand this reasoning that it's our fault for working for AMR and that if we don't like it we should just leave. We're not living in the 19th century, nor are we in China. Workers have rights. AMR gets paid lots of taxpayer money, but I don't think AMR serves our community well. Just as AMR negotiates with local governments and other companies for contracts, so will our union negotiate with AMR for better wages and working conditions.

I work as a medic on a medic/EMT ambulance, but I haven't had many conflicts with my EMT partners, so I don't have much to add on this topic. It's a different matter though with some fire medics that I work with. Don't get me wrong; I don't hate fire medics. Most of these guys are cool and have good skills, and I look forward to running calls with them. It's just that there are a few that treat us ambulance medics like we're EMT's. I know that it's not just because of their egos but because their captains are forcing them to take control of the scene and pretend like the ambulance people aren't there.

I don't believe that stuff about the 180% pay raise and the plasma TV's. It sounds like this union rep is trying to make these guys look bad. Many people may not like unions, but you need someone to represent you when you work for AMR. AMR only cares about making its shareholders happy.

Dust, the way things work in SD City is that there are fire medics on each engine and a paramedic and an EMT on the Rural Metro ambulances. They respond to call together, and then the Rural Metro paramedic takes the patient to the hospital. The Fire Department used to have its own ambulances, but no more. In the rest of SD County, most of the fire departments have medics on the engines, and some also have their own ambulances and transport themselves. A few are still BLS. In Chula Vista, AMR has the contract, and they have dual medics on their ambulances.

Private ambulance companies. And especially AMR. AMR just cares about making their shareholders happy. Because they do such a terrible job of serving our community (not staffing units, not trying to retain experienced employees, hiring 19 year olds), they are destroying the image of EMS in the public's eye. Professionalism is obviously a huge problem for EMS, and AMR is helping to make it worse. And of course that makes it easy for the fire department to step in and take over.

Sad, but not surprisng. Many people who enter EMS have lazy minds. When I was an EMT, I had two medic partners who didn't know what political party the president belonged to. Just the other day, I was listening to NPR and they were talking about Iraq, and the guy I was working with says, "Didn't they execute that guy? Saddam?"

i'm actually trying to get a job with SF Fire right now. they recently tested for EMT positions on their ambulances. they used to be dual medic, but are now going medic-EMT. i don't think they'll be testing again for EMT's for a long time. they will be hiring for medics sometime next year, but expect every non-fire medic in the bay area to be testing for that! the nice thing about SF Fire is that it's the only fire department in california that hires single-function medics. starting pay for an EMT is $54K; starting for a medic is $72; fire medics start at over $80K. if you're on an ambulance, you work four ten-hour shifts weekly. the cost of living in the bay area is very high, just as in LA.

Two of these lifeguard/paramedics were in my medic class at Daniel Freeman. Cool guys.

Hereis the California scope of practice. Counties can take things away (such as intubation for peds in LA) but can't add to it. 100106. Scope of Practice of Emergency Medical Technician II (EMT-II). (a) An EMT-II may perform any activity identified in the scope of practice of an EMT-I in Chapter 2 of this Division. ( A certified EMT-II or an EMT-II trainee, while caring for patients in a hospital as part of their training or continuing education, under the direct supervision of a physician or registered nurse, or while at the scene of a medical emergency or during transport, or during interfacility transfer when medical direction is maintained by a physician or an authorized registered nurse and according to the policies and procedures approved by the local EMS Agency, may: (1) Perform pulmonary ventilation by use of the esophageal airway. (2) Institute intravenous (IV) catheters, needle or other cannulae (IV lines), in peripheral veins. (3) Administer intravenous glucose solutions or isotonic balanced salt solutions, including Ringer's lactate solution. (4) Obtain venous blood samples for laboratory analysis. (5) Apply and use pneumatic antishock trousers. (6) Administer, using prepackaged products where available, the following drugs: (A) Sublingual nitroglycerine preparations; ( syrup of ipecac; © lidocaine hydrochloride; (D) atropine sulfate; (E) sodium bicarbonate; (F) naloxone; (G) furosemide; (H) epinephrine; and (I) 50% dextrose. (7) Defibrillate a patient in ventricular fibrillation. (8) Cardiovert an unconscious patient in ventricular tachycardia. (9) Assess and manage patients with the conditions listed in Section 100120 of this Chapter. (10) Perform the following optional procedures or administer the following optional drugs when such are approved by the medical director of the local EMS Agency, and included in the written policies and procedures of the local EMS Agency, and when the EMT-II has been trained and successfully tested in those topics and skills as required to demonstrate competence in the additional practice(s): (A) Perform gastric suction by nasogastric or orogastric intubation or through the esophageal gastric tube airway; ( visualize the airway by use of the laryngoscope and remove foreign body(ies) with forceps in airway obstruction; © perform pulmonary ventilation by use of endotracheal intubation; (D) administer calcium chloride; (E) administer morphine sulfate; and (F) utilize snake bite kits and constricting bands. © The local EMS Agency may approve policies and procedures to be used in the event that an EMT-II at the scene of an emergency attempts direct voice contact with a physician or authorized registered nurse but cannot establish or maintain that contact and reasonably determines that a delay in treatment may jeopardize the life of a patient. The EMT-II may initiate any EMT-II activity authorized in this section in which the EMT-II has received training, when authorized by the policies and procedures of the local EMS Agency, and certification until such direct communication may be established and maintained or until the patient is brought to a general acute care hospital. (d) An EMT-II may initiate only the following forms of emergency treatment prior to attempting voice or telemetry contact with a physician or authorized registered nurse in accordance with written policies and procedures approved by the local EMS Agency: (1) Administer intravenous glucose solutions or isotonic balanced salt solutions, including Ringer's lactate solution, when it is reasonably determined that the patient has sustained cardiac or respiratory arrest or is in extremis from circulatory shock. (2) Perform pulmonary ventilation by use of an esophageal airway, or endotracheal intubation if certified to do so, when it is reasonably determined that a patient has sustained respiratory arrest. (3) Apply and use pneumatic antishock trousers when it is reasonably determined that the condition of the patient necessitates such action. (4) Defibrillate a patient in ventricular fibrillation. (5) Cardiovert an unconscious patient in ventricular tachycardia. (6) Visualize the airway by use of the laryngoscope and remove foreign body(ies) with forceps in complete airway obstruction. (e) In each instance where limited advanced life support procedures are initiated in accordance with the provisions of subsection © of this section, immediately upon ability to make voice contact, the EMT-II who has initiated such procedures shall make a verbal report to the EMT-II base or satellite hospital physician or authorized registered nurse. Written documentation of the event shall be filed with the EMT-II base hospital physician, when possible, immediately upon delivery of the patient to a hospital, but in no case shall the filing of such documentation be delayed more than twenty-four (24) hours. Documentation shall contain the reason or reasons, or suspected reason or reasons, why the communication failed and the emergency medical procedures initiated and maintained, including, but not limited to, evaluation of the patient, treatment decisions, and responses to treatment by the patient. The base hospital physician shall evaluate this report and forward the report and evaluation to the medical director of the local EMS Agency within seventy-two (72) hours. (f) The scope of practice of an EMT-II shall not exceed those activities authorized in this section unless specifically approved in accordance with the provisions of subsection ((10) of this section.

