Leaderboard

"I did not believe I was looking at VT as the axis is leftward (VT should be extreme rightward), there is no precordial concordance (as seen in VT), the morphology looks asymmetrical and abbarant (not VT), the rate is awful high for VT, and the patient was somewhat young." This was a great case, but I'm going to clarify one point because it's very important. Ventricular tachycardia can have a frontal plane axis in any quadrant. A right superior axis helps support the diagnosis but absence of that finding does not exclude the diagnosis. Same thing with precordial concordance. There is no safe way to exclude VT based on QRS morphology. On rare occasions you might see ventricular flutter with a rate around 250 but you should suspect an accessory pathway whenever the rate approaches (or exceeds) 250. When it's a regular, monomorphic wide complex tachycardia, in theory it's okay to try adenosine, and in fact it may convert orthodromic or antidromic AVRT (or be diagnositc when the underlying rhythm is atrial flutter). Just remember to hit the PRINT button so you can see what happens during the asystolic pause. The drug of choice for this patient would be procainamide but in these types of situations "edison before medicine" is probably the wisest course of action for the hemodynamically unstable patient. Thanks for sharing the case, fiznat!

Hey guys, the physiology of diaphoresis is exceedingly complicated. Sweat glands are heavily innervated by cholinergic receptors but diaphoresis is often the result of a sympathetic response. Clearly, the basic intuition regarding autonomic nervous physiology breaks down. You need not have tachycardia to have diaphoresis; however, being that a sympathetic response is often associated with diaphoresis, it's no surprise that tachycardia is often associated with said response. Take care, chbare.

Done deal brother. I'm going to call the cops and walk the street to try and keep him from getting hit by a car until they get there. If he's as injured as you state, he will be manageable pretty soon, just bide your time until he tips over. If it's really hot, or really cold outside, the same applies. Wait for him to tip over and then do your deal. The situation that you describe above is not possible to solve in a morally/ethically/professionally sound manner. This is one of those time when you say, "It's not my emergency. I didn't cause it. He's made it impossible for me to solve it. So until one of the above conditions changes, I'm going to wait." You have to accept this as a limitation of your treatment options, right? Again, accept that sometimes in this situation not only will you have to stand by and wait for the situation to change, sometimes you may have to run away and leave him to fend for himself! If he suddenly reaches into his car and comes out with a knife or a gun..or even a broken whiskey bottle...I'm leaving his dumb ass there. I will run down the road and sext with Babs until the cops come and never lose a moments sleep over it. I know you want to help him because he's hurt, but tell me this; if he was on fire and running around would you stand still and wait for him to come to you under the thinking that, "If I can hug him, then I can roll us both around on the ground and put the fire out. That is what's best for the patient." And it would be best for him, right? I think you already knew the answer brother, you just aren't comfortable with 'do nothing' as an answer. And I really get that. But in this job you must ALWAYS have that as one of your scene options, always. Ok? Excellent question! Also, use your spell check and proof read your posts, ok? You're way too smart to spell like that.. Dwayne

Scene Safty is a very important part of our job, not only for ourselves but also for our pts. It is also the one thing that we tend to forget when we are in a high stress situation, or like myself compliant. I do a saftey check all the time but I do have to admit that it is not always the best as since Im in a small community and everyone knows me, so I think I'm safe. My New years day call made me really realize how my actions have actually rubbed off on others. Call person suicidal with a knife, the RCMP waited for us. Now in reality we are to wait until the officer comes out of the scene to let us know that it is safe (its good to have cops that also know this), My partner saw the cop go in and was going to rush in after him. I did stop her before she entered the home and after we had a good discussion about scene saftey. Like others have stated but in my little bubble "After me you come first" its very hard to watch someone in need and not be able to help right away but if you become the one in need you also become useless in the end. Happy

I chose amiodarone because, honestly, like chbare said, a definitive diagnosis of the rhythm is unlikely in the field and ACLS's recommendation is always, when in doubt, treat as V-tach. I also chose amiodarone because, and perhaps I need to review cardiology, I personally don't see enough there in that strip to make me think so much that it's something other than V-tach that I would be comfortable NOT treating it as V-tach in the field; and maybe part of that is inexperience. Also, the wide QRS complex makes me think that if this were atrial flutter, that there might be an accessory pathway present and to my knowledge amiodarone is the recommended treatment for such arrhythmias. None of this means that electricity is contraindicated, and I certainly don't see any problem with cardioversion regardless of what the actual rhythm is and I agree it is probably the safest choice. However I don't think amiodarone would be deleterious to the patient in this scenario and to be honest I AM hesitant to light somebody up if I can avoid it. Perhaps the correct treatment would be to cardiovert, and I'll defer to your guys' experience, but that's my rationale behind the amiodarone.

You have every right to be confused; you're young. It's a tough decision to make; decades ago; it was a decision of your life. Nowadays you can have multiple careers. That's what college is all about; confused young adults, trying to find there own. The only thing you really need to decide is which degree path you're going down: Arts or Science. Its a PITA (Pain in the Ass) to switch from one to the other, after several semesters. Enroll at your local Community College or Senior College (Hopefully it will have Nursing, Paramedics, and Other Allied Heath Professions); take English and Anatomy & Physiology I with 2 other classes that is needed for all Medical, Allied Health, & Nursing. The first 1 year (2 Semesters); its all the same. That way you can qualify for Financial Aide (You have to be Fulltime). This will allow for decision making; go to each dept and speak with an advisor; hear all your options and hear what your family & friends have to say. You must get all feedback to make a good decision. Any decision you make in Heathcare will be fine; if you change your mind; which you may; go back to school. Its not as hard as you think or expensive. Let me give you my like experience; I'm 35. I've been an EMT since 95 & a Paramedic since 98. I never graduated from HS; like you I was indecisive; school was so long. I was pressured to take the EMT class by my friends; I wasn't doing anything. I enrolled and got my GED; since it was a requirement. I loved the class; I did more rotations than required. I finished the course and passed. I worked at a Private Ambulance and Volunteered. This was exciting; I was young and energetic like yourself. I wanted to do more than oxygen, vital signs, & transport. I interacted with Paramedics and it was something I wanted to do. I took a Paramedic course at a Hospital; I passed with top honors & got a 911 job; very pristine in NYC: 4 months out of school. I worked in a Private while looking. I worked at several Hospitals in 911 and gained so much experience. I became a Manager at a Hospital Based EMS in 06 without a degree. My years there and experience got me the job. In 08 I received my Associates and now I'm completing the final phase for my Associates in Nursing, Class 2011. Since 08 (since the Hospital closed), I've been a Manager of a Private Ambulance. I found my calling and a job so flexible; I can finish school and continue with it. Retirement age is 67; I still have time; you have time. Its never too late. Whatever path you choose will be fine; its not set in stone, so you can always veer off the path. Ultimately, you need to do what's right for you and be content with your decision. Your future depends on it. All the best.

Yeah, man...No doubt that that is a poor way to go, but you know, he may have already gotten himself reelected next term. It's a world gone crazy. We're fighting the 'war on terror' against religions around the world while all the time proclaiming freedom of religion, and from religion, in our country despite the fact that religion still runs our country. It will be interesting to see how far the Anti defamation league is willing to go with this. I believe they should go all the way. Dwayne

As your in the states and its alittle different than canada, I think when the old timers talk about setting goals low, they mean that if your going to be a paramedic you should go for the highest level and dive right in. This is true to some degree (my opinion)in my case I am not interested in getting a higher level as I would not be able to use the skills on a regular basis (ok slam me here old timers)and it wouldn't help my community any more. When old timers talk about the crappy side of EMS it is to make people realize that it isnt the same as what TV protray's it as. There are alot of missconceptions of the medical fields because of the media and tv. I have been doing this for 15 yrs and I can say that alot of my calls have a great outcome, but it is those that are horrible that will bring you down. Personally I had the worst call of my Career just a week ago, I hate to say there are alot of worst calls as you go in your career. Its not that the old timers are trying to discourage future EMS they are trying to make sure as much as you can on the internet that you are making the right decission. This career has many +'s but the -'s do out weigh them. If your going to a person who want's advice from the old timers you will have to learn how to filter what they say to you as most of them have no filters. hope this helps