Anthony, I did my internship with LA City Fire. Their scope isn't as bad as you think. I had wonderful preceptors. Mt. Sac is awful. Like you, I also thought it was a good school before I went there. I knew lots of people who'd failed there (their failure rate is over 50%, and most of the people who pass are on their second try), but I figured that these guys just hadn't worked hard enough. Well, I went there for one week and dropped out because it was just so stupid. It's not like you learn more going to Mt. Sac; everything is just made out to be much harder than it really is. My experience with Daniel Freeman was awesome. I have nothing but good things to say about the program. Daniel Freeman is the second oldest paramedic school in the US, and you'll be proud to be an alumni.

Good luck with everything, Mike. I think you'll find that working in EMS is a great adventure. I respect the fact that some people can do very well as new medics without having any 911 EMT experience. However, I very rarely come across such people. Here in Riverside were I work, we get new medics all the time. They stay for 6 months to a year before they get hired by a fire department in LA or OC. Personally, I'm glad I spent three years as an EMT before I became a medic. I had the chance to educate myself with classes and reading, and I also had the chance to work with many veteran medics. One of my partners had been a medic in Vietnam and was one of the very first paramedics working in So Cal. I've learned many valuable things not only from these veterans, but also from the new medics that I worked with. Like the saying goes, the best way to learn is from other people's mistakes! Anthony, I think you have a misconception about the Inland Empire. This is a busy metro area with the same call volume as LA and OC. I worked for one year in LA including a part of South Central. We get the same type and volume of calls in Riverside as in LA, just not as many shootings. I actually live in Santa Monica but transferred to Riverside in order to get the chance to work alongside a paramedic. I also took the paramedic prep course, which was excellent. If you're looking for paramedic schools, I recommend Daniel Freeman. I loved every minute of it. The schools in the IE, like Crafton, Victor Valley, NCTI, and the one out of Riverside Community college are all good schools too. The only one I would absolutely tell you to stay away from is Mount Sac. Let me know if you have any specific questions and I'll be happy to answer them for you.

Why rush going to paramedic school? What's the point? There is so much to learn about the practice of medicine. Five months of classroom, a month in the ER, and two months in the field is not enough to make you a decent new medic. The new medics that I see who've had no prior 911 experience as EMT's are really scary.

Here are some links to protocols in several CA counties. You can compare them to other states. (For anyone reading this outside of CA, why not add links to your local protocols also.) Riverside County: http://www.rivcoems.org/documents/documents.html Orange County: http://www.ochealthinfo.com/medical/ems/guidelines/ Pittsburg, PA: http://www.pitt.edu/~roth1/Protocols/alsprotocols717.pdf Austin, TX: http://www.atcomd.org/downloads/cog2007v22.pdf Memphis, TN: http://memphistn.gov/pdf_forms/BLS2006-9-06.pdf

I work in Riverside County, so I can answer some of your questions. First of all, please do your future patient's a favor by working as an EMT running 911 calls for at least 2 years before you go to medic's school. I can't stress enough how important it is to have a good deal of 911 experience before you go to paramedic's school. While you get hands-on experience working as an EMT, do everything you can do educate yourself. Go to the library every week and bring home an armfull of books. Take as many classes (anatomy, physiology, pathophysiology, PHTLS, ACLS, etc.) as you can find. Once you become a medic, you can work for private companies like AMR or Rural Metro in San Diego. You can't work as a medic in LA because all the 911 here is done by fire department firefighter/medics. Riverside and San Bernadino counties are you're other options in So Cal. The problem is that you can't make enough to live a middle-class lifestyle, so then you're only other option is to join a fire department or go into nursing or PA. It sounds like you have good intentions about why you want to become a paramedics. You'll learn a lot more about this job once you start working as an EMT, and from there you'll get a better feel of whether or not this is the career for you. I love being on an ambulance, but be aware that the burnout rate for EMT's and medics is very high.