Just the hearse drivers. ha ha My life has been full and I have been privileged to have held jobs in so many different careers - all of which have made me the person I am today. But, when I first became a first responder, age became my biggest enemy. Well, fear of age. I'm too old to do this full time. I'm too old to work a 24 hour shift. I'm too old to go back to school. Heck, I'm too old to be smart enough to keep up with the young farts getting in to this business. Guess what? I'm not too old. And, with my background, I have the patience and wisdom to get through a call...calmly. With a little more experience under my belt, I'll be able to add "assuredly" to that sentence. People look at me with reverence. Even as a newbie, my patients feel comfortable with me because they think I've been doing this for years. Finally, gray hairs pay off. Look at me now. I graduated the full program in record time after not having taken a full load of classes in 20 years and with good grades. Yes, the 20 year-old students grasp the material a little more quickly than I at first glance...but I have the ability to take multiple concepts and merge them together. 24 hour shifts...heck. I work 48 hour shifts. It may take me a little longer to recover, but I eat/drink/live healthy, so I'm not worried about burnout. And, (I know...never start a sentence with "but" or "and") I have enough of a background that I can bring more than just my medic skills to the table. I hope this will make me more of a value-add to my service. As my husband says frequently, everything happens for a reason.

Its cool that NYC has implemented Hypothermic Cardiac Resuscitation. There's allocated hospitals for it. I'm all for change to benefit the patient. It would be great if the Department of Health and Human Services (DHHS) was on board; if they increased their scheduled reimbursement wages this will help healthcare institutions to survive. If they do; HMO/PPO/EPO will increase their remibursements too. DHHS needs to balance Gov't sponsored insurance. Premimums and Copays need to be enforced and inplemented. That's another argument for another time. Things always come full circle. If it was a hit then; it'll be a hit today. There are audits and restriction that has crippled the healthcare institutions. As science has advanced, wages and benifits increased, taxes gone up, insurance premiums on the rise, attorney retainers, stocking & re-stocking costs, vehicle maintenance, computer aide dispatching, GPS, refective strips, denial of insurance claims, payroll tax, etc: this has not made it easy on the employer. Ex. Many people have Medicaid in NYS especially the Nursing Home residents. At the base reimbursement for ambulance service at $139.50 (Regardless of care; ALS & BLS; travel distance: emergency or non emergency; carry down or carry up; morbidly obese or non obese). How do companies survive? Medicaid reimbursements has gone down over the last decade, as expensives has gone up. What I'm saying is; look at your net income and your expenses. Say if your net income continues to go down but your expenses goes up. How do you survive? You won't. So sorry for hating but we all hate something relating to the government. But awesome FYI stuff, thanks....

Well I have nothing to add to this thread twords the OP but I can answer this question for Dwayne. Dwayne to have the level of diaphoresis that was mentioned the patient needs a heart rate over 120. Once the body senses the high heart rate the chemicals begin fireing (dont know which ones, still learning my cardio) and one of the side effects is sweating. So as long as the body is sensing a high heart rate the higher it is the more profuse the sweating. Here is a perfect example. Personel example so i can give you the indepth to it all. When I was 24 I came back from a long trip (drove florida to NJ in one shot) without much movement. Well the next day I started feeling a little "off". Then I got "heartburn" a few hours went by and I just brushed it off. Hell I'm 24 and invincible right? The heartburn didnt go away and I began getting anxious. I couldn't sit still and when I did I was just sweating like I ran a marathon. I finally gave up and went to the ED myself. Turns out I threw a PE that developed in my leg. My heart rate upon arrivial at the ED was 157 BP was sky high. I went from waiting room (which was packed) to a bed in less then 3 minutes. I thought the nurse was going to crap herself when she looked at my vitals. Within a few minutes of that I had pads placed on me and several IVs running. Felt ominus sitting there with a LP12 (at the time I just called it the shock box) in between my legs waiting for the line to go flat. I thought the last thing I would hear is BEEEE. At the time I wasnt even dreaming of being an EMT and most of my medical knowledge was from ER (the tv show). I never realized just how bad off I was until now. Now that I am an EMT and work closely with Medics I realise how close I did come. The one thing I did remember from all this was the sweating, no matter what I did I couldn't stop. The Docs said that was the one sign that should have had me at the hospital immediatly. I asked why and thats when he said it means my heart rate is sustained over 120 and my body is trying everything to slow it down and as a result I sweat. Now that I talked about it I will go research more and find out exactly the pathology so i can give an even more accurate answer for you Dwayne. Just wanted to get this down before I lost track of it, I will get better information though as I know anticdotal evidence is not the best.